Mental Capacity assessments are often seen as a tool, a way of identifying if someone does or does not have the prerequisite cognitive ability to make a specific decision, and that is what the Mental Capacity Act (2005) tells us it is for, which it would its a piece of legislation, which is a tool telling us how to apply another tool.
But the test isn't a tool; no test is, not when it's applied correctly by a skilled practitioner.
Shift in Approach
The changes brought about by the Mental Capacity Amendment Bill (2019) saw a fundamental shift from a medical model or pathological approach to the test in the MCA to a more person-centred approach, with the focus being put on the functional test over the diagnostic test.
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 is important here; there is a difference between an assessment and a report. Before delving further, it's crucial to distinguish between an assessment and a report.
Assessment is defined as the act of "the action of assessing someone or something." assessing is essentially the act of sitting in someone's house and evaluating their ability.
A report is defined as "giving a spoken or written account of something that one has observed, heard, done, or investigated".
A Mental Capacity Assessment Report must be forensic, evidence-based and almost academic in its tone; this needs to be clinical. The report is a piece of piece of evidence that is being submitted to the courts.
The Therapeutic Approach
So while a report needs to be clinical, evidence-based, and forensic, the assessment should be humanistic in nature, focusing on a strength-based approach, which itself should lead to an empowering of P.
The alternative of a clinical assessment can, for the most part, place "p" under pressure, be stressful and result in outcomes that are skewed by the environment and (and often overlooked) result in poor outcomes for P.
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 best practice approach or therapeutic approach to assessing mental capacity needs to be different for every individual and calls on the practitioner to have a good grounding knowledge in counselling theories and sociology theories, such as systems theory. This underpinning knowledge and skills help to identify the right way of engaging with a client to ensure the assessment is a positive experience.
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).
With consideration of the best practice approach, the practioner is able to draw upon educational and counselling theories to explain to P and, therefore, indirectly explain to her sons the legislation surrounding [capacity, the logic and reason behind completing a cognitive assessment and the outcomes of these assessments. This ensures that all involved understand the legal requirements and the reason for what could be seen as unassociated questions.
The assessment itself can apply reflective tools and open questions to evidence understanding and retention of the relevant information while also creating a conversation as opposed to a clinical interview. This allows P to have a more relaxed and comfortable experience while also allowing time for her sons to witness and understand P's capacity. This assessment resulted in the same outcome for P; she lacked capacity. However, her sons were able to understand the reason why she lacked the capacity to make decisions moving forward in her best interests rather than from a place of frustration and anger.
By using the assessment tool as a therapeutic tool, the outcome became the right outcome for P, although the assessment process becomes transformative for her and her family, who are better able to understand her needs and ensure these are met.
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."
Although the outcome of the assessment was the same, the assessment's process was different, allowing for P's care team to reflect on and understand their client's abilities and needs, resulting in the right outcome for P: an increase in care support and improvements to her dignity.