Answering Your Questions: Crisis Plans and Psychiatric Advance Directives (PAD)

Family members and caregivers can play a key role in supporting loved one’s to complete crisis plans and psychiatric advance directives (PAD). In our webinar, “Mental Health Crisis Planning: How to Develop a Proactive Strategy,” we discussed the importance of these tools and provided steps caregivers can take to get started. These plans can be an essential part of managing mental health conditions and ensuring that the individual’s wishes are respected during a crisis.

In this article, Kaely Whittington, CPRS, Training Coordinator with On Our Own of Maryland, addresses some of the remaining questions our viewers had during the webinar.

What is the overlap between a medical advance directive and a psychiatric advance directive? Do I need both?

The overlap can vary depending on where you live. Some states in the United States allow mental health preferences to be listed in a medical advance directive while others do not. Check with a local patient advocate or legal professional to learn more about the laws and requirements in your area. 

How often should a person update their crisis plan or PAD?

Ideally, you and your loved one would want to revisit your PAD after a crisis when it is safe to do so. It’s important to remember that working on PADs can be triggering and it is okay for your loved one to take their time. Each crisis I have experienced has helped me develop insight about my patterns and what has and hasn’t helped. I’ve noticed that my treatment preferences and priorities have changed over time. It can also be helpful to periodically revisit a PAD in times of wellness when there hasn’t been a recent crisis.

How do I support my loved one in preparing for a crisis when they believe they are well, but they are showing signs that they are unwell?

When I have experienced signs of mania, the best support I have received was a listening ear. Having someone hear what I have to say without judgment and asking me how I would like support gives me a sense of autonomy and control over a situation that has felt out of control. I would encourage you to start a conversation with your loved one in a comfortable and safe environment. 

You could open by asking questions about how they are feeling or how their day has been going. Express that you are coming from a place of love, and not judgment, before sharing concerns. It may be helpful to share specific things you are seeing that makes you concerned. Some examples that apply to me when I have been unwell are

• “I noticed you’ve been posting on social media throughout the night. I’m worried that you’re not getting enough sleep.”
• “You’ve told me you’ve misplaced your keys and phone several times this week. In the past, you have shared that this was a warning sign.”

How can a PAD help a person receive non-medication treatment approaches in a crisis setting?

A power of attorney or proxy decision maker can advocate for the person in crisis by communicating coping skills and other interventions that have been helpful to their treatment team. They can also help by sharing approaches that haven’t been helpful. Some states allow a person to list these in their instructional PAD. 

Some non-medication approaches that have worked for me are listening to music, walking, and having time by myself to draw. One way my mom has advocated for me is by bringing me art supplies while I was in the hospital. 

My loved one designated me as her proxy, but I don’t agree with the choices she made in her PAD. How can I handle that conflict?

It’s awesome that your daughter trusts you enough to appoint you as her proxy! That is a huge decision that reflects positively on your relationship. I would recommend having a conversation with her about her preferences and reasons behind them. Approach the conversation with curiosity and an open mind. After your daughter has had the chance to explain, ask questions to clarify, then share the concerns you have. You may not come to an agreement and that is okay.

As a proxy decision maker, it is your responsibility to advocate for your daughter’s preferences even when they don’t align with yours. If her treatment team does not feel that the choices are medically appropriate, they have the power to override choices in your daughter’s PAD. It is their responsibility to make that call if needed. Not following her wishes has the potential to damage the trust she has with you. On the other hand, respecting her wishes can strengthen your relationship. Having my mom advocate for me in a way that I wanted has proved to me that she has my back no matter how difficult things get.

Where can I find a template to help me write my personal wellness plan?

The Substance Abuse and Mental Health Services Administration (SAMHSA) created A Practical Guide to Psychiatric Advance Directives which provides general education and a sample psychiatric advance directive on page twenty-five. 

You can also find helpful crisis planning resources through the Copeland Center for Wellness and Recovery. Learn more about their Wellness and Recovery Toolkits.

Visit the National Resource Center on Psychiatric Advance Directives for state-by-state resources, https://nrc-pad.org/. 

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As the CPRS Training Coordinator, Kaely Whittington, CPRS (she/her) coordinates multiple grant-funded projects, provides technical assistance for Certified Peer Recovery Specialist-focused initiatives, and presents training based on identified needs and emerging trends. She holds an A.A. in general studies from Wor-Wic Community College and is a Certified Peer Recovery Specialist. She is also certified as a WRAP Facilitator and Taking Action for Whole Health Management Mentor. Before joining On Our Own of Maryland, Kaely served as a family peer support specialist for the Eastern Shore Mobile Crisis Team. She has also spoken about her lived experience through a national panel with SAMHSA and MHAMD’s Youth Voice Video Project. Kaely is passionate about using her lived mental health experience to advocate for others, empower her peers and promote autonomy. Outside of work, she enjoys listening to electronic music, cooking, and spending time by the water.