Mental capacity, particularly in the context of social work, has often been understood through an individualistic lens that prioritises cognitive ability. However, recent scholarship suggests the need to shift toward a social model. There’s an emphasis that capacity is not merely a personal attribute but something shaped by relationships, environments, and the support networks around the individual.
The Importance of Relationships in Decision-Making
Professional relationships play a pivotal role in empowering individuals to exercise their autonomy. The research underscores that our decision-making capacity is profoundly influenced by the attitudes and behaviours of our support system (Ferguson et al., 2011).
Studies such as those conducted by Devi et al. (2020) underscore how decision-making in residential and supported living environments hinges on the cultivation of trust over time. Supporters who grasp nonverbal communication and behavioural cues can foster a more effective decision-making process (Watson et al., 2017).
Through these relationships, individuals use conversations to enhance their decision-making skills, as seen in Dowling et al.’s (2019) work. Here, trusted supporters act as guides during “teachable moments,” offering options and consequences to help individuals weigh their choices.
As demonstrated by Moore et al. (2019), this empowering role of trusted supporters can significantly aid in supported decision-making. It’s especially evident in cases involving individuals with brain injuries, inspiring hope for the social model’s potential.
Embracing a Social Model of Capacity: Moving Beyond Individualism
The traditional approach to mental capacity, which often centres on cognitive tests and isolated decision-making, does not align with the collaborative nature of most people’s decisions. This model assumes that autonomy must be exercised in isolation, disregarding that decisions are often made collaboratively within trusted relationships (Gooding, 2013).
The transition to the social model introduces a novel perspective on autonomy, framing it as a collective process where individuals interact with a ‘decision community’ (Martin and Hickerson, 2011). In this framework, individuals can delegate certain cognitive tasks to trusted others while retaining overall control of their decisions.
This concept is in line with research that demonstrates how supporters can challenge and express their own views, aiding individuals in reflecting on their choices without overstepping into substitute decision-making, which could potentially lead to an abuse of power (Campbell et al., 2018).
However, the distinction between substitute and supported decision-making is not always clear even in a relationship-based decision-making process. Where the line is blurred, the risk of undue influence or power dynamics becomes significant (O’Donnell et al., 2023).
The Role of Social Workers in a Social Model of Capacity
UK social workers are often called upon to assess capacity in various contexts, from care package arrangements to psychiatric hospital admissions under the Mental Health Act 1983. While the Mental Capacity Act (MCA) of 2005 provides legal guidance, social workers must navigate complex ethical issues and limited practical guidelines in their capacity assessments.
Research shows that effective capacity assessments often involve building relationships and understanding the individual in real-life settings, a process that allows for more nuanced evaluations of their decision-making ability (Lennard, 2016).
The social model challenges the constraints of the MCA by suggesting that capacity assessments should focus on the relational and contextual aspects of decision-making. For instance, the relationship between the social worker and the individual being assessed is crucial in ensuring that decisions reflect the individual’s values, past experiences, and sense of self (Kong, 2017).
Moreover, the principle of charity (Davidson, 1980) encourages assessors to assume consistency and correctness in the beliefs of those they support, allowing for a shared narrative that makes sense within the person’s socio-economic and geographical context.
Applying the Social Model in Practice
Implementing a social model of capacity requires social workers to shift from seeing decision-making as purely individual to understanding it as a collective, relational process.
For example, when assessing someone like “Jack,” a social worker may work with Jack’s family to explore his needs and preferences rather than presenting a narrow set of pre-defined options. Even if Jack ultimately moves into residential care, this collaborative approach can create opportunities for him to maintain important aspects of his life, such as family visits and attending church.
Similarly, for individuals like “Arran,” who may struggle with decision-making in pressured environments like a supermarket, social workers can support capacity by offering relatable, concrete examples of how specific decisions will impact their daily lives. Using open questions and offering a range of options helps ensure the individual’s decision-making process remains meaningful and grounded in their unique circumstances (Dixon et al., 2022).
Challenges and the Need for Further Research
Despite the growing body of literature advocating for a social model of capacity, practical implementation remains challenging. Social workers face time constraints, resource limitations, and institutional pressures that may prevent the relational approach needed for effective capacity assessments.
Moreover, the MCA’s focus on individual cognition means that even within the legal framework, applying a relational social model can be difficult. To fully integrate the social model into practice, more research is needed on how social workers can balance the MCA’s legal requirements with individuals’ relational needs.
Additionally, the power dynamics inherent in the social worker-client relationship must be carefully navigated to avoid the risk of undue influence. As the profession moves toward greater acceptance of supported decision-making, more detailed guidance is needed on how to assess capacity in a way that respects autonomy while addressing safeguarding concerns.
Conclusion
The shift towards a social model of mental capacity represents a significant opportunity for social work to align more closely with its core values of promoting autonomy and human rights. By focusing on the relational and contextual aspects of decision-making, social workers can enhance the autonomy of those they assess, even in complex and time-pressured situations.
However, to fully realise the potential of this approach, further research and practical guidance are needed, particularly around issues of power dynamics and the implementation of supported decision-making within the existing legal framework.
References
Ferguson M., Jarrett D., Terras M. (2011) ‘Inclusion and healthcare choices: The experiences of adults with learning disabilities’, British Journal of Learning Disabilities, 39(1), pp. 73–83.
Devi N., Prodinger B., Pennycott A., Sooben R., Bickenbach J. (2020) ‘Investigating supported decision‐making for persons with mild to moderate intellectual disability using institutional ethnography’, Journal of Policy and Practice in Intellectual Disabilities, 17(2), pp. 143–56.
Watson J. (2016) ‘Assumptions of decision-making capacity: The role supporter attitudes play in the realisation of Article 12 for people with severe or profound intellectual disability’, Laws, 5(1), pp. 6.
Dowling S., Williams V., Webb J., Gall M., Worrall D. (2019) ‘Managing relational autonomy in interactions: People with intellectual disabilities’, Journal of Applied Research in Intellectual Disabilities, 32(5), pp. 1058–66.
Moore S., Wotus R., Norman A., Holloway M., Dean J. (2019) ‘Behind the cloak of competence: Brain injury and mental capacity legislation’, The Journal of Adult Protection, 21(4), pp. 201–18.
Gooding P. (2013) ‘Supported decision-making: A rights-based disability concept and its implications for mental health law’, Psychiatry, Psychology, and Law, 20(3), pp. 431–51.
Martin W., Hickerson R. (2011) ‘Mental capacity and the applied phenomenology of judgement’, Phenomenology and the Cognitive Sciences, 12(1), pp. 195–214. New York, Springer
Campbell J., Brophy L., Davidson G., O’Brien A. M. (2018) ‘Legal capacity and the mental health social worker role: An international comparison’, Journal of Social Work Practice, 32(2), pp. 139–52
O’Donnell D., Davies C., Christophers L., Ní Shé É., Donnelly S., Kroll T. (2023) ‘An examination of relational dynamics of power in the context of supported (assisted) decision‐making with older people and those with disabilities in an acute healthcare setting’, Health Expectations, 26(3), pp. 1339–48
Lennard C. (2016) ‘Fluctuating capacity and impulsiveness in acquired brain injury: The dilemma of “unwise” decisions under the Mental Capacity Act’, The Journal of Adult Protection, 18(4), pp. 229–39.
Kong C. (2017) Mental Capacity in Relationship: Decision-Making, Dialogue, and Autonomy, Cambridge University Press.
Davidson D. (1980) Essays on Actions and Events, Oxford, Oxford University Press
Dixon J., Donnelly S., Campbell J., Laing J. (2022) ‘Safeguarding people living with dementia: How social workers can use supported decision-making strategies to support the human rights of individuals during adult safeguarding enquiries’, The British Journal of Social Work, 52(3), pp. 1307–24.
