Part 2 - Understanding the Decision

“Seek first to understand and then to be understood” (Dr Stephen Covey 2004)

Understanding: to comprehend/to master/to receive and interpret a message/An individual’s perception or judgement of a situation.

Understand – Mental Capacity

In the context of mental capacity, to understand the decision is to understand the information relevant to the decision being made. The degree of understanding for each decision will depend on its complexity. Within mental capacity assessments it is important that the threshold of understanding is not set too high.

Decision making in the legal context frequently involves understanding both verbal and written explanations. These decisions are of a higher complexity than those we encounter day to day (Zuscak et al 2016). Often the information is new, we may only make one Will or only make a Lasting Power of Attorney once. Some of us may choose to listen to advice about the decisions from the advice giver, some may supplement our understanding by reading more or drawing on other people’s experiences. But what if you can’t understand the words you are hearing? You can’t read the words that are written? Or you have no previous experience of the concept and have a communication impairment making it harder to do so?

Communication Impairments

There are many different medical conditions which give rise to communication impairments and the impairments can range from mild through to profound. Communication impairments can arise from Learning disability, stroke, dementia, progressive neurological conditions e.g. Motor Neurone Disease, head injury and mental health conditions. No two people’s communication profiles are the same. This is why, if you are working with an individual with communication difficulties, it is important that the conversation and resources are tailored to their specific needs.

Difficulties with comprehension (understanding) can be caused by many factors. The person with a hearing impairment may not be able to understand because their hearing aid has not been put in. Someone with aphasia due to a stroke may not be able to understand the language being used or misunderstand the word for a word which sounds similar. A person with a head injury may not understand due to difficulties with auditory processing. The person with a learning disability may not understand the written word as her symbolic understanding has not developed beyond picture level. It may be you don’t understand some of the vocabulary I have used, purely because these are new terms and phrases.

Understand to be understood

“Seek first to understand and then to be understood”. Dr Covey’s quote is a useful starting point to ascertain the level of comprehension held by your client. Once ascertained (through discussion with the client, their significant others, their speech therapist) you can then modify your own communication. This will mean information  is more readily understood by the individual, thus creating more effective interpersonal communication.

This might all sound obvious. After all where there is an obvious difficulty in expressing oneself we may make the assumption that there are difficulties in understanding too. However impairments to comprehension can in some cases be difficult to identify. This is due to some people with communication difficulties have strong social communication skills whereby their responses suggest a high degree of understanding. For example nodding in the right place, making affirmative noises during conversation, taking the cue of ‘do you understand?’ to respond with ‘yes’. In some conditions there can be a disparity between someone’s expressive and receptive skills, whereby they have relatively intact expressive language, but poor comprehension, or vice versa. This can often be seen in aphasia, a language impairment which can be caused by a stroke.

So how can you help with understanding in relation to mental capacity

There is not enough room to speak about all the possible options. The starting point is to ensure that you understand your client’s understanding. Is the information you are giving them with regards to making a Will in a format which they can understand? The use of visual aids, such as pictures or photos may help one client, but seem immature or condescending to another. Some clients may require a social story to help them understand. Other clients may require the use of Talking Mats to support their understanding. Aphasia friendly materials may be required and some people may require objects of reference to help them understand a specific concept.

The client themselves, their family and if involved, their speech and language therapist can all provide information as to how best to support the client in understanding the decision at hand.

Practical steps to support understanding

  • Have the conversation at a time of day which suits the client.
  • If they need hearing aids or glasses, ensure these are in place.
  • If the decision is complex or requires education, repeat this over several sessions.
  • Have the conversation in a quiet environment, free from distractions and where the client feels comfortable.
  • If you are using legal terminology, break this down and use layman’s terms to explain it. Make use of pictures to help explain the concept, being mindful that they may not always help.
  • To check understanding, ask the client to paraphrase what they have understood. Checking understanding of clients with reduced verbal output will require more specific approaches. For example, visuals, Talking Mats and supported conversation techniques.

If in doubt seek the professional advice of a speech and language therapist.

Here at TSF our mental capacity assessors are experienced in working with clients with communication difficulties.  We can therefore tailor the assessment to support the client’s individual communication needs. Some of our assessors are speech and language therapists with specialist knowledge and skills to support clients with more severe difficulties or those who use assistive and augmentative communication aids. Get in touch to find out more how we can help.

This is the second in a series of blogs by our assessor Jo Holder. Read the first in the series Communication and the Mental Capacity Act (2005).

Covey, S. (2004) The 7 Habits of Highly Effective People:Powerful Lessons in Personal Change.2nd ed. Simon & Schuster, UK.

Zuscak, S.J., Peisah, C.,and Ferguson, A. (2016) A collaborative approach to supporting communication in the assessment of decision making capacity. Perspectives in Rehabilitation. Vol.38, No.1, pp 1107-1114.