rectives (sometimes combined with instructional directives) allow people to designate someone to make treatment decisions on their behalf (Srebnik and La Fond, 1999). Allowing individuals to state their treatment preferences ahead of time increases the likelihood that care during times of psychiatric crisis and/or lack of decision-making competency will reflect their values and preferences. A number of approaches to preparing mental health advance directives have been developed, including completion of paper-and-pencil checklists, use of templates available on the Internet, and use of an interactive CD-ROM on a computer. Duke University’s Program on Advance Psychiatric Directives provides tool kits and user-friendly instructions for consumers, clinicians, and family members to use in completing psychiatric advance directives (Cook, 2004).
Although there is much interest in advance directives for mental health care, few people with mental illnesses create such directives or find them honored in times of crisis. The reasons for failing to honor an advance directive include lack of provider awareness of the directive; concerns about an individual’s competency at the time the directive was prepared; written directives that are unclear; poor communication with proxies about treatment preferences; limited availability of desired services in many communities; revocation issues, such as who can revoke a directive and under what circumstances; and legal and ethical issues involved in implementing directives that physicians disagree with or perceive as harmful to the individual (Cook, 2004). Moreover, although this option appears sensible and potentially applicable within the substance-use treatment field, there are as yet no published studies of its use in this field, and very few treatment programs have employed this approach with alcohol- or drug-dependent patients.
Several evaluation studies have found psychiatric advance directives to be feasible for use (with support) by individuals with severe and chronic mental illnesses (Peto et al., 2004; Sherman, 1998; Srebnik et al., 2004). Use of such directives is also perceived positively by consumers and associated with decreased feelings of coercion and increased perception of having a choice in their treatment decisions (Srebnik et al., 2004; Sutherby et al., 1999). Psychiatric advance directives, like advance directives for general medical conditions, can help ensure patient-centered care in times of diminished medical decision-making capacity (Backlar et al., 2001; Swanson et al., 2000).
The evidence reviewed earlier in this chapter shows the value of patients’ self-management of their illnesses. However, it is important to underscore that successful self-management programs go far beyond tradi-