New Push to Help Mental Health Patients Determine Their Treatment in Emergencies

Promise Resource Network peer support specialist Princess Harris walks Bill W. through the process of creating a psychiatric advance directive in her Charlotte office. Photo credit: Rose Hoban

With passage of a bill last summer, more mental health treatment providers are helping their clients fill out psychiatric advance directives.

Bill W was looking to change careers. After decades as an executive in the tire industry, he was most of the way through a program to become a chiropractor in South Carolina. But in early 2017, he rolled his truck, leaving him with broken ribs and several fractured vertebrae.

Recovering slowly, in pain while going to school and working, and a long-term heart problem had started getting worse.

To cope with all the stress, he started drinking for the first time in 14 years.

While visiting a friend in Charlotte over the holidays last year, Bill had chest pains that brought him to Novant Health Presbyterian Medical Center. There, doctors did a procedure to help Bill’s atrial fibrillation, but the doctors noticed he was agitated, depressed and suicidal.

“I knew I was sick, but I didn’t give a shit,” Bill remembered. “You have no hope whatsoever, and if I hadn’t had three children, I would’ve done it.”

He ended up on the hospital’s psychiatric floor for several months.

Bill, who has a history of bipolar disorder, was eventually discharged to a men’s shelter in Charlotte, pretty different from his prior life as a corporate executive.

But these days, for a man who’s lost almost everything – house, money – Bill is remarkably cheerful. He’s sober and in recovery from his mental health and physical issues, largely due to his time at Promise Resource Network, a mental health and substance use recovery program run out of a little building in Charlotte’s rapidly gentrifying NoDa district, within sight of downtown skyscrapers.

On a recent Tuesday, Bill sat down with Princess Harris to fill out a psychiatric advanced directive.

“I’ve had like six psychiatric crises since I’ve been grown,” he told Harris. “I wound up in the hospital six or eight times over the course of 20 years.”

Filling out a psychiatric advance directive would make it simpler to get the right treatment, the treatment that works for him, should he ever end up in psychiatric crisis again.

That’s the hope.

Not widely used

Psychiatric advance directives have been around for some time in North Carolina, but they’re still not widely used. A psychiatric advance directive (which many people refer to as a PAD) goes into effect if a person is temporarily incapable of making sound decisions for himself, like Bill was over the holidays when he contemplated suicide.

During the past legislative session, North Carolina lawmakers reaffirmed and encouraged the use of PADs as part of a bill meant to reform the process of involuntary commitment for mental health treatment.

Bill described how he gets when he’s depressed: “If I have bad posture, if I’m not talkative, if I’m not joking, if I’m real serious.”

“Usually, I’m charismatic. If I’m not engaging people, you know something is up and I need help.”

Bill can also be manic, not sleeping for days at a time.

“I paint my house and my neighbor’s house, in a day,” he said. “And I’m mad, extremely mad. I sit with my back against the wall because if I hear a sudden noise, and I’m hyperreactive, that shows my PTSD is kicking in.”

When things get bad, Bill has flashbacks to when he was 12 years old and driving with his parents. They all were in a car accident, he witnessed both his mother and father die violently.

So for Bill, when he’s agitated, he needs a quiet place, the right medications and someone to talk to. For example, he has a bad reaction to Prozac-like drugs.

But if he shows up at a psychiatric emergency room, there’s no way for physicians in the facility to know this about Bill, especially if his mental state leaves him unable to adequately express himself.

Having a PAD in place recognizes that mental health treatment is so personalized for each person that what works for one person might not work for another.

“It lets treatment providers… know what works for you but also what doesn’t,” Cherene Allen-Caraco, the head of Promise Resource Network, told a room full of people attending a workshop where they got help filling out their psychiatric advance directives.

She advised the group to add details.

“If you’re saying, you don’t want Haldol, write a justification: ‘If I take Haldol, this is the effect it has on me,’” she said. “You can’t write too much. You can write too little but if you write a justification, and are very clear, and give your reasons why your preferences are what they are, it will be helpful.”

“You have a legal right to make sure that if you can’t speak for yourself your preferences around your mental health treatment, your hospitalization, medications, which hospital you want to go to, you have a right for all of that to be documented and reviewed in case you end up being hospitalized,” Caraco explained to the group.

Peer to peer

Promise Resource Network holds these informational workshops every six weeks to explain what the documents are and to give people assistance with creating them. They get help going through the process of filling out the multi-page form with someone who’s also had the experience of having coped with a mental illness.

The agency emphasizes the role of peers in treatment, so much so that it’s completely staffed and run by people who have had their own experiences with mental illness and substance use, and who are in recovery.

Which is why the Promise Resource Network workshop was about evenly divided between people who were there to learn about creating a psychiatric advance directive and people who were there to help.

“This is a perfect opportunity for folks who may go into crisis at a certain time just to have a voice in a treatment,” said Marcus Boyd, a court liaison for the Mecklenburg County court system who was also at the meeting.

He said there’s an “understanding that ‘Hey if it becomes a situation where we can’t take all of those plans into consideration we’ll definitely do our best to abide by it as much as possible.’”

Boyd said a psychologist will still review the document.

“There may be something that they have to institute that may not be in the client’s wishes,” for example, an involuntary commitment to a psychiatric facility, he said. “But we want to make sure that [the patient’s] wishes are always considered.”

The only problem with PADs is that most people with mental health issues have not filled one out, Caraco said. That’s why she organizes these workshop every six weeks to explain PADs to their clients and facilitate people getting them done.

Once the PAD is complete, people can carry it with them, or for $10, they can file it on a password protected part of the North Carolina Secretary of State’s website. That way, the person only needs to carry a wallet card with a username and password that says they have a PAD on the website and directs a health care professional how to find it.

Step by step

After a 30-minute group introduction to the psychiatric advance directive, Bill and Harris retreated to a small office she shares with another peer support specialist.

Over the next hour, Harris walked Bill through the questions on the document. They listed his medications in detail, including even non-psychiatric medications such as Synthroid, a common thyroid hormone replacement drug which can produce psychiatric effects if the dose isn’t correct. Bill described how the wrong dose of Synthroid can actually nudge him into either a manic or depressive phase of his mental illness.

Bill and Harris discovered they had a common experience of having been admitted to the sixth floor of Novant Hospital, and receiving treatment there. They found other points of commonality, medications, ways of coping. As the hour passed, Bill’s posture in his chair became more relaxed. By the end, his legs were stretched out, ankles crossed, as the two shared confidences and swapped stories.

When they were done, it was hugs and gratitude.

“I knew Princess would take care of me,” Bill said, throwing his arm around her shoulders and giving her a side squeeze.

November 14, 2018
By Rose Hoban

New Push to Help Mental Health Patients Determine Their Treatment in Emergencies