PADs elevator speech

By Jeffrey Swanson, PhD

Effective salespeople often practice something called an “elevator speech,”—a clear, persuasive pitch for their product that’s so succinct they can deliver it on the ride between the lobby and the mezzanine.  Recently I found myself giving exactly such an impromptu presentation, literally on an elevator in a conference hotel in Atlanta, trying to explain to a fellow conferencista the nature and significance of our study with Assertive Community Treatment (ACT) teams implementing Psychiatric Advance Directives (PADs) in North Carolina.

“So, there are these legal documents called psychiatric advance directives, or PADs,” I said.  (We were attending the annual conference of the Robert Wood Johnson Foundation’s Public Health Law Research Program; she wasn’t a mental health specialist.)  “They’re similar to ‘living wills’ but they’re for people with serious mental illnesses who want to plan ahead for their own treatment during a future mental health crisis.  At a time when they’re feeling well, people can complete a PAD to document their treatment choices and preferences and also appoint someone they trust to make treatment decisions for them.  Ideally, PADs are a ‘recovery tool’ that helps people to obtain treatment they prefer—something that works for them during a mental health crisis—including medication and hospitalization, when needed, but without involuntary commitment. In the meantime, PADs can help clear the lines of communication between the person with mental illness and clinicians and even family members; just the exercise of completing one of these documents can make people feel more in control of their own lives, and give them some peace of mind.”

“Wow!  That’s the best new idea I’ve heard all day,” my elevator-companion responded.  Just then the elevator doors opened on the hotel lobby and the ride was over.  Unfortunately, my speech was just getting started; I guess I’d make a terrible salesperson. But now my new friend seemed interested and didn’t walk away, and so we stood there in the lobby and I kept talking.

“It’s a good idea, all right, but so far it’s mainly just that—an idea,” I said.  “Twenty-six states have enacted special laws authorizing PADs, but they’re hardly used at all.  If you actually talk to people with a serious mental health condition, which we’ve done, and you explain to them what a PAD is, most of them will tell you they would like to have one.  But very few consumers—only about 12%—have actually completed a PAD or authorized a health care agent.”

“Really?  But if it’s such a great idea, what’s the problem?  I would think psychiatrists and the whole mental health care system would be all over this.”

“Well, one reason is that people need help to complete PADs—these documents can be pretty daunting—and mental health professionals often don’t have time to facilitate them.  Actually, some clinicians don’t even know about PADs themselves, and a lot of them have the misconception that seriously mentally ill people will use PADs to refuse all treatment, or that they’ll sue their psychiatrist for not following their PAD instructions.  It turns out those fears are way overblown.”

“So what’s the answer? Is that what your research study is about—how to overcome those barriers?”  The elevator was back now for the third time, disgorging more conference rats. She kept listening, so I droned on.

“Yeah, in our study [1] we want to see if ACT teams can help people complete these legal documents, especially if they rely on ACT team members who are ‘peer specialists’—trained staff people who are, themselves, recovering from a mental illness. If this works, it might be a key to getting PADs finally established as a routine part of community mental health care.  And if they really took hold, PADs could help improve long-term health outcomes for people with serious mental illnesses at the population level.”

“Huh.  Well, good luck with all that!”

We parted ways.  Maybe I should have stopped with the “elevator speech” part and been satisfied with her first reaction:  That’s the best new idea I’ve heard all day.  It would have been nice, but the fact is that PADs are not a new idea.  They’ve been talked about for over three decades.  Dr. Paul Appelbaum first introduced the idea of PADs in a letter to the New England Journal of Medicine in 1979.  (To my knowledge, that’s the first mention in the medical literature of a legal mental health advance instruction or proxy decisionmaker.)

“The advantages of bypassing the current unsatisfactory alternatives of guardianship, court-ordered treatment or surrender to the patient’s desire to be allowed to remain psychotic are too appealing to ignore,” Dr. Appelbaum wrote.  “Psychiatrists and their patients await the action of some brave state legislature willing to take the lead.”[2]

Thirty-five years on, many state legislatures have enacted mental health advance directive statutes; the National Resource Center on Advance Directives (www.nrc-pad.org) details their features with state-by-state information. What we’re waiting for now is a few courageous behavioral health care agencies to step up and implement them.


[1] Our study is titled “Implementing Psychiatric Advance Directives with Peer Specialist Facilitators” and is funded by a research grant from the Department of Education, National Institute for Disabilities and Rehabilitation Research.

[2] Appelbaum, PS (1979).  Michigan’s sensible ‘living will’ (letter). New England Journal of Medicine, 9(5):4 2.

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