Transcript Communication and Capacity

Communication and
Capacity
Sandy McAfee
Consultant Clinical Psychologist
St John’s Hospital
Livingston
[email protected]
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?
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The Adults with Incapacity
(Scotland) Act 2000
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The Act defines ‘incapable’ as
incapable of acting
 making decisions
 communicating decisions
 understanding decisions
 or retaining memory of the decisions

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

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

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
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Some Assessment Issues
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Do we have valid and reliable measures,
appropriate to specific client groups and for
specific capacity questions?
Sensitivity and specificity:
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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?
Some Assessment Issues

Hands up if you would like £50

I haven’t said what you’ve got to do for it
yet!
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
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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?”
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
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People with physical impairment (e.g. cerebral
palsy) can appear cognitively impaired
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?
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is nodding the head sufficient?
 is a spoken “yes” or “no” sufficient?
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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?
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Remember, people are allowed to make
bad decisions in their own lives
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.
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.
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…
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e.g. fear of making the wrong judgement –
erring on the side of caution
 e.g. our own values, previous experiences,
received wisdom
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“Make every effort to ensure that communication
and understanding are optimised”
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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
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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)
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Reliability Issues
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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
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Reliability Issues
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Test – Retest reliability
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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
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