Psychiatric Advance Directives and Joint Crisis Plans: Promoting Patient Empowerment Concepts

Intervention and involuntary commitment laws become major consideration in cases of severe mental illness [1][2] [8]. Some states have the requirement of an “imminent danger” or “immediate danger”, making involuntary commitment difficult.

Pete Earley, an author who chronicled his own attempts to help his son during a psychiatric disturbance  in his book, “Crazy: A Father’s Search Through America’s Mental Health Madness”, is one of many mental health care advocates who believes the criteria of imminent danger is too strict and prevents people from getting help until they hurt themselves or someone else.  Earley claims that when he sought psychiatric intervention for his son he was forced to lie — telling a social worker his son had threatened to kill him when he had not — in order to get him admitted to a hospital.


During times of psychiatric crisis that results in involuntary commitment, people may experience a frightening loss of choice and self-direction, which can be damaging and traumatic.  Forced hospitalizations often fail to encourage participatory concepts.   While intervention may be deemed an absolute necessity during a mental health crisis, coercive psychiatric treatment tends to have an adverse effect on patient empowerment because of the loss of autonomy and exclusion from participation in treatment options [2] [7].

Likewise, the double effect of coercive treatment can be challenging for mental health care providers to establish partnerships with individuals who are forced into contracting their services.  Many patients experiencing a severe mental illness are at a disadvantage in becoming engaged patients working towards recovery.   This is especially so for those individuals facing incarceration [7].

Earley and many other mental health care advocates recommend  Psychiatric Advance Directives (PADs), or Joint Crisis Plans (JCP). PADs are legal documents that allow individuals to express their wishes for future psychiatric care and to authorize a legally appointed proxy to make decisions on their behalf during incapacitating crises. 

The JCP is a statement expressing a mental health consumer’s wishes for treatment in the event of a future psychotic episode.  It is developed with the clinical team and an independent facilitator.  JCPs address the loss of autonomy and choice during a crisis.  The use of these documents offers potential solutions to the rise in compulsory treatment and creates a tool for patient empowerment, self-determination and recovery  [3] [4] [5][6].[7].

The methods used to initiate intervention and forced hospitalizations can create an initial negative impact on establishing an effective provider-patient partnership.   The nature of psychotic symptoms places a patient at a disadvantage to achieve empowerment, even more so for those facing incarceration.  The emerging field of participatory medicine is a movement that has the potential to ensure and strengthen the ability of mental health care patients to become full partners with their providers and participate in managing their recovery.  Advocacy for the use of PADs and JCPs support concepts of participatory medicine in mental health care.  

To learn more about Psychiatric Advance Directives, go to the webiste of the National Resource Center on Psychiatric Advance Directives.

1.  Sheehan KA. Compulsory treatment in psychiatry. Curr Opin Psychiatry. 2009 Nov;22(6):582-6.

2.  Kallert TW. Coercion in psychiatry. Curr Opin Psychiatry. 2008 Sep;21(5):485-9.  

3.  Van Dorn RA, Scheyett A, Swanson JW, Swartz MS. Psychiatric advance directives and social workers: an integrative review. Soc Work. 2010 Apr;55(2):157-6.

4.  Scheyett AM, Kim MM, Swanson JW, Swartz MS. Psychiatric advance directives: a tool for consumer empowerment and recovery. Psychiatr Rehabil J. 2007 Summer;31(1):70-5. 

5.  Borbé R, Jaeger S, Steinert T. Joint crisis plans in psychiatry [in German]. Psychiatr Prax. 2009 Jan;36(1):7-15. 

6.  Henderson C, Flood C, Leese M, Thornicroft G, Sutherby K, Szmukler G. Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial. BMJ. 2004 Jul 17;329(7458):136.

7.  Mangicaro MA. Psychosis possibly linked to an occupational disease: an e-patient’s participatory approach to consideration of etiologic factors. J Participat Med. 2011 Mar 28; 3:e17.

8.  Greenberg GA, Rosenheck RA. Jail incarceration, homelessness, and mental health: a national study. Psychiatr Serv. 2008 Feb;59(2):170-7.


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