1. Decision-making and mental processes: Assessing capacity in borderline personality disorder
Taj Nathan

2. Mental Capacity Act 2005
2.–(1) For the purposes of this Act, a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of impairment of, or disturbance in the functioning of, the mind or brain
3.–(1) For the purposes of section 2, a person is unable to make a decision for himself if he is unable-
to understand the information relevant to the decision
to retain that information
to use or weigh that information as part of the process of decision making the decision, or
to communicate his decision

3. Capacity test and mental machinery
to understand the information relevant to the decision
to retain that information
to use or weigh that information as part of the process of making the decision, or
to communicate his decision

4. Capacity test and mental machinery
to understand the information relevant to the decision
to retain that information
to use or weigh that information as part of the process of making the decision, or
to communicate his decision

5. Classical - v - neurobiologically-informed model
Science: Schrödinger's cat explained with neutrinos: Physicists show quantum weirdness of neutrinos over longest distance yet. By Katyanna Quach 20 Jul 2016

6. Capacity to decide to stay within an abusive relationship
Information relevant to the decision:
Understand?
Retain?
Communicate decision?
Use that information as part of process of making the decision?
Can think about both remaining and leaving relationship
Accepts that may violence recur
Accepts that others may believe it is an unwise decision
Understands there is a potential risk to self and to child
But more optimistic about change

7. Borderline personality disorder
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
Frantic efforts to avoid real or imagined abandonment.
A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation.
Identity disturbance: markedly and persistently unstable self-image or sense of self.
Impulsivity in at least two areas that are potentially self damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
Recurrent suicidal behaviour, gestures, or threats, or self mutilating behaviour.
Affective instability due to marked reactivity of mood.
Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger.
Transient, stress-related paranoid ideation or severe dissociative symptoms.

8. Domestic violence and family proceedings
Partner relationship versus mother-child bond
Pattern of remaining within, or returning to, a domestically abusive relationship
Even following capacitous acceptance of adverse consequences
Even when ‘threatened’ with child being removed

9. Decision-making (prioritisation)
Prioritisation of own needs over the child’s needs
Model of understanding decision-making
Decision-making involves cost-benefits analysis
Choices are the outcome of rational processes
Rational = based on or in accordance with reason or logic
Use relevant information as part of process of making the decision?

10. The trolley dilemma
New York Times: Philippa Foot, Renowned Philosopher, Dies at 90

11. System 1 and System 2

12. 2 + 2

13. 27 x 13

14. System 1 and System 2 Implicit Associative Spontaneous Automatic Fast
Low effort
Explicit
Serial
Controlled
Slow
Effortful

15. Availability heuristic
“A mental shortcut that relies on immediate examples that come to a given person's mind when evaluating a specific topic, concept, method or decision.”
“The availability heuristic operates on the notion that if something can be recalled, it must be important, or at least more important than alternative solutions which are not as readily recalled.” 
“Subsequently, under the availability heuristic, people tend to heavily weigh their judgments toward more recent information, making new opinions biased toward that latest news”
Wikipedia

16. Annual Reviews

17. Annual Reviews

18. Domestic abusive – model of understanding
Purely cost-benefit model does not describe real world decision-making
For all of us, but more so if disordered dynamics
Needs (e.g. peer/partner relatedness; parental)
Cognitive / emotional
Model for domestic abuse and childcare
Competing/conflicting needs
Peer/partner relatedness, connectivity
Child nurturing, protecting etc

19. Domestic violence Why remain in, or return to, the source of abuse
Explanations for decisions
Self-reinforcing rationalisations
Involve distortions
Why?

20. Domestic abuse (dynamics)
Control
Dominance
Threat
Harm
Expectation of change
Forgetting history

21. Domestic abuse (dynamics) (victim position)
Control – being controlled
Dominance – being subservient
Threat – being threatened
Harm – being harmed
Expectation of change – accepting claims of change
Forgetting history – forgetting what has happened before

22. Domestic abuse (dynamics)
Effect of previous experiences of
being controlled
being subservient
being threatened
being harmed
accepting claims of change
forgetting what has happened before

23. Powerful effects of previous experiences
Developmental period
Repeated threat
Adaptation to
improve preparedness
reduce the impact
make sense (seek meaning)
Representations of world, self and others
‘Internal working models’

24. Adaptive recalibration
improve preparedness
expect threat
reduce impact
dissociate
make sense
feeling of blameworthiness
Dyadic resonance/fit
Susceptibility to hold contradictory positions ‘simultaneously’

25. Contradictory positions
Integration of complexity of self and others v
Distinct unrelated components and self and others
Role of relationships (esp in childhood)
Role of affect

26. Capacity to decide to stay within an abusive relationship
Decision and rationalisations
Influenced by distorted emotionally based processes
Shaped by earlier adversity
Feelings of blameworthiness
Reduced sense of dissonance with dominance/subservient dynamic
Impaired emotionally based representation of others and self
Dissociation of thoughts and feelings
Autobiographical memory problems
Underpin borderline personality traits

27. Questions
Assessing decision-making or assessing rationalisation of decision-making?
Assessing emotional/implicit processes using explicit approach?
Assessing dichotomous constructs in a dimensional world?

28. Thank you