Impact of psychiatric advance directive facilitation on mental health consumers: empowerment, treatment attitudes and the role of peer support specialists

J Ment Health. 2021 Oct;30(5):585-593. doi: 10.1080/09638237.2020.1714008. Epub 2020 Feb 4.


Background: A psychiatric advance directive (PAD) is designed to prevent involuntary mental health interventions by enabling people with serious mental illnesses to plan ahead for their own treatment during a future incapacitating crisis. This study implemented PAD facilitation in assertive community treatment (ACT) teams.

Aims: We examined ACT clients' attitudes toward PAD facilitators, satisfaction with PAD facilitation, the short-term impact of PAD completion on subjective sense of empowerment and attitudes toward treatment, and whether the type of PAD facilitator made a difference.

Methods: Participants were randomly assigned to be offered PAD facilitation by a peer support specialist or non-peer ACT team clinician, and interviewed at baseline (n = 145) and post-facilitation 1-2-month follow-up (n = 116), to assess perceived consumer-directedness of PAD facilitation, empowerment and various treatment attitudes. Mean scores before and after the intervention were compared for PAD-completers, non-completers, and those who completed a PAD with a peer vs. non-peer. The effect of PAD completion was assessed using logistic and linear regression analysis.

Results: There was no evidence of bias against peer-facilitators. There was a modest positive impact of PAD facilitation on treatment attitudes and empowerment.

Conclusions: PAD facilitation by peer support specialists and others working in community mental health settings supports recovery.

Keywords: Assertive community treatment; empowerment; peer support specialist; psychiatric advance directive; recovery; serious mental illness; treatment attitudes; treatment relationships.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Advance Directives* / psychology
  • Attitude
  • Attitude of Health Personnel
  • Empowerment
  • Health Knowledge, Attitudes, Practice*
  • Humans
  • Mental Disorders / diagnosis
  • Mental Disorders / psychology*
  • Mental Disorders / therapy*
  • Mental Health*
  • Patient Care Planning
  • Patient Satisfaction
  • Peer Group*
  • Specialization