As psychiatrists, we are practicing in an era of significant legal reform in Ireland. The Assisted Decision-Making (Capacity) Act, 2015 (ADMCA), amended in 2022 and implemented in 2023, placed the functional model of capacity at the heart of health and social care practice, allowing for a tiered system of decision-making supports and legislating for advance healthcare directives (AHDs) for the first time in Ireland. The foundational principle behind the ADMCA is that a person’s own will and preferences should hold a central position in guiding their care at times when they lack capacity. The Mental Health Act, 2026 (MHA 2026), signed into law on 7^th May 2026 and heralding a new era in Irish mental health care, follows this approach. Among sweeping changes is a new focus on ‘treatment of persons lacking consent’ with increased safeguards and legal oversight. One important change is that AHDs will be fully integrated into mental health practice and fully accessible to service users detained in hospital. International evidence outlines benefits of advance care planning in terms of reducing involuntary admissions (Molyneaux et al. Reference Molyneaux, Turner, Candy, Landau, Johnson and Lloyd-Evans2019), the only intervention to do so (de Jong et al. Reference de Jong, Kamperman, Oorschot, Priebe, Bramer, van de Sande, van Gool and Mulder2016), improving therapeutic relationships (Nicaise et al. Reference Nicaise, Lorant and Dubois2013; Thornicroft et al. Reference Thornicroft, Farrelly, Szmukler, Birchwood, Waheed, Flach, Barrett, Byford, Henderson and Sutherby2013), and empowering service users (Braun et al. Reference Braun, Gaillard, Vollmann, Gather and Scholten2023). Yet advance care plans and advance directives remain little used in Ireland (Morrissey Reference Morrissey2015; O’Donoghue et al. Reference O’Donoghue, Lyne, Hill, O’Rourke, Daly and Feeney2010; Redahan et al. Reference Redahan, Rock, Grudzien and Kelly2025).

This Special Issue on ‘Advance Decision-Making, Law, and Mental Health’ presents a wide range of empirical studies and legal and ethical analyses from Irish and international authors on AHDs and other reforms in mental health and capacity law. The aim is to harness an interdisciplinary and international approach to enrich our understanding of new legislation and how it can shape mental health practice in a person-centred and rights-oriented way. Of course, these issues are not straightforward. New laws often bring controversy, and change is rarely driven by legislation alone. The Special Issue also highlights and debates thorny conceptual and practical challenges in this area.

The Issue opens with Rosy Wilson’s editorial and a collection of three of her poems. Wilson generously shares her experience as a service user and holder of an advance directive, and a long-time campaigner for change in Irish mental health services (Wilson Reference Wilson2025). She writes of her own experience making difficult decisions for her mother at the end of her life and her desire that her own children not be put in the same position. She speaks of past trauma in inpatient mental health care and her use of an AHD to express her will and preferences for care in future episodes. She also gives an account of the activism and campaigning which she and others have done over many years, work which is exhausting, deeply personal, and frequently unpaid. I want to sincerely thank Rosy for her contribution.

The Issue continues with original research on AHDs. Three Irish studies highlight current interest in this area. Redahan et al., present a survey of views of 47 inpatient psychiatry service users (a group often excluded from research studies) on AHDs (Redahan et al. Reference Redahan, Rock, Grudzien and Kelly2025). While baseline knowledge and experience of AHDs were low, over two-thirds of those surveyed expressed their interest in making an AHD if supported to do so, with interest significantly higher among younger service users. Meanwhile, Joy et al., highlight how the current Mental Health Act, 2001 (MHA 2021), excludes service users who are detained in hospital under the risk criterion, i.e. under Section 3(1)(a), from access to legally binding AHDs (Joy et al. Reference Joy, Carey and Kane2026). Studying three years of involuntary admissions to a Dublin mental health unit, they found that AHDs would be binding for 74% involuntary service users on admission and for 84% of total involuntary bed days. The authors criticise the use of detention criteria to delineate binding and non-binding AHDs, an approach which the MHA 2026 also rejects. Finally, Allen et al. present findings from a mixed methods study of views of mental health professionals in older adults’ services (Allen et al. Reference Allen, Donnelly, Morton and MurphyForthcoming). Themes include advance care planning as a response to existential anxiety in older adults, a way to give service users a voice, and a tool requiring a person-centred approach. Giving guidance to professionals looking to support implementation, Allen discusses the importance of training, timing, and relationships of trust in supporting service users to engage with advance care planning.

We then turn to learning from abroad. Two qualitative articles by Gieselmann et al., highlight the views of German mental health professionals on advance directives. The first paper examines opportunities and challenges of joint crisis plans (JCPs), a form of advance directive completed collaboratively between service users and their clinical team, already well-integrated in German mental health services (Gieselmann et al. Reference Gieselmann, Werning, Potthoff, Vollmann, Scholten and Gather2026). Professionals valued JCPs as an opportunity to strengthen the therapeutic relationship, promote self-determination, reduce coercion, provide therapeutic benefits, and shift professional attitudes. However, they highlighted difficulties including limited resources, lack of buy-in from service users and professionals, and JCPs not being regularly updated. They felt implementation could be optimised through engaging professionals and service users, developing infrastructure to facilitate writing, storage and access of JCPs, and ensuring that valid JCPs are honoured. Such lessons are highly likely to be applicable to other jurisdictions including Ireland. The second article examines professional experiences of ethical conflicts arising from advance treatment refusals (Gieselmann et al. Reference Gieselmann, Werning, Potthoff, Vollmann, Gather and Scholten2025). Participants responded to a case vignette, giving reasons why they were inclined to respect or overrule a service user’s advance directive to refuse ECT. While views on respecting autonomy and self-determination led professionals to wish to adhere to the directive, they also expressed concerns that strict adherence might harm the service user’s well-being (e.g. through prolonged hospitalisation without treatment), prevent restoration of their autonomy, or potentially put others at risk. They raised ethics consultations as a potential aid for resolution of difficult cases. However, such structures are, as of yet, under-developed in Ireland.

Desvignes et al., present a mixed methods study from France looked at the role of peer workers in facilitating psychiatric advance directives (Desvignes et al. Reference Desvignes, Harrison, Mougeot, Boucekine, Loubière, Auquier and Tinland2025). Qualitative interviews with service users highlighted how peer workers occupy a boundary role between service users and clinicians, and this role promoted trust and relational symmetry in AHD facilitation. It also emphasised special skills of peer workers in supporting service users to revisit previous traumatic experiences of care. Peer support workers may also be a helpful group to be involved in AHD facilitation in the Irish context.

Moving to the United Kingdom, Babatunde et al. present findings from the first phase of a study examining how advance choice documents (similar to AHDs) can be implemented for Black communities, a group disproportionally affected by involuntary admission (Babatunde et al. Reference Babatunde, Simpson, Gilbert, Simpson, Stephenson, Owen, Chua, Ruck Keene, Smith and Henderson2025). Their workshops with service users, carers and staff highlighted the importance of understanding lived experience, stakeholder communication, systems for accessing documents, training, and independent facilitation in implementation.

Finally, Stephenson et al.’s case, also from the UK, highlights in detail how an advance directive can work in practice for a person with bipolar disorder (Stephenson et al. Reference Stephenson, Scholten, Kane and Owen2026). This is the first published case report examining service user and staff views of an advance directive prior to, during, and following a mental health crisis which required involuntary admission (in this case, a manic relapse). Here, while the service user rejected the contents of her advance directive during her crisis, when interviewed later she was clear that she had been unwell and in an ‘altered mental state’. She then reiterated her endorsement of the directive and was pleased that some professionals had taken it seriously. Feedback from the crisis team psychiatrist included that the advance directive contained very helpful information which informed the way the team tried to work with their patient.

The Special Issue then presents psychiatric, legal, and recovery perspectives on mental health AHDs. Kelly argues that AHDs which specify advance refusals of treatment following self-harm present specific legal and ethical complexities. He raises anti-suicide legislation, the presumption toward preservation of life, the role of conscientious objection, and doubts about capacity at time of writing such AHDs. Writing on AHDs more generally, Ruck Keene lays out legal complexities and challenges associated with various stages of the AHD life cycle. Relevant to Kelly’s point, he outlines the debate in England and Wales which culminated in a policy decision that AHDs need not include capacity assessment at time of writing and highlights that English case law already exists in which an AHD without a contemporaneous capacity assessment was challenged retrospectively and overruled. Reidy and Slattery respond with close examination of these points in the Irish context. They highlight distinctive features in Irish law and key interpretive questions for future case law in Ireland, e.g., around the need for those writing AHDs to precisely specify both treatments and circumstances under which the directive be applicable. All three articles also refer to potential implementation challenges for AHDs and Norton offers one approach to implementation (Norton Reference Norton2026). Arguing that Wellness Recovery Action Planning is already embedded in Irish mental health care, he outlines the Wellness Recovery Action Planning (WRAP) crisis and post-crisis plans as a potentially effective framework and template for mental health AHDs in Ireland and beyond. Kane and Allen present a report from an implementation-oriented UCD Conference on ‘Advance Healthcare Directives in Mental Health – from Law to Practice’ (Kane and Allen Reference Kane and Allen2025). Themes from the day included the importance of support, the value of lived experience, trust and the therapeutic relationship, and mental health complexity.

Beyond AHDs, the Special Issue also explores other topics related to mental health and capacity law reform. Anticipating the new Mental Health Act, O’Mahony et al. present a retrospective cohort study of clinical features of individuals admitted involuntarily to Galway University Hospital over a ten-year period (O’Mahony et al. Reference O’Mahony, Aylward, Cevikel, Hallahan and McDonald2025). They found that those admitted under the ‘risk criterion’ of the MHA 2001 were more likely to be subject to restrictive practices but less likely to have psychosis. They comment that it remains unclear how changes to detention criteria (with shifted emphasis on risk and treatability) in the MHA 2026 will be interpreted by clinicians in practice.

Hynes-Ryan and colleagues outline their work in co-designing information resources for those offered antipsychotic medications (Hynes-Ryan et al. Reference Hynes-Ryan, Carolan, Norton, Cussen, McWilliams, Renwick, O’Donoghue and Keating2026). Using the Double Diamond Design Thinking Model, they involved stakeholders to evaluate existing resources and to develop new antipsychotic medicines information videos to enable shared decision-making. Such work provides a good practice example of what practicable steps to support decision-making, a fundamental principle under the ADMCA, can look like in mental health practice.

Several perspective articles then consider the legal landscape in Ireland since ADMCA implementation in 2022. Doherty and Matthews write from a liaison psychiatry perspective on gaps under the current legislation and the resulting challenges in caring for people who lack capacity in acute hospitals (Doherty and Matthews Reference Doherty and Matthews2025). They criticise the current reliance on the Inherent Jurisdiction of the High Court to authorise intervention for what are frequently occurring clinical scenarios, e.g. unsafe discharges, refusals of life-saving treatment, and persons with eating disorders who require refeeding. Rafferty and McCarthy respond in support, arguing that older adults are disproportionately harmed by legislative gaps, especially in the context of cognitive impairment and social isolation (Rafferty and McCarthy Reference Rafferty and McCarthy2026). They advocate for early integration of advance care planning to help guide clinicians. Meanwhile, O’Keeffe considers co-decision-making under the ADMCA, a relatively novel category of supported decision-making that aims to empower those with partial capacity for particular decisions (O’Keeffe Reference O’Keeffe2025). He discusses decision-making capacity as a continuum rather than a binary, with the co-decision-making model giving people ‘credit’ for the abilities they retain. However, he acknowledges challenges in practice, for example, in identifying which form of support under the ADMCA is most appropriate for an individual and in ensuring that administrative mechanisms can keep pace with a person’s evolving support needs.

As a helpful comparative, Lynch and colleagues outline progress toward implementation of the Northern Ireland Mental Capacity Act, an ambitious statute that aims to fully replace mental health legislation and to reduce discrimination between medical and psychiatric patients (Lynch et al. Reference Lynch, Hann and Flynn2025). The authors discuss opportunities and potential challenges of the new Act and identify the need for culture change and adequate resourcing before full implementation can be realised; a point likely to be relevant to Ireland’s MHA 2026 too.

Further perspective articles delve into conceptual challenges in mental health and capacity law. McDonald discusses various uses of the term ‘insight’, ranging from a more biological ‘anosognosia’ associated with psychotic illness to psychological defence mechanisms of denial (McDonald Reference McDonald2025). He presents evidence linking lack of insight to treatment incapacity. He then considers how identifying the will of service users with persistent lack of insight on illness remission presents challenges, which are also relevant for clinicians enacting AHDs under the new legislation. Broderick explores the ability of the capacity concept to capture emotional aspects of decision-making (Broderick Reference Broderick2026). Examining neuropsychological evidence, she discusses how capacity can at times be impaired in individuals with emotionally unstable personality disorder or frontal lobe damage through overwhelming or insufficient emotional states. She argues that current models of capacity assessment can accommodate emotion but may require special attention to values and motivational factors and tailored approaches to decision-making support.

Wicks discusses the role of mental health and capacity legislation in suicide prevention (Wicks Reference Wicks2026). She considers suicide risk associated with mental illnesses (e.g. schizophrenia and mood disorders) for which involuntary treatment under mental health legislation constitutes a form of suicide prevention, while acknowledging that treatability must come into play especially for prolonged detentions. Other cases, she argues, may represent a ‘rational choice to die’ and capacity assessment should seek to identify these through focusing on the continuity of a person’s values and choices over time, something she acknowledges may not be easy in practice.

Finally, Dunne and colleagues present a nuanced discussion of ethical issues in treatment of anorexia nervosa in adults and children (Dunne et al. Reference Dunne, Malone, Öğütlü and McNicholas2026). They highlight complexity relevant to multiple ethical principles: respecting autonomy can be complicated by impaired capacity and difficulty in establishing a patient’s authentic wishes; ensuring beneficence can be challenging when treatment outcomes are uncertain for individual patients; upholding non-maleficence raises questions about the role of harm reduction and palliative care approaches; and, finally, considering justice requires appreciation of the current ‘postcode lottery’ in provision of care for eating disorders in Ireland.

In totality, these articles present a compelling case that true reform requires as much attention to real world implementation as it does to legislative change. Without adequate resourcing and stakeholder input, mental health practice and culture are unlikely to shift. The Special Issue evidences the interest from clinicians, academics, and service users in Ireland and beyond in improving care and treatment of those suffering with mental health conditions. Let us hope that the majority of us can see the current changes as an opportunity to do so.