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What is a therapeutic mental capacity assessment?

Mental capacity assessments are often described as a tool for identifying whether someone can make a particular decision. In England and Wales, the Mental Capacity Act 2005 supplies a legal framework, but applying it well also requires attention to the person’s experience of the assessment.

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But the test isn't a tool; no test is, not when it's applied correctly by a skilled practitioner.

Shift in Approach

Editorial correction, 18 October 2026: the Mental Capacity (Amendment) Act 2019 concerned deprivation-of-liberty arrangements; it did not introduce a new general capacity test or move the MCA from a diagnostic to a functional test. The decision-specific functional question and its causal connection to an impairment or disturbance must both be addressed. The reflective argument below is about how assessment is conducted, rather than a change made to that test in 2019.

Pre-COVID, the rhetoric around mental capacity assessments was that they were a "clinical assessment" and needed to be as they were evidence-based and forensic in nature.

Assessment vs. Report

Language matters here. I distinguish the process of assessing someone from the report that records the evidence and reasoning.

The assessment is the process of gathering and evaluating evidence about the person’s ability to make the relevant decision, with the support they need.

The report records the question, evidence, methods, support, reasoning, conclusion and any limitations.

A report for court needs careful evidence and reasoning and must meet the applicable procedural requirements. Other reports should be proportionate to their purpose. Clarity does not require an inaccessible academic tone, and a supportive assessment can still produce evidence that is open to scrutiny.

The Therapeutic Approach

My argument is that the assessment process should be humanistic and strengths-based, while the report remains independent, evidence-led and clear. “Therapeutic” describes that approach here; it is not a different legal test or a guaranteed treatment benefit.

A rigid or pressured interview may be stressful and can make it harder for the person to participate. The assessor should consider how the environment, communication and emotional response affect the evidence, without assuming that distress proves incapacity.

Best Practice Approach

But if we apply a therapeutic nature to an assessment, then the test becomes a tool that can empower, strengthen and support P. In social work, there is an approach referred to as "the best practice approach." Essentially, this approach explains that the process is more important than the outcome; after all, the outcome will be what it is, how we as practitioners manage the assessment process, though it can have profound impacts on P.

Tailoring the Therapeutic Approach

This approach needs to be tailored to the individual. Communication skills, relevant professional knowledge and reflection can help the assessor choose how to engage, recognise distress and explain the process. No approach can ensure that every assessment feels positive for every person.

Case Example 1

A case example of the importance of a therapeutic assessment is when P was creating a will; P had two sons, and her husband had passed, and P was diagnosed with advanced dementia.

An initial assessment was completed by a GP at their office; the GP asked questions specifically related to Banks Vs Goodfellow (1870) and completed a mini-mental state examination, with an outcome that P didn't meet the criteria. P was stressed by the interview and became tearful; her son, who had been in the room at the time, was frustrated and angry at why his mum had been asked who the prime minister was and what this had to do with her writing a will.

P's son requested a second opinion, this time with the practitioner taking a therapeutic approach to the assessment. Firstly the most suitable environment for P was identified (her home) and the time (morning rather than afternoon), date and time were set, and the practitioner advised the son to remind mum of the assessment and its reason, and the practitioner's name prior to the assessment, the practitioner gained additional knowledge around P's likes and dislikes, her cultural and religious needs and built up a picture of P to allow for a better engagement.

At the assessment itself, P and both sons were present; initially, the practitioner could see that both sons were frustrated from the outset and that they would not get the outcome they wanted (for P to have capacity).

Drawing on educational and counselling approaches, the practitioner explained to P and her sons the purpose of the assessment, the relevant testamentary capacity test and the reason for any cognitive screening. A cognitive score can inform the evidence but does not, by itself, determine whether a person can make a will.

Reflective discussion and open questions were used to explore the relevant information and make the conversation less pressured. The reported conclusion was the same: P lacked capacity to make the proposed will. Her sons were better able to understand that conclusion. It did not determine P’s capacity for every other decision or give them authority to make a will for her; any statutory will would require the appropriate Court of Protection process.

In this account, the value of the approach was in how the family understood the evidence and the person’s support needs, rather than in securing a different capacity outcome.

Case Example 2

A further example of how a therapeutic assessment can be beneficial is in the case of a lady living with addiction disease. P was a care home resident, nonverbal and non-mobile, fully supported by her care team. An initial assessment was completed for lasting power of attorney for health and welfare, with the outcome being that P lacked the capacity for this specific decision. The assessment was completed in P's room at the care home with no other people present.

The care home manager complained that the assessment was untrue and that P "had full capacity to make all her own decisions".

A second opinion was sought, and the practitioner organised for the assessment to be completed at the right time for the client and to ensure her support staff and the care manager were present to ensure that communication was better supported.

At the outset of the assessment, the relevant information was given to all present at the assessment and a description of the test; the practitioner then engaged directly with P. Potential attorneys were identified as family members; instead of interviewing P, the practitioner discussed family, who they were, where they lived and P's connection to them. P was unable to provide evidence of any understanding of her relationship with the prospective attorneys. The practitioner simplified the conversation to support P in her decision-making and discussed her parents; again, P was unable to provide evidence of their relationship. At this point, the care manager stepped in and asked for the assessment to be halted, as she felt it unnecessary.

The care home manager explained, "We got it wrong; I didn't realise how poor her capacity had become. I think we have been allowing her to make decisions she doesn't have the capacity to make, and we should have been making decisions in her best interest. She's gone without things because she's declined them, but I don't think she understood properly."

The account reports that the second assessment helped the care team reflect on P’s support and led to increased care. The manager’s comments above are retained as part of that history, not as a general conclusion about P’s capacity. Lack of capacity to make a health and welfare LPA does not establish lack of capacity for every care decision; each question and any resulting authority must be considered separately.

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