Aaron is 25-year-old male artist who recently released his second album. Although his first album received critical acclaim, his second has received more subdued reviews. Even so, there’s enough demand for him to undertake a nine-month tour, and there’s even talk of extending the tour if ticket sales go well.
Although Aaron has no formal diagnosis of a mental illness, he’s recently been experiencing panic attacks and bouts of anxiety. He has been self-medicating with alcohol and recreational drugs. Aaron’s partner is six months pregnant with their first child, and Aaron has recently bought a property for them to move into.
As Aaron’s manager, you’ve asked Aaron whether he’s willing to undertake the tour around his second album. Now we’re going to figure out if he is capable of making that decision.
Mental Capacity
Mental Capacity is decision specific. This means that while Aaron might be able to make a decision about one thing, he may not be able to make a decision about something else. This is due to the threshold of understanding, i.e., what he needs to understand to be able to make the specific decision. In this instance it would be what he needs to understand in order to decide whether to go on tour.
It is important to note that mental capacity is time specific, meaning that it may vary from time to time. For Aaron, it is highly likely that when he is using drugs and alcohol he may not have capacity, yet when he’s sober, he may have it. This is known as fluctuating capacity.
The decision in question will fall under the Mental Capacity Act (2005) – an Act of Parliament of the United Kingdom. We will use this framework (the 5 principles and the ‘2 stage test’) when assessing whether Aaron has the capacity to decide to go on tour.
Firstly, we need to identify whether Aaron is suffering from an impairment to the functioning of the mind or brain which might affect his ability to make the decision regarding going on tour. There does not have to be an actual diagnosis. In the case of Aaron he presents with several impairments that may affect his ability to make the decision in question: his anxiety, panic attacks and drug and alcohol use.
Next, we need to identify if there is a direct link between these impairments and his ability make the decision regarding touring. For the sake of the case study let us say that when he is anxious or experiencing panic attacks, he appears unable to think clearly and respond to his current situation and that he will withdraw from all forms of decision making. In this case there is clearly a link between his decision making and his mental health. There is also a link between his alcohol and drug use and his ability to make informed decisions when not sober.
Having identified that Aaron has an impairment that will be impacting his ability to make a decision we now need to consider his ability to:
- Understand relevant information
- Retain that relevant information
- Weigh up and use that relevant information
- Communicate that relevant information
Understanding relevant information
The key word here is ‘relevant’. It is not expected that Aaron will understand everything about everything. However, it is necessary that he is able to understand all the relevant information, and to the level that you would expect of an average adult.
So, what is the relevant information? In the case of Aaron, we would expect him to be able to understand the pros and cons of touring. This will include financial, career, physical and psychological health aspects. He would need to understand the possible impact it would have on his family life. In addition to this he would need to have some understanding of the support he would or would not receive while touring, and his options should he change his mind.
It is vital that Aaron understands the risks and consequences of his actions. If Aaron has no prior knowledge of touring you would need to provide him with this information in a format that he can understand.
Retaining relevant information
As with understanding, Aaron only needs to be able to retain the relevant information, i.e., that which has been identified above. The decision to tour would be classed as a ‘one-off’ decision (albeit one that may be revisited a number of times throughout the actual tour) and so Aaron would only need to be able to retain the information while considering the decision. It may be that Aaron would need reminding of some bits of information to enable him to make the decision regarding touring, especially if this information was given to him when he was not sober or when he is experiencing anxiety or panic attacks.
Let us assume that when sober and his mood is stable, Aaron has no problem retaining information but when he is under the influence of drugs or alcohol, he appears confused, and when he is experiencing panic attacks, he appears unable to understand any of the positives associated with touring.
Ability to weigh and use information
One of the key things we’re looking for here is whether Aaron is making an unwise decision (see principle 3 of the Mental Capacity Act) or an incapacious decision, meaning that he may not be able to demonstrate a sequential series of steps to his thought process and decision making, or may not be able to weigh up all the risks and consequences of his decision.
In the case of Aaron, is he able to weigh up the impact touring may have on his emotional and mental health, his drug and alcohol use and his family, and weigh this against the financial and career benefits that touring may bring? And is he able to weigh and apply the type of support he would need against what he would likely receive (or not receive) while out on tour?
Communication
Aaron just has to be able to communicate in any way possible, either verbally or non-verbally. To move forward, let’s assume that even when inebriated or suffering with poor mental health Aaron is able to communicate without issue.
Outcome
In the case of Aaron, a lot depends on how he presents at the time he is being asked to make the decision, i.e., whether his mood is stable and he is not under the influence of drugs and alcohol. As it stands Aaron has capacity to decide whether to go on tour when sober and his mood is stable. However, it should be noted that capacity can change over time and so needs to be regularly reviewed.
For example, let’s assume that Aaron starts his tour but after a month his anxiety has escalated to the stage where he is self-isolating and his alcohol and drug use has risen to the extent that he is rarely sober. Aaron is no longer able to understand the impact that touring is having upon his psychological health even when sober. Aaron would at this point be deemed to lack capacity and a decision would need to be made in his best interests as to whether to he should continue touring at this point.
If Aaron seeks professional help, he may be able to build emotional resilience, develop coping skills and alleviate his symptoms. If he receives a psychiatric diagnosis, his physician may prescribe him medication. In other chapters of this book you can find advice from psychiatrist Dr. Jonathan Hamill on medication for depression and anxiety.
