Advance directives and advance agreements =)

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Correspondence Advance directives and advance agreements *M. Zinkler *

Newham Centre for Mental Health, East London and City Mental Health Trust,

Glen Road, London E13 8SP, UK.

Correspondence: E-mail: martin.zinkler@...

The paper by Amering *et al*

(2005<http://bjp.rcpsych.org/cgi/content/full/187/4/388#REF1>)

adds to the growing literature on advance directives. The main difficulty

with advance directives seems to be that with the available training

programmes very few service users can be enthused to draft one. The

authors recommend

more training of service users and substantial administrative commitment

from service providers.

The same could be said about advance agreements, another tool to empower

patients to become partners in negotiating individualised treatment and care

in time of crisis. Advance agreements (*Behandlungsvereinbarungen*) are

widely used in German-speaking countries and according to a quick web search

are offered routinely in at least 50 psychiatric hospitals in Austria,

Switzerland and Germany.

Unfortunately no systematic research on advance agreements has been

conducted in these countries; the only trial that has been published is from

the UK ( *et al*,

2004<http://bjp.rcpsych.org/cgi/content/full/187/4/388#REF3>)

and showed a significant reduction in the use of compulsory admission and

treatment. Interestingly, advance agreements are seen as legally binding in

Germany but not in the UK. & Cahill

(2004<http://bjp.rcpsych.org/cgi/content/full/187/4/388#REF4>)

sceptically commented on the study that 'Liberation cannot be

handed to the oppressed by the oppressor'. Basaglia

(1979<http://bjp.rcpsych.org/cgi/content/full/187/4/388#REF2>)

would probably answer that this is precisely what the psychiatrist is

supposed to do: 'to enter a dialogue with the patient, a dialogue not

between subject and object, but between two human beings, who have become

subjects. If we don't accept this logic of contradictions between two

individuals, we should better trade bananas than work as doctors'.

Advance agreements, from the experience in German-speaking countries, are

usually initiated by nurses and doctors working in in-patient settings, who

have perhaps the strongest incentive to reduce compulsion in mental health

(as those who restrain, detain and enforce treatment). Negotiating job plans

with senior and junior doctors, with ward managers and nurses where

time is allocated

to discuss and draft advance agreements might be a way forward.

EDITED BY KIRIAKOS XENITIDIS

*REFERENCES*

*Amering, M., Stastny, P. & Hopper, K. (2005)* Psychiatric advance

directives: qualitative study of informed deliberations by mental health

service users. *British Journal of Psychiatry*, *186*, 247 –252. 247–252.

[Abstract/Free Full

Text]<http://bjp.rcpsych.org/cgi/ijlink?linkType=ABST & journalCode=bjprcpsych & res\

id=186/3/247>

*Basaglia, F. (1979)* The power of the state and psychiatry. Quoted and

translated from: *Die Entscheidung des Psychiaters, Bilanz eines Lebenswerks

*. Bonn: Psychiatrie Verlag, 2000.

*, C., Flood, C., Leese, M., et al (2004)* Effect of joint crisis

plans on use of compulsion in psychiatric treatment: single blind RCT. *BMJ*,

*329*, 136 –138.[Abstract/Free Full

Text]<http://bjp.rcpsych.org/cgi/ijlink?linkType=ABST & journalCode=bmj & resid=329/\

7458/136>

*, P. & Cahill, A. B. (2004)* Compulsion and psychiatry – the role of

advance statements. *BMJ*, *329*, 122 –123.[Free Full

Text]<http://bjp.rcpsych.org/cgi/ijlink?linkType=FULL & journalCode=bmj & resid=329/\

7458/122>

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Authors' reply: *M. Amering *

Department of Psychiatry, University of Vienna, Austria

*P. Stastny *

Bronx Psychiatric Center, New York, USA

*K. Hopper *

S. Kline Institute for Psychiatric Research, New York, USA.

Correspondence: E-mail: Hopper@...

EDITED BY KIRIAKOS XENITIDIS

In practice, rights are only as visible as the mechanisms put in place for

their exercise. Formal recognitions – laws, regulations, policies – may

assist but do not suffice on their own. The thrust of our exploratory report

into the making of psychiatric advance directives was twofold. First, when

presented with the opportunity and a modicum of support, many service users

prove eager and able to participate in planning for future treatment

eventualities: taking inventory, lining up support and laying out

preferences. But second, the invitation to draft needs to be a credible one.

At least in the context we studied, the system of care appears to be

woefully out of step with that readiness and ability.

In line with the first, we would join Dr Zinkler in welcoming all manner of

collaborative arrangements and shared decision-making that represent

practical steps towards a progressively more transparent and reciprocally

accountable service system. In line with the second, however, we would

underscore the formal importance of one critical ingredient in the programme

that *et al* (2004) studied: the appointment of a designated third

party to ensure that crisis plans are faithfully integrated into treatment.

Such positions serve two purposes. They are strategic mechanisms for

expediting the formal agreement to negotiate mutually acceptable treatment

plans, bridging the power differential and ensuring that each side is heard.

They are also the administrative equivalent of 'earnest money' – the

collateral or upfront investment that ratifies an institutional commitment.

Once standardised, that small modification has the potential to build the

necessary momentum to alter 'the way we do business here', which makes for

sustainable change.