Advance directives and advance agreements

The paper by Amering et al (2005) 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 (Henderson et al, 2004) 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. Thomas & Cahill (2004) sceptically commented on the Henderson study that ‘Liberation cannot be handed to the oppressed by the oppressor’. Basaglia (1979) 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.