Communication and Capacity

1. Communication and Capacity Sandy McAfee Consultant Clinical Psychologist St John’s Hospital Livingston sandy.mcafee@wlt.scot.nhs.uk

2. Turn to the Person next to you… • Think of an important decision you made recently • Explain to the person next to you: • what your rationale was • what the pros and cons were • what the implications of your decision was for yourself and other people • how could someone else tell if you had the mental capacity to make that decision?

3. The Adults with Incapacity (Scotland) Act 2000 • The Act defines ‘incapable’ as • incapable of acting • making decisions • communicating decisions • understanding decisions • or retaining memory of the decisions

4. The Adults with Incapacity (Scotland) Act 2000 • Capacity is decision specific – if incapable of making one decision it does not follow that a person must be incapable of making other decisions • Therefore decisions about capacity are based on judgements about cognitive functions in relation to specific questions

5. The Adults with Incapacity (Scotland) Act 2000 • The Act does not define how incapacity should be assessed • Recognises there are no formal assessments of capacity • Stipulates that the assessment should be carried out by a medically qualified practitioner • S/he can draw on the expertise of others

6. The Adults with Incapacity (Scotland) Act 2000 • The Act states that the doctor who is carrying out the assessment should make every effort to ensure that communication and understanding are optimised • No specific methodology advanced for this however

7. Some Assessment Issues • Do we have valid and reliable measures, appropriate to specific client groups and for specific capacity questions? • Sensitivity and specificity: • want to have high sensitivity (correctly identifies those who have capacity) • specificity may be less important (correctly identifies those who do not have capacity) • but always balancing civil liberty against risk • Is neuropsychological assessment the most appropriate methodology?

8. Some Assessment Issues • Hands up if you would like £50 • I haven’t said what you’ve got to do for it yet!

9. Some Assessment Issues • Understanding the difference between cognitive biases (e.g. do you want to live in your own home? => “YES”) and ‘capacity driven’ choice • Understanding the role of social psychological issues during the assessment process, e.g. ageism, peer pressure, leading questions, halo effect

10. Some Assessment Issues • Ecological validity of any tests we use – i.e. does a language test such as verbal fluency have any real world validity in relation to the question being asked, such as “Do you want to spend your money taking your brother’s family to Greece on holiday with you?”

11. Some Assessment Issues • Need to design personalised assessments to take account of the individuals particular abilities and the specific capacity question to be answered • Differentiating impairment from incapacity • People with physical impairment (e.g. cerebral palsy) can appear cognitively impaired

12. Assessment needs to answer the following questions… • Can the client understand the capacity issue in question e.g. “Do you consent to have sex with Bob” • Can the client demonstrate that they have understood the issue in question? • is nodding the head sufficient? • is a spoken “yes” or “no” sufficient?

13. Assessment needs to answer the following questions… • Can the client make a decision regarding the issue in question? • Can the client communicate this decision? • Does the client understand the decision? • Can he/she give a rationale for it? • Understand the pros and cons? • Understand the implications? • Remember, people are allowed to make bad decisions in their own lives

14. Effect of Interpersonal Environment on Cognition “It is now becoming clear that virtually all the losses and difficulties of later life are socially constructed: that is, they are a consequence not of the ageing process in itself, but also of the norms and collective arrangements that are taken for granted as applying to old age.” Kitwood, T. (1989). Brain, mind and dementia: with particular reference to Alzheimer’s Disease. Ageing and Society. Vol. 9. pp. 1-15.

15. Concept of ‘Excess Disability’ “The discrepancy that exists when a person’s functional incapacity is greater than that warranted by the actual impairment” Brady (1971) quoted in Sabat, S.R. (1994). Excess disability and malignant social psychology: a case study of Alzheimer’s Disease. Journal of Community and Applied Social Psychology. Vol. 4. pp. 157-166.

16. Communication is a 2 way process… • There are ways of enhancing communication… • There are ways of shutting it down… • Sometimes our own stuff can get in the way… • e.g. fear of making the wrong judgement – erring on the side of caution • e.g. our own values, previous experiences, received wisdom

17. “Make every effort to ensure that communication and understanding are optimised” • Communication skills of assessor • clear explanations • willingness to take the time to explain • willingness to take the time to listen for response • repetition if necessary • using simpler language if necessary • using written explanations • providing for written responses

18. Environmental and Social Issues • Take the time to get to know the client • Choose an environment that promotes good communication • Perhaps the client would like someone else they trust or feel at ease with to be present • Check for sensory deficits! • Check your interpersonal distance (cf Michael Argyle)

19. Reliability Issues • When making your decision regarding the client’s capacity… • Remember to comment on the reliability of your assessment • Comment on any factors which could have detracted from reliability, e.g. environmental noise, sensory deficits, client’s motivation to participate in the assessment, other untreated medical or psychiatric conditions, reliability and validity of assessment tools

20. Reliability Issues • Test – Retest reliability • Is a one-off assessment sufficient? • Re-testing has several benefits in the context of capacity assessment: • Allows to test for memory of decision • Allows to test for consistency of decision • Allows to test for consistency of rationale/ understanding