In the past few months, Yvonne Hysick, PACT peer specialist for the Hampton-Newport News Community Services Board, has helped nine clients complete advance mental health directives. All have schizophrenia or schizo-affective disorder, she said. Within days, one had cause to use hers in an emergency hospitalization.

Changes to the Virginia Health Care Decisions Act in 2009, subsequently amended in 2010, allowed for the addition of mental health treatment to an advance medical directive.

A psychiatric advance directive, or PAD, is designed to ease psychiatric crises and give individuals more control over their mental health care.

Under its terms, individuals can employ the "Ulysses clause" to indicate that any refusal of treatment during periods of incapacity should be ignored, and also to instruct health providers about specific treatment preferences. The clause is so-called for the Homeric hero who withstood the lure of the Sirens' song and certain shipwreck by instructing his crew in advance to ignore any orders he gave while under their spell.

For the Ulysses clause to be binding, it must be signed by two physicians, or one physician and a licensed clinical psychologist, indicating a person's competency at the time of signing. To activate it also requires two physicians, while to restore competency requires only one.

"It's very empowering. It's not the norm for an individual that has these mental conditions to be asked what's important to them. It opens the door; they want to do something where they have some control," said Cheryl DeHaven, peer recovery services coordinator with the agency.

Individuals can list their preferred medications, medications they'd refuse (and why), best methods to deescalate a crisis, and where and how they'd choose to be treated. Hysick finds that her clients particularly like the sections regarding who's responsible for their homes and families during a crisis; their desired treatment during a crisis — including being able to state their preferred facility or any they do not wish to go to; and being able to list medications that work for them "so as not to be a pincushion." All nine of her clients denied the use of electroconvulsive therapy, she noted.

"It gives the tools to manage a mental health crisis more effectively without the courts. It's less coercive, more voluntary. They could get to a hospital in less traumatic fashion," said attorney John E. Oliver in a presentation about the directive to Board case managers in May.

Oliver is part of a research project led by Richard Bonnie at UVA Law School and Dr. Jeffrey Swanson at Duke University Medical School, which has found that the use of advance health care directives by people with serious mental illness leads to more engagement with treatment and a 50 percent reduction in psychiatric crises and hospitalizations. Oliver advised that "none of us is immune from future dementia," and an advance directive allows for necessary mental health care without subjecting the individual and family to the traumas of the involuntary commitment process.

If there's a Ulysses clause and an agent, then patients can start on a treatment plan instead of being held for a hearing on emergency medications, Oliver explained. "It's not a panacea but it can be very valuable." He recommended that individuals appoint an agent and a successor agent and give copies of the document to trusted family members, case workers, and also carry a wallet card. The Community Services Board scans the document into its electronic medical records system so it's readily accessible in an emergency.

Like attorney Andy Nea of Williams Mullen, who guides seniors in completing advance directives, Oliver also recommended using a broad approach and allowing a trusted agent to make the detailed decisions — such as which visitors to allow — as any changes require revoking and re-doing the document. By naming an agent, it avoids the possibility of having a guardian appointed by the court, which can lead to a loss of fundamental rights, he said. "It's a tool effective in keeping people out of involuntary commitments. It's part of empowerment, it's part of recovery," Oliver said.

Finding the right agent to take on the responsibility can be an issue for those with limited family, according to Hysick, who said most choose a parent. Though the chosen agent does not have to sign the directive, she makes sure that her clients notify their agent to avoid any surprises.

Both Hysick and DeHaven are spreading the word about the directive as part of wellness planning and an increased emphasis on involving patients in their own care. "They don't want to think that something might happen to them. That's what's hard for them. Also they're afraid that an agent will automatically control what they do," said Hysick. She explains that that's not so, that it doesn't take effect until an individual is deemed incompetent, and it's a team effort involving physicians, the patient and their agent. "It's really inspiring. They're being really proactive in their care," she said.

The series

Part One: Advance medical planning is for everyone

Part Two: Advance mental health directives promise better psychiatric care during crises

Part Three: Detailed advance planning for the final year of life allows patients to direct treatment

Part Four: Health columnist finds out what's involved in filling out and registering an advance directive