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13 September 2023

A systematic review of the reasons behind self-binding directives

New research from the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) at King’s College London and Ruhr-Universität Bochum has explored the pros and cons of the use of Self-Binding Directives in psychiatric care.

Stethoscope on a notebook

Self-Binding Directives are a form of Advance Decision-Making document that include a clause enabling mental health service users to provide advance requests for involuntary hospital admission and treatment in the event that they become unwell in the future. Advocates for their use suggest that they give service users more say over the type of care they receive while well enough to do so, while others suggest that their use is controversial as it provides a clinician the ability to override a person’s present expressed wishes around treatment refusal on the grounds that they do not have the proper capacity to make that call.

Researchers in this study, published in Lancet Psychiatry, examined 50 eligible papers that had explored the use of Self-Binding Directives.

They found that more than three quarters (76%) of the papers examined argued for their use on the basis that they helped to promote service user autonomy by giving priority to the decisions made by a service user while they are well, while 48% of the articles suggested that Self-Binding Directives can promote wellbeing and reduce harm by personalising crisis care.

“Of the papers that we researched, service user empowerment was the most commonly used argument for their use, but the arguments were much more wide ranging. Many also focused on the topic of coercion, either saying the Directives made it easier to justify and thereby making coerced treatment less ethically problematic, or lessened the impact of coercion altogether by providing clinicians with alternatives.”

Dr Lucy Stephenson, a Clinical research associate at King’s IoPPN and the study’s lead author

Dr Lucy Stephenson, a Clinical research associate at King’s IoPPN and the study’s lead author said, “Experiencing a mental health crisis can be a terrifying experience, and service users may experience inpatient admission and treatment against their will. Self-Binding Directives are designed to make the process more egalitarian, by placing power back into the hands of the service user to have more say over when and how involuntary treatment is used. They might, for example expressly state that they would like to be admitted at an earlier stage to prevent harms during an episode of illness escalating. The point of a Self-Binding Directives is that they can make this kind of request while anticipating that at the time the admission is required they are likely to refuse it.’

While the papers reviewed largely provided supportive arguments for the use of Self-Binding Directives, researchers did find evidence of concerns. The most commonly cited of these (52% of papers) suggest that, rather than promote autonomy, they actually do the opposite. Some papers argue that service users are exposed to poor/unnecessary treatment due to a poorly implemented Directives, while others suggest that certain service users might feel under pressure to commit to involuntary treatment because of pressure from others or internalised stigma.

Outside of this, researchers also highlighted that many papers (42%) suggest that actually creating and implementing a Self-Binding Directives is difficult due to the complexity of the process, and is therefore unmanageable. A further commonly held concern was issues around the assessment of mental capacity, with critics suggesting that there is no guarantee that someone is well when writing the Directive, or that they may be wrongly judged as not having capacity when in hospital.

Dr Matthé Scholten, the study’s senior author from Ruhr University Bochum said, “while this literature review indicates that the implementation of self-binding directives will likely not only have benefits but also carry risks, our further research with stakeholders suggests that these risks can be addressed by implementing suitable safeguards and support mechanisms. Professionals could, for example, develop templates and information material, provide support during the drafting process, involve family members or other persons of trust in the process, and develop a technical infrastructure to ensure that the self-binding directive is stored securely and accessible in a crisis.”

Researchers suggest that future pilot implementation projects that operationalise the clarified definition of capacity-sensitive Self-Binding Directives with safeguards around informed consent, capacity assessment, support for drafting, and independent review are required.


Self-binding directives in psychiatric practice: a systematic review of reasons (DOI10.1016/S2215-0366) (Lucy Stephenson, Astrid Gieselmann, Tania Gergel, Gareth Owen, Jakov Gather, Matthé Scholten) was published in Lancet Psychiatry.


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In this story

Gareth  Owen

Professor of Psychological Medicine, Ethics and Law

Lucy Stephenson

Clinical research associate