Hargrave v. Vermont and the Quality of Care

To the Editor: Paul S. Appelbaum's column (1) on psychiatric advance directives in the July issue of Psychiatric Services suggests that the sky is falling in the wake of the U.S. Court of Appeals decision in the Hargrave v. Vermont case. The court's modest conclusion—that Vermont cannot discriminate against people with psychiatric disabilities when it comes to expressing binding preferences for their treatment should they become incapable of making such decisions in the future—merely extends coverage of the Americans With Disabilities Act to an area that has been the exclusive domain of psychiatrists.

That Dr. Appelbaum finds the Hargrave decision so potentially cataclysmic says more about the profession of psychiatry and its uneasiness about consumer input than anything else. Change can be unsettling, but, as last year's report of the President's New Freedom Commission on Mental Health reminds us, transforming the existing mental health system depends on adopting a new vision of recovery in which a partnership of personalized care is central.

The commission's final report (2) states: "This partnership of personalized care means basically choosing who, what, and how appropriate health care will be provided…sharing in decision making, and having the option to agree or disagree with the treatment plan."

Far from being the end of high-quality public mental health care, the Hargrave decision may be a fresh beginning. When mental health professionals can no longer automatically override a consumer's wishes—especially with respect to psychotropic medications—they may have to resort to other tools, such as trust building, peer support, talk therapy, and other naturalistic supports that have been shown, by the late Loren Mosher and others (3), to be successful in helping people with psychiatric disabilities achieve long-term recovery and greater satisfaction with their quality of life.

As always, the Bazelon Center stands ready to help realize this new vision for public mental health in which the goal of high-quality outcomes and respect for consumer choice guide treatment decisions to promote recovery.