Psychiatric Advance Directives and Social Workers: An Integrative Review (Report‪)‬

Individuals with severe mental illness (SMI) often experience episodic crises alternating with times of stability. During crises, social workers and other providers often implement mandated interventions, such as involuntary hospitalization. On the one hand, many providers see these interventions as necessary to prevent harm and protect those with SMI (Swanson, McCrary, Swartz, Van Dorn, & Elbogen, 2007); on the other hand, many people with SMI describe such interventions as frightening, disempowering, traumatic, and a barrier to treatment (Swartz, Swanson, &Hannon, 2003; Van Dorn, Elbogen, et al., 2006). Social workers thus face difficult ethical decisions when engaging in crisis intervention. They may be required to choose between supporting individual autonomy and self-determination and preventing possible harm to the client or others. Psychiatric advance directives (PADs) offer one strategy to reduce mandated interventions (Swanson et al., 2008). PADs are legal documents that allow individuals to express preferences for future treatment (Joshi, 2003) and are designed to be created while the individual is competent and go into effect during periods of decisional incapacity (Swanson, Swartz, Ferron, Elbogen, &Van Dorn, 2006). (PADs are one type of "advance statement" for mental health treatment. Others include wellness recovery action plans, joint crisis plans, and crisis cards. Goals for documenting preferences are somewhat similar [compare, Henderson, Swanson, Szmukler, Thornicroft, & Zinkler, 2008]; however, PADs are the only method that is legally binding on the clinician, but clinicians are not legally obligated to provide care that conflicts with community practice standards. We discuss this in the Overriding PADs and Community Standards of Care section.) PADs support individuals' autonomy and self-determination when they are in crisis and cannot voice their preferences and needs because of their illness (Swanson, Tepper, Backlar, & Swartz, 2000). PADs may also affect clinical outcomes that indirectly reduce crises and coercion. For example, PADs have the potential to improve treatment engagement, adherence, and service utilization, which may then affect crisis management, including deescalation of crises as an alternative to hospitalization, timely notification of clinicians and family members regarding decomposition, or (if hospitalization is required) improved inpatient management strategies.