What do we mean by ‘selection pressure’? Doesn’t evolution just happen anyway?
When assessing an individual’s mental capacity it is important that we confine ourselves to assessing that person’s ability to make this particular decision (or type of decision) at this time. This is what the Act means when it refers to ‘time and decision specific’ assessment.
At first glance this seems obvious and clearly reasonable. However on closer inspection it brings up a number of issues relating to ‘established practice’ that need to change. It also provides many workers from support workers to nurses, social workers and many others with a very real source of anxiety. Here’s why.
In the past capacity decisions tended to be made by certain professionals such as psychogeriatricians or psychologists. One typical approach would be to ask a doctor to come and assess a service-user’s capacity, not in relation to a specific issue but ‘globally’. This would be done using one of several techniques, the most common in UK being the Mini Mental State Examination (MMSE).
The MMSE is a reasonable tool to assess cognitive deficit and is helpful in diagnosing certain conditions such as dementia but it is not an assessment of capacity. Diagnosis is not the same as capacity. The fact that a person has a particular diagnosis does not tell us anything about their capacity to make particular decisions. The MMSE is not decision specific unless the care and treatment being offered relates to the service-user’s ability to count backwards from 100 in 7s or to name the current Prime Minister.
The MMSE does not inquire into preferences of diet, whether or not a person understand how to cross a road safely or what time they would like to go to bed. These are the sorts of questions that must actually be assessed on a day to day basis when we are making decisions about a person’s capacity.
The other major problem with ‘global’ assessments of capacity (apart from the fact that they do not asses capacity in the first place) is that they are not time specific. A psychogeriatrician’s assessment at the start of the month will have little bearing upon the service-user’s day to day decision-making capacity at the end of the month. So unless we can persuade the Dr to visit each service-user every mealtime to assess their capacity to choose between carrots and peas we have to use a different system.
Fortunately the Mental Capacity Act provides us with just such a system and, although unfamiliar to many it is very straightforward and in fact reflects what we’ve all been doing since early childhood anyway. You see assessing capacity is not difficult in itself so long as you understand it – and also understand what we are NOT expected to assess just as clearly as what we are expected to assess.
The Mental Capacity Act is clear….
“The decision maker is the person delivering the care or treatment”
This means that the support worker who decides that Albert needs a bath is responsible for assessing whether or not Albert has the capacity to consent to that bath. If he or she decides that Albert does not have the capacity to consent to that bath then the support worker is also responsible for deciding whether or not the bath would be in Albert’s best interests.
This may seem unfamiliar when it’s written down like that but actually that is precisely what has happened day in and day out in practice for decades in health and social care settings. Nobody calls the GP every time they think a resident in a care home might need their hair washed – they just decide. What the Mental Capacity Act does for us is it provides us with a way to show that our decisions make sense and gives us the legal backing to be free from prosecution for assault so long as we can justify our actions.
Part 5 of the Mental Capacity Act is subtitled ‘Protection from liability’ and deals with just this issue, ensuring that care workers can do what is necessary so long as they can show that the individual lacked capacity and that their actions were both proportionate and in their best interests. This is very empowering for care workers because it allows them the respect they deserve in making day to day decisions and provides them with legal protection at the same time.
Caring for people with psychosis can be both stressful and mystifying. People who hear voices and respond to visions that the carer can neither hear nor see present particular problems and frustrations. It’s distressing for the individual voice-hearer and, for different reasons it’s distressing for their relatives and other carers as well.
“It’s real for them” is a common expression intended to promote empathy and understanding but there are very real drawbacks if that’s as far as it goes. We all know it’s real for them – that’s why they’re distressed, but if we simply accept that without question we give up a vital part of the recovery process.
In this video we explore the positive benefits that can come from refusing to accept that ‘it’s real for them’ whilst still accepting the other person’s experience. We look at the power of attribution in psychosis, especially in relation to hallucinations and consider the benefits of helping people to change their view about their hallucinations. It isn’t trivialising the problem to see it for what it is. A voice has no power unless the voice-hearer gives it some. However distressing and disturbing voices are they’re still only voices.
By helping people to reframe their interpretation of voices they hear we can reduce the power, the distress and the disruption of those voices.
Please feel free to comment either here on the blog or by using the contact form below and let me know how helpful or otherwise this video has been for you. Please also let me know if you’d like me to cover any other issues facing carers and relatives. I can’t promise to cover everything but I’ll do my best to help if I can.
Those of us who work in mental health services, be that for the NHS or in social care settings receive both payment and training for our efforts. However, there’s an army of unpaid, informal mental health carers who receive neither, despite the fact that without their contributions the whole system would collapse.
It’s estimated that informal carers save the NHS more than it actually spends each year and that situation doesn’t look like it’s going to get better any time soon.
The ‘Carers in mind’ project is my attempt to help redress the balance by providing information and training in practical ways for carers struggling everyday to hold their families together, often in truly desperate circumstances.
If you’re a carer involved in mental health please feel free to comment and let me know what you’d like me to cover. I can’t promise to fulfil every request but I’ll do my best.
Please leave a comment to let me know what you’d like me to cover as this series progresses or use the contact form below to get in touch privately.
The third in the ‘big 3’ trilogy of psychotic symptoms is, for many people, the most difficult to understand. Unlike delusions which are all about ‘what’ we think, thought disorders are about ‘how’ we think. It is thought process, not thought content.
There are two main ways to identify thought disorders. Both rely upon the way that we represent thought symbolically to others. They are language, either written or spoken, and imagery. Let me explain what I mean by this…
To arrange training for your social care or mental health staff please complete the contact form below…
Over the last few weeks I’ve been experimenting with video presentations. I know I’ve a lot to learn (although I think I’m improving) but I really need honest feedback.
Please have a look and let me know how I can improve my efforts.
I’ve been getting a lot of new inquiries lately, which is wonderful. It seems that training budgets are becoming available to the small specialist trainers again without organisations having to rely upon the off-the-shelf generalists on their ‘pre-approved supplier lists’. There are many courses that only a specialist clinician can provide. Click below to download the Mind The Care brochure…
That’s great news for the little man like me. It means I can get to more organisations and train more staff from the perspective of the expert practitioner. Learning from someone who actually does the job is always better than listening to a training executive with a script.
So I thought I’d put a little post up for those organisations who haven’t experienced my training yet (and it is an experience), outlining my most popular courses and seminar topics and inviting them to get make contact. Just click here and I’ll be in touch to design the exact training or speaking programme you need to help you look after and get the best out of your care team.
Click here 170429 Mind The Care brochure to download Mind the care’s most recent brochure.
I used to think that mental health care would be really complicated. So I looked for complicated theories to underpin everything I did. For many years I studied and tried hard to negotiate my way through the complex world of mental disorder. And because I looked for complicated answers, complicated answers were all I found. That was a great mistake.
The more I studied, the more I realised that good quality mental health care doesn’t need to be complicated. It may not always be easy to deliver but that doesn’t mean it should be hard to understand. Often the simplest solutons are the most effective.
Eventually I realised that there are some straightforward, basic principles that we need to follow. Everything else flows from there. These are the simple ideas that make the difference between good care and bad, between illness and recovery.
If only someone had distilled those principles for me when I first began. My early career would have been so much easier and more effective. But nobody did that in those days. That’s a great shame.
So I’ve done it myself. I’ve boiled down the basic ideas into usable, teachable concepts that every care worker can quickly understand and apply. These are the fundamental principles that underpin every Mind The Care Training course and seminar. Subscribe to this page and come back often to find out more.