Views of People with Mental Illness on Assessment of, and Support During, Diminished Capacity.

Abstract

Definitions of incapacity are socially constructed, resulting in inconsistency in judicial approaches to supporting people with mental illness with diminished capacity in New Zealand. Debates on the nature of incapacity and decision-making during diminished capacity have largely occurred in academic, legal and professional arenas, yet people with mental illness are uniquely able use their experience of diminished capacity to contribute to these debates. This mixed-methods, exploratory study sought to ascertain the range of views held by people with mental illness on: 1. factors deemed relevant to capacity assessment, 2. who should be involved in capacity assessment and decision-making, and 3. how decisions should be made during diminished capacity. Twenty-eight people participated in qualitative focus groups and / or individual interviews in Dunedin. Constant comparison analysis, content analysis, keyword-in-context and quantitative statistical analysis were used to analyse data. There was no significant consensus in response to the research questions. Instead, participants argued for holistic, individualised assessment and decision-making that accounts for their individuality, their context and their experience. Participants wanted choice in who was involved, often preferred more than one person, and wanted these people to have knowledge of them, their illness and their sense of ‘control’. Significant barriers to involving others were identified, often culminating in stigma and social isolation. Participants endorsed their own involvement in decision-making and supported decision-making in the first instance. Beyond this first preference, participants favoured an individualised menu of decision-making options. Several requested decisions be overridden should these prove ‘risky.’ A spontaneous finding highlighted the importance of relational autonomy in facilitating capacity, whether retained or diminished. It is recommended that current legislation be reviewed to allow flexibility and choice in capacity assessment, decision-making, and involving others, and that people with mental illness be encouraged to engage in discussion on principles guiding decision-making should their capacity be diminished.