Decision-making and mental processes: Assessing capacity in borderline personality disorder

1. Decision-making and mental processes: Assessing capacity in borderline personality disorder Taj Nathan

2. Mental Capacity Act 2005 • 2.–(1) For the purposes of this Act, a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of impairment of, or disturbance in the functioning of, the mind or brain • 3.–(1) For the purposes of section 2, a person is unable to make a decision for himself if he is unable- • to understand the information relevant to the decision • to retain that information • to use or weigh that information as part of the process of decision making the decision, or • to communicate his decision

3. Capacity test and mental machinery to understand the information relevant to the decision to retain that information to use or weigh that information as part of the process of making the decision, or to communicate his decision

4. Capacity test and mental machinery to understand the information relevant to the decision to retain that information to use or weigh that information as part of the process of making the decision, or to communicate his decision

5. Classical - v - neurobiologically-informed model Science: Schrödinger's cat explained with neutrinos: Physicists show quantum weirdness of neutrinos over longest distance yet. By Katyanna Quach 20 Jul 2016

6. Capacity to decide to stay within an abusive relationship • Information relevant to the decision: • Understand? • Retain? • Communicate decision? • Use that information as part of process of making the decision? • Can think about both remaining and leaving relationship • Accepts that may violence recur • Accepts that others may believe it is an unwise decision • Understands there is a potential risk to self and to child • But more optimistic about change

7. Borderline personality disorder • A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: • Frantic efforts to avoid real or imagined abandonment. • A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation. • Identity disturbance: markedly and persistently unstable self-image or sense of self. • Impulsivity in at least two areas that are potentially self damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). • Recurrent suicidal behaviour, gestures, or threats, or self mutilating behaviour. • Affective instability due to marked reactivity of mood. • Chronic feelings of emptiness. • Inappropriate, intense anger or difficulty controlling anger. • Transient, stress-related paranoid ideation or severe dissociative symptoms.

8. Domestic violence and family proceedings • Partner relationship versus mother-child bond • Pattern of remaining within, or returning to, a domestically abusive relationship • Even following capacitous acceptance of adverse consequences • Even when ‘threatened’ with child being removed

9. Decision-making (prioritisation) • Prioritisation of own needs over the child’s needs • Model of understanding decision-making • Decision-making involves cost-benefits analysis • Choices are the outcome of rational processes • Rational = based on or in accordance with reason or logic • Use relevant information as part of process of making the decision?

10. The trolley dilemma New York Times: Philippa Foot, Renowned Philosopher, Dies at 90

11. System 1 and System 2

12. 2 + 2

13. 27 x 13

14. System 1 and System 2 • Implicit • Associative • Spontaneous • Automatic • Fast • Low effort • Explicit • Serial • Controlled • Slow • Effortful

15. Availability heuristic “A mental shortcut that relies on immediate examples that come to a given person's mind when evaluating a specific topic, concept, method or decision.” “The availability heuristic operates on the notion that if something can be recalled, it must be important, or at least more important than alternative solutions which are not as readily recalled.” “Subsequently, under the availability heuristic, people tend to heavily weigh their judgments toward more recent information, making new opinions biased toward that latest news” Wikipedia

16. Annual Reviews

17. Annual Reviews

18. Domestic abusive – model of understanding • Purely cost-benefit model does not describe real world decision-making • For all of us, but more so if disordered dynamics • Needs (e.g. peer/partner relatedness; parental) • Cognitive / emotional • Model for domestic abuse and childcare • Competing/conflicting needs • Peer/partner relatedness, connectivity • Child nurturing, protecting etc

19. Domestic violence • Why remain in, or return to, the source of abuse • Explanations for decisions • Self-reinforcing rationalisations • Involve distortions • Why?

20. Domestic abuse (dynamics) • Control • Dominance • Threat • Harm • Expectation of change • Forgetting history

21. Domestic abuse (dynamics) (victim position) • Control – being controlled • Dominance – being subservient • Threat – being threatened • Harm – being harmed • Expectation of change – accepting claims of change • Forgetting history – forgetting what has happened before

22. Domestic abuse (dynamics) • Effect of previous experiences of • being controlled • being subservient • being threatened • being harmed • accepting claims of change • forgetting what has happened before

23. Powerful effects of previous experiences • Developmental period • Repeated threat • Adaptation to • improve preparedness • reduce the impact • make sense (seek meaning) • Representations of world, self and others • ‘Internal working models’

24. Adaptive recalibration • improve preparedness expect threat reduce impact dissociate make sense feeling of blameworthiness • Dyadic resonance/fit • Susceptibility to hold contradictory positions ‘simultaneously’

25. Contradictory positions Integration of complexity of self and others v Distinct unrelated components and self and others • Role of relationships (esp in childhood) • Role of affect

26. Capacity to decide to stay within an abusive relationship Decision and rationalisations • Influenced by distorted emotionally based processes • Shaped by earlier adversity • Feelings of blameworthiness • Reduced sense of dissonance with dominance/subservient dynamic • Impaired emotionally based representation of others and self • Dissociation of thoughts and feelings • Autobiographical memory problems • Underpin borderline personality traits

27. Questions • Assessing decision-making or assessing rationalisation of decision-making? • Assessing emotional/implicit processes using explicit approach? • Assessing dichotomous constructs in a dimensional world?

28. Thank you