More training needed on mental capacity

Gemma Hall with a letter from our December edition.

I was pleased to see the Mystify film review titled ‘a glorious celebration…and a revelation’ in the November issue, with the questions it raised surrounding traumatic brain injury (TBI).

During my year working within neurorehabilitation, I have become struck by the lack of awareness surrounding TBI; especially regarding the process of Mental Capacity assessments. Specifically, those with frontal lobe contusions can suffer a ‘knowing doing dissociation’ whereby they struggle with everyday tasks (for example, taking their own medication) but would refute the idea that they need any help or support with these tasks. This is because the areas of the brain that are responsible for self-monitoring and self-awareness are impaired; commonly referred to as the ‘frontal lobe paradox’.

This paradox is best illustrated when considering how patients with frontal lobe damage can have significant functional difficulties in their everyday lives, yet appear entirely unimpaired in assessment settings. Unsurprisingly, this can have major implications on the individual. As George and Gilbert (2018) state in their seminal paper, failing to take the ‘frontal lobe paradox’ into account when conducting Mental Capacity Act assessments could be the most disastrous implication of all.

Mental Capacity is most often assessed by local authority social workers or care managers on the basis of short interviews. Unfortunately, many of these professionals receive little or no specialist training on brain injury. If they are unaware of the ‘frontal lobe paradox’, they could easily overestimate an individual’s ability to live independently. This is the exact situation that occurred with one of my clients who was misclassified as having mental capacity over his care, despite being unable to perform everyday tasks independently and with a history of exploitation, homelessness, substance misuse and crime. He was discharged from a residential environment to a flat of his own.

This outcome echoes that of the ‘Serious Case Review of Tom’ in 2016 who – like many others before and after his time – sustained a traumatic brain injury but was not afforded the appropriate level of support and ultimately ended up taking his own life. The same story was told in the November issue with the life of Michael Hutchence, whose TBI is thought to be implicated in his eventual suicide. How many people share the same story? Perhaps more importantly, how many people must share the same heartbreaking end of this story before the gravity of TBI is recognised?

The ‘frontal lobe paradox’ may be a familiar term in the world of neuropsychology but for those professionals who are assessing Mental Capacity in patients with an acquired brain injury, I would like to see more training become openly available. Conducting assessments in collaboration with those who have observed an individual in a functional environment, such as close friends / family or occupational therapists, could also improve outcomes.

Gemma Hall
Assistant Psychologist
Liverpool

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