Many mentally ill people go through crisis periods where we are no longer reliably capable of assessing our own needs: from psychosis to mania to suicidal fits to a garden-variety emotional breakdown. Friends of mentally ill people often find themselves at a loss for what to do: is it okay to trick their friend into taking their medication? Is it okay to manipulate or pressure their friend into eating? How best to respond to delusions? What grounding techniques work? How do they distract their friend without risking triggering them? Can their friend consent to sex? Should they call the cops? Should they take their friend to the hospital?
It doesn’t help that the standard advice for dealing with this sort of situation is one-size-fits-all and, uh, not exactly autonomy-respecting.
But most mentally ill people aren’t incapable of assessing our own needs all the time. Instead of waiting for a crisis, we can be proactive and make sure our loved ones know how to help us.
A lot of mentally ill people do this already. I know I’ve had a lot of conversations along the lines of “it’s okay to fuck me when I’m suicidal” or “NO HOSPITAL. NO MEDICATIONS. EVER.” But the mental illness advance directive lets us do it in a clearer way. If we write it down, our friends won’t forget something important. If we make a point of going through our preferences with people we think might take care of us when we’re in crisis, we can make sure there aren’t any misunderstandings and we haven’t overlooked anything important.
This is particularly important for those of us who don’t want to be hospitalized. Unfortunately, we live in a society in which it is completely impossible for me, as a person in relatively sound mind, to say “I do not want to be hospitalized if I am suicidal, it will not help” and know that this will be respected when I am suicidal. My one chance is making sure that my friends know to try to prevent my hospitalization and how to do so. (Don’t interact with the mental health care system until I’m better. Look, I didn’t set up this perverse incentive.)
Here is a sample advance directive:
When I am feeling well, I am (describe yourself when you are feeling well):
The following symptoms indicate that I am no longer able to make decisions for myself, that I am no longer able to be responsible for myself or to make appropriate decisions:
When I clearly have some of the above symptoms, I want the following people to make decisions for me, see that I get appropriate treatment and to give me care and support:
I do not want the following people involved in any way in my care or treatment. List names and (optionally) why you do not want them involved:
Preferred medications and why:
Acceptable medications and why:
Unacceptable medications and why:
Acceptable treatments and why:
Unacceptable treatments and why:
Home/Community Care/Respite Options:
Preferred treatment facilities and why:
Unacceptable treatment facilities and why:
What I want from my supporters when I am experiencing these symptoms:
What I don’t want from my supporters when I am experiencing these symptoms:
What I want my supporters to do if I’m a danger to myself or others:
Things I need others to do for me and who I want to do it:
How I want disagreements between my supporters settled:
Things I can do for myself:
I (give, do not give) permission for my supporters to talk with each other about my symptoms and to make plans on how to assist me.
Indicators that supporters no longer need to use this plan:
You don’t have to fill out this form: it’s perfectly fine to just write a letter explaining your preferences. (For instance, I don’t really need all the medication categories– my medication preference when I’m in crisis is NO.) But this form covers the important areas in case you forget something.
The Icarus Project recommends getting signatures from witnesses and an attorney. I am not sure how likely that is to make sure that your advance directive is respected, but it can’t hurt.
I think it might also be useful for people who haven’t had a crisis in the past but worry that they might. If you have a family history of mental illness, symptoms that resemble schizophrenia prodrome, suicidal ideation, or similar issues, you might want to make a plan just in case.