I was recently introduced to the idea of a mental illness advance directive from the Icarus Project and I thought it would be helpful to signal-boost it.
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.
Thing of Things 
Good idea, but Ozy, you are talking about two different things. An informal letter to your friends so that they understand how to help you sounds like a good idea, but it’s different from a legally binding advance directive. If you want to do the latter, look up the appropriate form in your state (if there is one, http://www.nrc-pad.org/) and you definitely need witnesses. And be aware that an extreme position like “NO HOSPITAL. NO MEDICATIONS. EVER.” might not be enforceable, especially in a life-threatening emergency.
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Enforceable is one thing, but I’m not even sure that someone who would agree to the NO HOSPITAL clause is a good choice of SO. Friends do not let friends bleed out on their bathroom floors.
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Friends don’t violate friends’ fundamental bodily autonomy by ignoring their thought-out, explicitly-stated decisions and organizing a kidnapping, even “for their own good.”
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The solution is mob doctors.
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Lol@ the “for your own good” in scare quotes, as though preventing a person in psychosis from killing themselves is unacceptable
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@ Anonymous
The only reason we consider it acceptable is because we think the non-psychotic version of the same person would ask us to do so. But if you already have a non-psychotic directive telling you otherwise, what makes it acceptable?
That said, right now failing to call an ambulance in such a case might be illegal in some places, and I don’t think it’s right to demand that your friends go to jail for you.
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It depends on what “bleed out in the bathroom” means, honestly. A lot of times you can wrap yourself up and be fine (esp. if you don’t mind a nasty scar). But there is definitely a point at which you need to go to the hospital. Fortunately, if you’re bleeding, even if it was a suicide attempt, your partner can probably be like “IT WAS SELF-INJURY, NO SUICIDAL INTENT”. (This also works for some overdoses.)
And, yeah, I don’t want to go to the mental hospital, the consensus of psychiatric research on my condition is that it is neutral to bad for people like me to go to the mental hospital, and I really don’t appreciate that I can be legally kidnapped!
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@ Nita, Osberend, Ozy:
I may be a tad less flexible on this than I am on most other relationship issues because I once found my then fiancee bleeding out on the bathroom floor, so let me elaborate:
If you (the hypothetical you who are writing the directive for me to follow) are capable of convincing me that your life is objectively bad enough that you need to die, I’ll lend a hand. (I hear Amsterdam is nice this time of year and if you can convince me, I’m sure we can collectively convince some doctors where euthanasia is legal)
If you are not capable of doing that, you are not going to ‘trick’ me into letting you die by getting me to agree to a broad clause and then provoking unforeseen circumstances.
Thus, such a directive as we’re talking about need to define significantly more fine-grained and specific boundaries than NO HOSPITALS.
For instance:
If you are cutting yourself, I’ll be happy to do some limited embroidery in order to patch you back together, and frankly I’m not bad at it. The moment you puncture an artery, it’s time to call in the professionals.
We can agree to no psychiatric hospitals in order to ‘help’ you (mainly on the basis that I’ve never seen them do any good that me and a few dogs can’t do better,) but if you manage to damage yourself enough that you need surgery, this is rather different.
If you represent a clear and present danger to those around you, especially in the case of children, some sort of locking you up may be necessary, but we can agree that psych hospitals are a last resort. (we can also come up with some definition of clear and present danger. For instance, I’m big and resilient enough that I’m OK with being punched and to some degree stabbed a bit. The moment you break out the shotgun, we need to reassess.)
On the no medication bit, we can agree to no psych drugs, but if you get an infection and need antibiotics, that’s different again. Also psych drugs only count as psych drugs if they are used for that purpose. Ketamine in order to get you through an operation is not a psych drug even if it is mind altering.
With enough such lines defined, we are a lot closer to a directive that I’m likely to follow. When I did find my fiancee bleeding out on my bathroom floor, the only thing a NO HOSPITALS directive would have caused would have been for me to break the contract, not to let her die. I don’t like accepting directives that I have no intention of actually following and I don’t think other people should either.
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@Fossegrimen: I’m curious whether people would prefer jail to a psych hospital if they become a danger to others. The benefit of jail is that you get more access to lawyers and judges, but it’s also probably a harsher and less safe environment–plus the future consequences of getting arrested are probably worse.
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What does that even mean? The experience of living my life is inherently subjective. I can no more convince my partner (or anyone) that my life is “objectively” unbearable than I can convince him that liquorice is “objectively” delicious.
However, I agree that detailed negotiation is a good idea (if it doesn’t create a legal risk for the potential directive-follower).
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@ Caryatis:
The main difference between jail and the psych ward is that in order to end up in jail, you will usually have to actually have harmed someone which is something most people in their saner moments would want to avoid.
There are however, options before that. The same person I mentioned above tended to get violent too. (When I say my ex was crazy, it’s not a figure of speech.) We went for a couple rooms kept with no weapons or sharp implements and me for company to attack. Hitting, kicking scratching, biting and screaming at someone seemed to help. The trick was to spot the signs early so as to get her away from dangerous items. (Though I was stabbed once because it was 4PM and I’m still idly curious as to how that worked.)
She’s much better now.
@Nita
There are established criteria for that. I would be willing to accept any arguments that are considered valid in any country where euthanasia is legal. I would probably be willing to accept quite a lot more arguments too because I don’t think death is as horrible as people make it out to be, but that is more of a personal thing.
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In the US jail certainly does not require that you have actually hurt anyone. People get put in jail all the time for hurting property and for possessing intoxicants. A person who is going through a mental episode can easily end up in jail if the police thing the episode is due to being on drugs, and, if they prefer jail to a psychiatric hospital, having their friends tell the police it is due to drugs is one way to make sure that is where they will go. Access to a lawyer and such is unlikely though, tasering and time in a padded cell is much more likely.
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It might be a good idea to find someone you can completely trust, legally marry them or something to give them the rights that are attached to marriage for no good reason, and have them execute your instructions. The legal problem isn’t really totally solvable, but there’s probably things like this that can help.
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Isn’t that like power of attorney? (except, of course, that the consummation part is optional)
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Yep. You can give someone power of attorney if and only if you are incapacitated. But again, if there’s a life-threatening situation, a hospital would likely try to overrule that person.
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