Authors' reply

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 Henderson 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.