Psychiatric Advance Directives: How to Put Your Treatment Preferences in Writing Before a Future Crisis

Most people write down their treatment preferences only after a crisis has already made the decisions for them. They remember the medication that left them unable to think, the hospital that never called their sister, the night nobody knew they had a therapist. A psychiatric advance directive is the way to get those facts on paper first, while you are well enough to decide what you want.

This guide explains what a psychiatric advance directive contains, how the process of completing one usually works, and why the weeks of a residential stay are one of the most practical times to write it.

What a Psychiatric Advance Directive Is

A psychiatric advance directive (PAD) is a written document, completed while a person is able to make their own decisions, that records how they want to be treated if a future mental health crisis leaves them unable to make or communicate those decisions. SAMHSA’s practical guide to psychiatric advance directives, a 2019 federal publication (PEP19-PL-GUIDE-4), describes PADs as a tool for self-directed care, crisis planning and protecting the rights of people living with mental illness. A PAD usually does two jobs: it states treatment preferences, and it names a trusted person who can speak for you when you cannot.

You can read SAMHSA’s overview of the guide on the SAMHSA psychiatric advance directives resource page.

A PAD is different from a crisis plan or safety plan, although they overlap. A crisis plan is a working tool you and your care team use day to day. A PAD is a formal document meant to be shown to clinicians, hospitals and emergency staff who may never have met you.

Why Decisions Made During a Crisis Often Go Badly Without One

When someone arrives at an emergency department or a new treatment program in acute distress, the people treating them are working with very little information. These are the gaps a PAD is designed to close:

• Missing treatment history: A new team may not know which approaches have helped you or caused side effects in the past, so it may start from scratch.
• No one to call: Without a named contact and a signed release, staff may not know who to notify or may not be permitted to share information with family.
• Preferences that only exist in your head: Things that make a crisis worse for you, such as being touched without warning or being left alone, are invisible to people who have just met you.
• Family guessing under pressure: Relatives who love you often disagree about what you would want, and a written record removes the guesswork.

What a PAD Typically Contains

The exact format depends on where you live and which form you use, but most PADs cover the same ground:

• The name and contact information of a person you trust to make or communicate decisions on your behalf, plus a backup
• Your current diagnoses, prescribers and therapist, with phone numbers
• Medications or treatments that have helped, and ones you would prefer to avoid and why, described in general terms you have reviewed with your prescriber
• Hospitals or programs you prefer, and any you would prefer to avoid
• Early warning signs that you are becoming unwell, written so a family member can recognize them
• What helps you calm down and what makes things worse
• Practical responsibilities that need covering, such as children, pets, rent or work notification
• Who may, and may not, receive information about your care

Keep it specific. “Please call my sister Dana before anyone else, and do not discuss my care with my former partner” is far more useful to a hospital social worker than “contact family.”

How the Process Usually Works

Completing a PAD is a procedural task, and it goes more smoothly when it is broken into steps:

1. Find out what your state recognizes. Rules differ from state to state. Some states have a stand-alone psychiatric advance directive law; others handle mental health preferences through a general advance health care directive. In California, people commonly use the state’s Advance Health Care Directive, and state law places limits on what an appointed agent can authorize for certain psychiatric treatments. A legal aid organization, patient rights advocate or attorney can confirm what applies to you.
2. Draft it with your treatment team. Your prescriber can help you describe medication history accurately. Your therapist can help you name early warning signs and what helps.
3. Choose and talk to your agent. The person you name should know they have been named, have a copy, and understand what you want. A PAD that names someone who has never seen it is much harder to put to use.
4. Sign it according to your state’s requirements. Many states require witnesses or a notary. Follow the instructions on the form you are using.
5. Distribute copies. Give copies to your agent, your prescriber, your therapist and your primary care provider, and ask each of them to add it to your record.
6. Review it regularly. Update it after any significant change in medication, diagnosis, relationships or address.

Why a Residential Stay Is a Practical Time to Write One

The hardest part of a PAD is not the form. It is getting accurate medical history, a clear sense of your own warning signs and a conversation with the person you want to name, all at the same time. A residential stay can put several of those pieces in one place for a few weeks: a psychiatric provider who is reviewing your medication history anyway, a therapist who is already helping you map what happens before a crisis, and, where the program includes family sessions, a structured time to talk with the person you would name as your agent.

There is also an inconvenient operational truth worth knowing. A PAD in a drawer at home does very little. Emergency departments and admission teams work from whatever information reaches them when the person arrives. If no one brings the document, mentions it or knows it exists, it may not be seen. The distribution step matters as much as the writing step.

Bodhi Mental Health’s residential mental health treatment across several states includes discharge planning, and a PAD or crisis plan can be part of that conversation. You can review the full range of options on our treatment programs page, or call our admissions team at 877-883-0780 to ask how planning for future crises fits into a stay.

Something You Can Do Before Your Next Appointment

You do not need a finished legal document to start. Before your next appointment with a prescriber or therapist, write down three things on one page:

1. One treatment that has helped you and one that has not, in your own words
2. The one person you would want called first in a crisis, with their phone number
3. One thing that makes a crisis worse for you and one thing that helps

Bring the page and ask your provider two direct questions: “Can this be added to my chart?” and “Will you help me turn this into a psychiatric advance directive?” That conversation is the first real step.

What a PAD Cannot Do

It is important to be clear about limits. A PAD is not a guarantee. Depending on state law and the circumstances, clinicians may be permitted to act differently in an emergency, particularly when someone’s safety is at immediate risk. A PAD also cannot replace emergency care.

If you or someone you care about is thinking about suicide or is in emotional crisis, call or text 988 to reach the 988 Suicide and Crisis Lifeline, which is available 24 hours a day, 7 days a week by call, text or chat. Congress designated the 988 dialing code in 2020, and you can learn more on SAMHSA’s 988 Lifeline page. If someone is in immediate danger, call 911 or go to the nearest emergency room. A residential treatment program is not an emergency service.

Planning Ahead Is Part of Recovery

Writing down what you want during a crisis can feel uncomfortable, because it asks you to imagine becoming unwell again. Once it is done, knowing your preferences are on record can make a future crisis feel less out of your control. Regular attention to sleep, routine, support and follow-up care, the kind of everyday practices described in NIMH’s guidance on caring for your mental health, works alongside a PAD rather than instead of it.

If you are considering residential care and want to understand coverage first, you can verify your insurance online, or call 877-883-0780 to talk with our admissions team about next steps.

This article is for educational purposes only and is not medical, legal or psychiatric advice. It does not create a provider-patient relationship. Laws governing advance directives vary by state; consult a qualified attorney or patient rights advocate about your situation, and talk with a licensed health care provider about your treatment. If you are in crisis, call or text 988, or call 911 in an emergency.