Dr Abby Seltzer Consultant Psychiatrist MENTAL CAPACITY AND RISK IN DID Dr Abby Seltzer Consultant Psychiatrist

Outline of today’s workshop: Introductions Risk – defining it, assessing it, managing it Mental Capacity - the legal framework - assessing mental capacity   CONFIDENTIALITY REMINDER!

WHAT IS RISK – 1 OED DEFINITION A SITUATION INVOLVING EXPOSURE TO DANGER ‘flouting the law was too much of a risk’ mass noun ‘all outdoor activities carry an element of risk’ THE POSSIBILITY THAT SOMETHING UNPLEASANT OR UNWELCOME WILL HAPPEN ‘reduce the risk of heart disease’ A PERSON OR THING REGARDED AS A THREAT OR LIKELY SOURCE OF DANGER ‘she's a security risk’ ‘gloss paint can burn strongly and pose a fire risk’ A PERSON OR THING REGARDED AS LIKELY TO TURN OUT WELL OR BADLY IN A PARTICULAR CONTEXT OR RESPECT ‘Western banks regarded Romania as a good risk’

WHAT IS RISK – 2 THE MENTAL HEALTH CONTEXT SELF HARM – active/passive – with or without suicidal intent HARM TO OTHERS – vulnerable others - think safeguarding HARM FROM OTHERS – think safeguarding SELF NEGLECT RISK FACTORS – STATIC - DYNAMIC - PROTECTIVE FACTORS   Case discussion deleted from this set of slides

WHAT IS RISK – 3 RISK AND DISSOCIATION SELF HARM – Suicidal parts HARM TO OTHERS – Aggressive/homicidal parts HARM FROM OTHERS – Vulnerable parts SELF NEGLECT – Fragile parts RISK FACTORS – STATIC - DYNAMIC - PROTECTIVE FACTORS  

RISK ASSESSMENT IN PRACTICE How serious is the risk? How immediate is the risk? Is the risk specific or general? How volatile is the risk? What are the signs of increasing risk? Which specific treatment, and which management plan, can best reduce the risk?

SUMMARY - PRACTICALITIES Consider whether you and your colleagues are safe Where there is a substance or alcohol misuse problem, always enquire about violence, especially domestic violence Explore the meaning behind symptoms and unusual statements Explore implications of the patient’s emotions and beliefs Think about what you don’t know Look for patterns and escalations Don’t be frightened to discuss your thoughts with colleagues. Be aware that interventions have the potential to increase risk, despite good intentions. Know who to contact if you are concerned about risk - if it is not your role to assess and manage risk, whose is it?

SUMMARY – FINAL THOUGHTS Risk cannot be eliminated, but it can be rigorously assessed and managed or mitigated A risk assessment should identify key factors that indicate a pattern or that risk is increasing Risk is dynamic and can be affected by circumstances that can change over the briefest of time-frames. Therefore, a good risk assessment needs to include a short-term perspective and frequent review WHEN ASSESSING RISK ALWAYS THINK SAFEGUARDING!  

MENTAL CAPACITY ACT 2005 Key principles: Applies to everyone involved in the care, treatment and support of people aged 16 and over living in England and Wales who are unable to make all or some decisions for themselves A person must be assumed to have capacity unless it is established that he lacks capacity A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success A person is not to be treated as unable to make a decision merely because he makes an unwise decision An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests. Least restrictive method of achieving purpose Not covering court of protections, advanced directives and DOLS – PLEASE NOTE THESE SLIDES ARE NOT A SUBSTITUTE FOR FULL TRAINING IN ASSESSMENT OF MENTAL CAPACITY

MENTAL CAPACITY ACT 2005 – The two stage test Does the person have an impairment of their mind or brain, whether as a result of an illness, or external factors such as alcohol or drug use? Does the impairment mean the person is unable to make a specific decision when they need to? People can lack capacity to make some decisions, but have capacity to make others. Mental capacity can also fluctuate with time – someone may lack capacity at one point in time, but may be able to make the same decision at a later point in time

MENTAL CAPACITY ACT 2005 INABILITY TO MAKE DECISIONS A person is unable to make a decision for himself if he is unable— (a)to understand the information relevant to the decision, (b)to retain that information, (c)to use or weigh that information as part of the process of making the decision, or (d)to communicate his decision (whether by talking, using sign language or any other means). What sort of decisions does it cover? Financial, health and housing eg MAJOR Best interests – what does this mean?

MENTAL CAPACITY ACT and DID No case law relating to DID outside criminal court! So…how to assess?? Case discussion deleted from this set of slides