Why mental capacity is not always clear-cut after brain injury

By Anna Long, PBS lead, Acuity Care

One of the significant challenges faced by individuals with Acquired Brain Injury (ABI) is the alteration of mental capacity across various domains.

As professionals, a key element of our role is to support the individual’s safety while encouraging them to maintain as much independence as possible.

Although we understand that capacity  is not static and can fluctuate due to numerous factors, assessments can often  remain rigid and ‘set in stone’.

It is common to observe individuals demonstrating decisional capacity; they can, in the right setting and at the right time, exhibit the ability to make sound decisions.

However, they may struggle to execute these decisions effectively.

Most capacity assessments fail to address this distinction adequately, as they are typically conducted in environments designed to elicit the best performance from the individual.

Neglecting the difference between decisional and executive capacity can pose significant risks when individuals are required to make decisions in ‘real time’.

To illustrate this point, I would like to present a case study.

I worked with a young man a few years post-injury who exhibited poor short-term memory. Nevertheless, with some verbal guidance, he was generally able to perform many tasks independently.

He frequently accessed social media platforms to engage in activities familiar to many of us, such as ‘doom scrolling’, reconnecting with old friends, and  seeking new connections.

He also expressed a desire to find someone with whom he could have private and intimate conversations.

An external professional assessed him and deemed him to have capacity, based on an interview discussion.

During this assessment, he demonstrated an understanding of the risks associated with sharing information online; he recognised that he should not disclose his financial details or home address to strangers and acknowledged the possibility of encountering fake accounts.

However, he also stated, “But if she is fit, she can take my money if she gives me attention.”

This raises the first challenge: was he making an unwise decision, or was his  impulsivity and cognitive deficit, resulting from his brain injury, impairing his ability to recognise the risks involved?

The second challenge arose from support staff reporting concerns regarding his  social media usage.

They observed him refusing general support, spending excessive amounts of time online, and, most importantly, attempting to share personal details, such as his address, and making payments as requested by individuals he did not know.

One safety net in this situation was his poor memory recall, which meant he relied on staff for personal and financial information.

This brings us back to the question: is this an ‘unwise’ decision or a lack of capacity?

As care providers, we face the difficult task of balancing these two aspects. We must adhere to the legal framework surrounding capacity while fulfilling our duty of care  and ethical obligation to keep the individual safe.

Consequently, we collaborated closely with the wider multidisciplinary team (MDT) to implement additional safeguards for the individual.

As a Positive Behaviour Support (PBS) Lead, I was responsible for educating the individual about relationships and socially acceptable interactions with various groups, including age-appropriate communication.

A digital wellbeing practitioner assisted in enhancing his understanding of online safety and utilising safety settings  on social media platforms, while an occupational therapist focused on improving his memory recall.

Most importantly, we fostered a trusting and open relationship between the individual and support staff, enabling them to oversee his online activities through professional curiosity and general support.

For instance, we reviewed videos and profiles together to help him identify signs of artificial intelligence or non-legitimate content.

We also supported him in recognising when external factors, such as fatigue or heightened emotions, might influence his decision-making, leading to more impulsive choices.

During these times, he agreed that staff could advise him to limit his social media access or provide direct support  to guide conversations, thereby preventing him from engaging in potentially risky  situations.

Understanding the variability of capacity in individuals with brain injuries is crucial when working in rehabilitation services.

Appropriate support and early interventions can significantly enhance the individual’s quality of life, promote independence, and reduce risks.

However, the rigidity of the legal framework continues to pose challenges for both the individual and the professionals supporting them.

Learn more about Acuity Care