Clinician impact on consumer decisions regarding psychiatric advance directives

This dissertation examines associations between clinician attitudes both towards Psychiatric Advance Directives (PADs) and towards coercive intervention with consumers' decisions regarding PADs. In addition, it examines associations between characteristics of clinician/consumer relationships and consumers' PAD decisions. The research is grounded in the Health Beliefs model expanded to include the theory of relational autonomy. A secondary analysis of data from a randomized trial of Facilitated PADs (N=469) was completed. Multilevel logistic regression analyses examined whether clinician characteristics and attitudes were significant predictors of PAD completion by consumers and whether consumers valued PADs more highly for proscriptive purposes. Multivariate logistic regression analyses examined whether characteristics of the clinician/consumer relationship were significant predictors of these same dependent variables. Results showed that neither dependent variable was significantly associated with clinician characteristics and attitudes. PAD completion was significantly more likely if consumers were older, demonstrated greater PAD understanding, valued treatment for relational purposes, and reported having a friend; it was significantly less likely if consumers reported medication satisfaction, victimization, or if consumer and clinician were discordant on PAD attitudes. Valuing PADs as a proscriptive tool was significantly more likely if consumers were white, had experienced involuntary hospitalization, reported treatment dissatisfaction, or reported having no one to trust, and showed a trend towards significance if the consumer reported avoiding treatment for fear of forced treatment; it was significantly less likely if consumers reported not knowing enough about PADs, reported avoiding treatment for fear of being put in seclusion, agreed that consumers should talk with their provider about PADs, and if neither consumers nor their clinicians agreed that people should have a PAD to protect them from hospitalization. Findings suggest that consumers make decisions regarding PAD completion and purpose based on: 1) prior experiences with treatment; 2) perceptions regarding treatment benefits/barriers; 3) understanding of PADs; and 4) the relational context in which they make decisions. Due to the exploratory nature of the study and limitations of a secondary data analysis additional research is needed to understand the dynamics of these factors in greater detail