I am sharing my experiences of leadership and the journey of a healthcare entrepreneur. I hope that this will inspire others into following the same journey and create opportunities for all!

The Maslow Foundation aims to ensure social inclusion, using the voice of lived experience to create services that meet their ambitions and I am proud to be Chair of Trustees creating hope, joy and meaning in our lives. Our services include creating safe spaces to ensure meaningful conversations, being able to connect individuals into wider services with a model of trauma stabilisation and connection. We are pleased to be offering housing to those who cause harm from domestic violence and enabling their partners to remain in their local community. This has revealed the challenges with employment and our move to creating an entrepreneurial laboratory and microbusiness support. We are champion the Child Impact Assessment to support mothers who may be sent to prison and their children to inform judges and provide a robust plan for the family. To support the charitable sector I have launched Urban Nest Housing Solutions to access housing with safety at our heart.

Nurture Health and Care Ltd has been co-founded by myself and my team to nurture workforces across the public sector. This is built on a model of Psychological Safety and recognises the need for connection, sense making and action. By creating sense making structures through our supervision model or decision making groups in our investigation team, we can enable people to make sense of risk and uncertainty. We are proud to be offering services to the NHS for investigations and the Prison and Probation Ombudsman/NHS England for clinical reviews. In addition, we are providing sexual offence examiners to sexual assault referral centres, with a unique workforce strategy which includes the accredited Sexual Assault Nurse Examiner programme (SANE) and our inspection ready governance delivery. We use our four ways of knowing to help provide understanding, equality of voice and values based decision making to create new insight for our services. We provide post graduate preceptorship programmes and enjoy the contribution of our Nurse Ambassadors and run a Nurture Ripple and Cultural Architect Programme generating psychological safety to embrace the ambition and creativity of our workforce enabling success.

I am interested in how language can represent culture and be measurable through artificial intelligence and have set up a new organisation, the Centre of Artificial Intelligence Interface (CAII), with the launch of our new website and first product which acts to create different perspectives as a basis of decision making: https://www.3friends.ai/ and looks how ethical AI solutions can contribute to healthcare.

As a Trustee for Survivors In Transition, I continue to support my passion of providing services to those who have experienced sexual violence and am lucky to work alongside Fiona Ellis, who as CEO has created a values based innovative organisation to provide therapeutic interventions.

I am also exploring setting up a microgrant funding system to create financial support, coaching and an incubator of change recognising how passion, entrepreneurialism and the agency of people can support change in our services. I look forward to sharing this journey.

Alexis Hutson (https://www.alexishutson.com/) facilitated the Faculty of Medical Leadership and Management course – Tomorrows Strategic Leader which I attended and highly recommend. She was an excellent resource and identified the concept of ‘Taking a Thought for a Walk’ which I have named this blog after. Simon Bennett (http://www.simonbennettcoaching.com/) is my personal coach and I advocate this support, It enables us to explore the journey that we are all undertaking in a psychologically safe space.

I believe that without aiming for the impossible, miracles cannot happen and through authentic leadership, we can enable every person to be able to reach their own potential.

In light of recent elections and the diverse distribution of votes across the political landscape, Sir Keir Starmer’s speech highlighted the importance of service and the need for a cohesive team to drive change. This is set against a backdrop of toxic cultures exposed by the Post Office Scandal, ongoing NHS national reviews, and the immense pressures on our systems. Understanding others has never been more crucial.

Embracing Differences of Opinion
Every individual is unique, and our role is to create conditions where everyone can thrive. By enabling genuine participation, we allow others to express their authentic views. Rather than changing minds, we should accept and validate different experiences, aiming to move forward together without necessarily sharing the same perspective.

Leadership Priorities
As leaders, our priority should be to create safe spaces for people to share their experiences. This fosters restoration, sense-making, positivity, and connection. Promoting psychological safety through trauma-informed practices is essential. By understanding and noticing trauma signs and preventing re-traumatisation, we can build trust, empowerment, choice, and collaboration through peer support, emphasising self-kindness and kindness to others.

The Importance of Environment
Providing people with insights without changing their environment can lead to frustration and misplaced aggression. Therefore, facilitating diversity of thought and skill sets within our teams is key. Team composition should go beyond culture and heritage, ensuring the presence of neurodiversity, personalities and ‘styles’ which creates a broad range of perspectives to find new solutions.

Role Modelling in Teams
As leaders, we must not tolerate poor behaviour, as it becomes normalised and persistent. Change starts with each of us, challenging the status quo, modelling the change we want to see, and motivating others. Reflecting on skills like situational awareness, situational ethics, cognitive flexibility, creative abrasion, creative destruction, strategic sparring, and the spiral maze of improvement can help us explore new concepts.

Building on Values
By focusing on values as goals and setting a clear direction, we can inspire real change. Today’s political and NHS struggles provide case narratives that underscore the importance of understanding, collaboration, and proactive leadership in driving meaningful progress.

In light of recent revelations from the Francis Report on the Mid Staffordshire NHS Foundation Trust to the Ockenden Report about Shrewsbury and Telford Hospital NHS Trust, it’s clear that some areas of our healthcare system have consistently fallen short. These reports highlight the pivotal role of organisational culture as the foundation of high-quality care. Yet, despite recognising this, transitioning to new operational paradigms remains a challenge.

Our restructured organisations offer us a unique chance to reassess governance models. Drawing from past failures, we are now pivoting towards more flexible systems that value diverse perspectives. In a world dominated by logic and rules, we must also embrace a holistic approach to healthcare. This means integrating disciplines such as psychology, sociology, neuroscience, and philosophy with traditional evidence-based practices, considering the broader context of culture and history.

Traditional processes and metrics work well for predictable scenarios, but they falter in the face of human behaviour and complex, dynamic systems filled with uncertainties. We must, therefore, value experience, empathy, instinct, and collaborative decision-making more than ever.

Inspired by Michael Polanyi’s four types of knowing, we can apply these insights to our healthcare systems:

• Propositional (Facts): Often found in medical records and data, these are considered truths, although they can be skewed by assumptions and biases.
• Procedural: Consistent practices established through logical constructs, seen in legislation, regulation and evidence-based medicine.
• Perspectival: Gaining insights from multiple viewpoints is crucial but often overlooked in healthcare, where incorporating diverse ideas is not a practiced skill.
• Participatory: This involves active engagement in sense-making, moving beyond mere task execution to contribute meaningfully with one’s energy and intuition.

Healthcare has traditionally focused on rigid policies and procedures rather than embracing the wisdom gleaned from life experiences and reflective practice. As Albert Einstein famously said, “INSANITY is doing the same thing over and over and expecting different results.” This sentiment mirrors the quality improvement cycles which often repeat the same projects repeatedly.

Stress can narrow our focus and diminish our capabilities, leading to defensive or avoidant behaviours. Conversely, environments that foster psychological safety promote collaboration, creativity, and innovation, allowing us to utilise our experiences effectively.

For organisations, understanding patient safety and delivering high-quality services requires a shift from fixed to growth mindsets and from goal-oriented to values-based decision-making. Embracing feedback and moving away from a constant need for approval are essential steps in this process.

We’ve implemented several strategies to support this shift:

• Inclusion of lived experiences in all system aspects.
• Person-Centred Solutions that truly place individuals at the heart of decisions.
• Job Canvases that centre the person in their role.
• Decision-Making Groups to enhance quality assurance in various operational processes.
• Celebration of differing opinions and reflexivity in practice encouraging a diverse and dynamic environment.

Practical exercises such as attempting to understand differing viewpoints, summarising others’ opinions without interjecting one’s own, and routinely challenging the status quo can help normalise these practices.

With a new lens of understanding and values which include psychological safety, we are pioneering a model called Participation-Centred Care (the Wisdom of the Crowd), merging personalised medicine with participatory practices, organisational development, and distributed wisdom. This approach promises to reshape the foundations established by evidence-based medicine into a more inclusive and holistic framework.

I’m sharing my insights into evidence-based medicine (EBM) because, like many, I have long believed it to be the gold standard. However, we have interpreted the evidence with a preference to the mean and ignored the outliers alongside wider biases leading to unintended consequences.

The Dark Side of Randomised Controlled Trials (RCTs) in EBM
Biases in research can arise from poor study design. systematic differences and performance bias, detection and contamination bias, interviewer and chronology bias, misclassification and recall bias with confounding, and confirmation biases.
The most influential is “conflict of interest bias,” where pharmaceutical industries manipulate study designs and selectively publish results, embedding systemic disadvantage. Regulatory bodies often rely on flawed metrics, leading to counterproductive practices.

Despite being trusted for clear, reliable answers, RCTs have their pitfalls. They must meet stringent criteria to be effective, but often:
• Clinical questions are inadequately framed.
• Statistical methods are misapplied.
• Target samples are poorly chosen.
• Randomisation lacks clarity and bias prevention.
• Data collection and analysis are flawed.
• Personal biases influence result interpretation.

Challenges in EBM
Building on the research bias, EBM’s simplicity often fails to capture ecosystem complexity. Narrow participant choices and inadequate demographic datasets analysed through a fixed, medical model mindset exacerbate these problems and assume the mean is more important than understanding the outliers.

Yet, we implement evidence based approaches as if they are the ‘truth’ and where anomalies appear, we reject our own ideas and create self-deceiving cycles.

Interdisciplinary approaches incorporating social sciences, ethics, and patient advocacy offer potential solutions, yet access to research funding and publication is often not easily facilitated and we have created an exclusive scientific community.

The Negative Impacts of EBM
Acknowledging EBM’s potential for harm is distressing. While there are positive outcomes, negative consequences like misinterpreted risks of hormone replacement therapy and the opioid crisis highlight its dangers.

National audits, benchmarking, and performance metrics can perpetuate these issues, reinforcing systemic biases.

Complexity of Patient Require Flexible Solutions
Patients’ real-life circumstances complicate EBM application and where anecdotal experience provides information, this insight is ignored. The focus is on those who seek care, neglecting those who don’t with service evaluations often ignoring the opinions of non-users, reinforcing bias.

Meta-analysis Reinforce Bias
Meta-analyses can amplify statistical effects. Issues like population differences, study quality, and publication bias limit reliability.

Moving Forward
The future of EBM lies in its ability to evolve and incorporate diverse perspectives and methodologies. By integrating qualitative and quantitative data, promoting patient and public involvement, enhancing diversity and inclusion, improving transparency, and fostering interdisciplinary collaboration with understanding when EBM is applied, we can create a more holistic, equitable, and effective healthcare system.

Ultimately, the goal is to ensure that EBM not only advances medical knowledge but also aligns with the real-world needs and experiences of all patients, leading to better health outcomes for everyone.

In the vast expanse of our daily interactions and responsibilities, it’s physically impossible for us to focus on everything simultaneously. Whether it’s a photographer capturing the beauty of a sunset or a professional navigating the complexities of workplace performance, our attention is constantly being filtered and directed, both consciously and subconsciously. This process, known as selective attention, plays a crucial role not only in how we perceive the world around us but also in the decisions we make within it.

The Influence of Systems and Culture

Our working environments are inundated with information, often using dashboards and metrics to manage the deluge. However, the culture within these systems often leads us to prioritise conformity and the appearance of success over the nuanced understanding of underlying issues. This creates a landscape where decision-making is driven more by existing policies and groupthink than by critical analysis and personal insight, fostering an environment ripe for oversight and bias.

Reflecting on Personal Experiences

Through my recent appraisal, the writing of organisational performance reports, and undertaking investigations, I’ve observed firsthand how selective attention influences our professional lives. In my appraisal, the fear of exposing one’s vulnerabilities often leads to an overemphasis on positive outcomes, overshadowing areas needing improvement. Similarly, investigations within a “Just Culture” may reveal systemic errors but also highlight the challenges of translating these findings into meaningful change with impartiality. Writing performance reports, I’ve grappled with the tension between presenting success and sharing the granular detail which we find.

The Post Office Scandal: A Case Study in Systemic Failure

The Post Office scandal serves as a poignant reminder of the consequences when truth is obscured by narrative. It illustrates how a likely problem with software, was disguised by Fujitsu as they had promised perfection in their system, that then was believed and a lie became truth, with honest citizens, their employees criminalised and demonized by people ‘doing their job’. When left unaddressed, small initial problems, can culminate in systemic failures, undermining trust and integrity across an entire organisation which includes criminal activity, fraud and dishonesty.

Artificial Intelligence: A Double-Edged Sword

The advent of artificial intelligence offers a seemingly impartial tool for decision-making. However, without careful consideration, AI can perpetuate the same biases it seeks to overcome. It’s imperative that we critically assess how these technologies are implemented, ensuring they serve to enhance rather than hinder our pursuit of truth and fairness reinforcing lies, rather than providing clarity.

Strategies for Navigating Information Overload

Acknowledging the impossibility of processing all available information is the first step toward more effective practice. By adopting a flexible mindset and being open to alternative perspectives, we can better navigate the complexities of our environments. How we then present ourselves and the world around us to others should be a welcome addition to our reflective supervision, case management and performance reports.

An example of a publication this week from the Institute for Healthcare Improvement, which flipped the narrative was:

https://www.ihi.org/insights/success-cause-analysis-learning-what-works-advance-safety

Embracing Our Humanity

In our quest for perfection and certainty, we must appreciate our humanity. Although ‘to err is human’, our capacity for creativity by recognising our biases, engaging in meaningful dialogue, and embracing the diverse perspectives enrich our collective understanding.

Questions for Self-Reflection

To foster personal and professional growth, consider reflecting on the following questions:

What was my situation?

• What am I feeling and what is my state of arousal?
• What is my physical body doing?
• What are my thoughts at that time?
• What was happening around me?
• How did I interact with others and connect?

What was I paying attention to?

• Did I use tools, templates, guidance, processes to guide next steps?
• Did I use my experience, memory and recognise a pattern that was able to guide next steps?
• Did I use intuition and gut instinct?
• How did my values and beliefs influence practice?
• Did I use my imagination to consider the possibilities (and risks)?
• Did I use the views of others to guide next steps?
• Was there anything you that was not on your radar?

What was my judgement?

• How did I create the next step?
• Did I base it on ‘feeling right’?

How well did it go?

• What went really well?
• What did not go so well?
• What impact did you have?

What happens next time?

• Is there anything in myself that will stop me?
• Is there anything from others that will stop me?
• Is there something in the context that stops me?

A Call for Courage and Openness

The challenges of selective attention and representation in professional settings are profound, but not insurmountable. By embracing our vulnerabilities, being open to change, and valuing diverse perspectives, we can foster environments that not only recognise but also celebrate the complexity. We should accept our need to shine light on certain aspects however be open to discussion about the shadows, to ensure that we create understanding, not compliance and perfection.

We should move forward with the courage to question, the willingness to listen, and the commitment to act with integrity and empathy even when at times we showcase our own failings.

In the ever-evolving landscape of healthcare, we are often confined to established practices, benchmarking against an evidence base that may not always be as robust as we assume. Last year, while working on clinical reviews and investigations, it reinforced a critical flaw in our approach: the statistical mean, often considered a benchmark, does not apply in most contexts. By studying the outliers, we can gain a deeper understanding and possibly unearth more effective practices.

Our healthcare systems and the people within them cannot be neatly categorised into rigid structures. This realisation is not just academic; it impacts real lives and possibly has led to the decline of quality within our systems.

The narrative presented in Giovanni D. Tebala’s “The Emperor’s New Clothes: a Critical Appraisal of Evidence-based Medicine” resonates deeply with this sentiment. Tebala’s work, along with the drama ‘Mr. Bates and The Post Office’, shines a light on how organisational structures often create an infrastructure blind to the truth, reinforcing falsehoods.

Read Tebala’s Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6158662/#:~:text=The%20Emperor%20will%20be%20our,up%2Dto%2Ddate%20medicine.

In the realm of healthcare, complexity often induces a sense of panic, stemming from a deviation from the norm. This deviation can lead to a fear of rejection among healthcare professionals. However, it is precisely these deviations that can lead to breakthroughs and improvements in patient care.

The call to bring back the patient and the practitioner to the centre of the decision-making process, as advocated by Tebala, is a step in the right direction. Clinical choices should be based on a triad: the evidence base, the personal experience of the practitioner, and the expectations of the patient. This approach aligns well with the latest guidelines on decision-making from the General Medical Council, emphasising the importance of shared decision-making and valid consent in patient centred care.

General Medical Council’s Guidelines on Decision Making and Consent: https://www.gmc-uk.org/professional-standards/professional-standards-for-doctors/decision-making-and-consent

This brings me to my propositions for a shift in mindset and practice:

• Reviewing Outliers: We need to focus more on outliers than on the statistical mean. This approach can reveal insights overlooked in average data.
• Language in Policies and Records: The language used in our policies, procedures, and patient records should reflect shared decision-making, prioritising humanity over the technical and managerialism.
• Healthcare Innovation: We must explore new ways of understanding and doing things, stepping outside our comfort zones and traditional methodologies.

The pivot of this decision-making process is the practitioner, who must evaluate and interpret evidence, from basic research to meta-analyses, in the context of their experience. This requires an understanding and judgment that goes beyond mechanical rule-following. It’s about engaging in meaningful conversations with patients, ensuring that decisions are made collaboratively.

Evidence Based Medicine, a movement in crisis: https://www.bmj.com/content/348/bmj.g3725

In our teams, we need to foster lateral thinking. We should explore how we construct our understanding, how we co-create meaning with others, and how this reflects in the broader healthcare ecosystem. This goes beyond the rigidity of traditional Evidence-Based Medicine frameworks. While ensuring patient safety is paramount, to improve clinical outcomes, a shift in mindset is essential.

This approach forms a new evidence base, one that goes beyond simple triangulation. It celebrates qualitative research, narrative medicine, and case reviews, creating more equality in the evidence hierarchy.

Rita Charon’s work in narrative medicine could provide valuable insights here. By emphasising the importance of patient stories and experiences, we can understand healthcare from a more holistic perspective. This approach aligns with the concept of shared decision-making and recognises the individuality of each patient’s journey.

This is not just about changing practices; it’s about transforming the culture of healthcare.

In conclusion, our duty in healthcare is not just to follow established protocols, but to continuously question and refine them. By focusing on the outliers, using language that emphasises humanity, and adopting a more holistic approach to decision-making, we can improve patient care and outcomes. It’s time we see beyond the system and reconnect with the obvious – the well-being of our patients and those who care for them.

When considering decisions related to valid consent and the Mental Capacity Act (MCA), it’s essential to remember that we often assume that all the choices important to us are readily available. We assume that the consequences of our choices, whether wise or unwise, remain neutral, and that these decisions won’t restrict our future plans through unforeseen consequences.

However, when working in the criminal justice system, it becomes apparent that power dynamics and the social constructs within which we operate can significantly impact decision-making. This, in turn, prompts us to contemplate the implications of these dynamics in relation to the Mental Capacity Act.

One of the consequences of being in an institution, such as a prison, is the presence of strict routines. To survive within such an environment, individuals often find themselves compelled to conform or behave in ways that can lead to negative outcomes and punishments.

Our behaviours tend to change when we’re in institutional settings like schools, workplaces, prisons, and hospitals. Take, for example, the famous Stanford prison experiment conducted by psychologist Philip Zimbardo in 1971. In this study, college students were randomly assigned to either play the roles of inmates or prison guards in a simulated prison environment. The experiment aimed to explore the psychological effects of perceived power and authority in a controlled setting.

What quickly became evident was how participants who assumed the roles of guards began to exert their authority over the “inmates.” They enforced rules, employed coercive tactics, and displayed dominant behaviours. Consequently, both the “inmates” and the “guards” experienced significant changes in their behaviour. The “guards” became increasingly authoritarian and abusive, while the “inmates” displayed signs of stress, anxiety, and submissive behaviour. Some prisoners even experienced emotional distress, leading to their premature removal from the study.

This study underscored how power dynamics and institutional roles can profoundly alter individual behaviour and autonomy. Unfortunately, we still have much to learn about how decision-making and consent are affected by these environments. While many individuals may possess the ability to demonstrate ‘capacity’—by identifying the relevant information, considering outcomes, and communicating their choices—determining whether a decision is genuinely freely given within an institution can be complex.

Here are some key factors influencing autonomy in institutional settings:

Conformity to Rules and Norms: Institutions often have strict rules and norms that individuals must adhere to, leading to a potential reduction in personal autonomy. This is particularly pronounced in prisons, where control and surveillance are high.

Hierarchical Structures: Institutions often have hierarchies with figures of authority, such as prison guards or medical professionals. This can pressure individuals to modify their behaviour and limit autonomy.

Standardisation: Institutions frequently standardise processes, leaving little room for personal creativity or decision-making.

Socialisation: Institutions socialise individuals into specific values and beliefs, shaping behaviour and limiting autonomy.

Accountability: The fear of consequences can influence behaviour and limit autonomy.

Group Dynamics: Peer pressure within institutions can either enhance or constrain autonomy.

Individuals with labels of learning disabilities, behavioural disorders, or conduct disorders may face unique challenges. Their impulsivity, defiance of rules, and difficulty controlling their behaviour can lead to disciplinary issues, further restricting autonomy.

Understanding how power dynamics operate in therapeutic and personal relationships, as well as in other systems creating power imbalances, presents challenges in the context of decision-making. This topic will be explored in a future blog.

We must adopt a more flexible approach to implementing the Mental Capacity Act. The Act serves two main purposes: protecting the autonomy of individuals with capacity and safeguarding those who lack capacity by involving them in decisions relating to them reflecting their wishes.

It’s important to note that legislation often does not apply to prison settings, adding complexity to the situation. Existing guidance, such as that from the National Institute of Clinical Excellence (NICE) and the General Medical Council (GMC), provides process information but may not fully address the challenges arising from power dynamics and decision-making barriers in specific contexts.

To better understand how the Mental Capacity Act can be applied in prison settings, we need to consider the influence of power on choice. We must examine how individuals can be documented as having capacity, how consent leads to choices and decision-making, and how power dynamics should be integrated into the narrative of consent and decision-making.

For more in-depth information and case law examples related to the Mental Capacity Act in prison settings, you can refer to the following article: https://www.cambridge.org/core/journals/the-psychiatrist/article/mental-capacity-act-and-mental-healthcare-in-prison-opportunities-and-challenges/8629D59D8E5F244512C0F845ED4DE9B9

By addressing these complex issues and acknowledging the pervasive influence of power in decision-making processes, we can strive for a more equitable and ethically sound application of the Mental Capacity Act in diverse settings. Such efforts have the potential to positively impact outcomes and enhance the overall experiences of those involved. We also recognise and empathise with the challenges that professionals often face in navigating this complex area of practice

In this second blog post, we delve into the intricate challenge of defining capacity within a binary system, particularly for individuals dealing with hyperarousal or trauma. We explore how these circumstances can hinder optimal cortical function and, consequently, influence capacity assessments.

As a sexual offence examiner working closely with trauma, I couldn’t help but notice how compliance was exhibited by many of the individuals we assessed. They seemed capable of articulating the information relevant to their decisions, retaining and weighing it, and effectively communicating their choices. However, we were acutely aware that these decisions were often rooted in compliance resulting from trauma. It’s well-known that the cortex struggles to function effectively in states of heightened adrenaline, leading to impaired decision-making.

So, how exactly does trauma impact capacity?

Traumatic experiences can deeply affect an individual’s cognitive processes, altering their perception of self, others, and the future. It’s common for trauma survivors to view themselves as inadequate or damaged, see the world as unsafe and unpredictable, and regard the future as bleak. These cognitive patterns profoundly impact their belief in their ability to utilise internal and external resources effectively.

In response to these challenges, we implemented a trauma-informed approach. This involved using grounding and reframing techniques, offering choices whenever possible, and recognising the crucial role of crisis workers as advocates.

As the professional responsible for these examinations, I had a dual responsibility: to ensure valid consent for the assessments made within this complex environment and to uphold my Professional Duty of Care, which encompasses the imperative to “do no harm.” This balance led me to reflect on the complexities of the Mental Capacity Act and the realisation that our clients might not fully comprehend the intricacies of their situations.

Our service was trauma-informed, with a commitment to avoiding re-traumatisation from repeat account recall and reducing the recording of inconsistencies in accounts. We also minimised the collection of sensitive medical history to protect confidentiality in the criminal justice system. Additionally, we employed empowerment and grounding techniques to help individuals reconnect with their cortex and mitigate the effects of adrenaline.

However, my inner thoughts remained unspoken, as I grappled with the fear of appearing paternalistic and potentially undermining individuals’ human rights and capacity to make decisions. This inner struggle created a self-deceptive thought process, hidden from those around me.

The unintended consequence of this inner conflict is that those who emulate my practice may view the mental capacity assessment as a straightforward process, overlooking the careful considerations I wrestle with.

In the many environments where I work as a forensic medical examiner, trauma and hyperarousal are common occurrences. In this context, the black-and-white questions of a binary system often feel overly simplistic, especially in a system where non-compliance carries consequences within the criminal justice system. Consent could often be considered compliance rather than valid but is recorded in our notes as an individual who made a choice and had capacity to make that decision.

Has The Mental Capacity Act impacted on our culture?

I have observed a lack of advocacy within our systems, with professionals fearing litigation if they deviate from the Mental Capacity Act. This may contribute to a loss of compassion, especially for those who appear to have capacity.

Trauma has a profound impact on the functioning of the limbic system, affecting the adrenal axis, cortisol levels, and neurotransmitter regulation, which can all lead to cortex shutdown. This results in tunnel vision, impaired memory, reduced creativity, and a tendency to follow the group, exhibiting behaviours like defensiveness, withdrawal, compliance, and an inability to make decisions. Our cognitive processes may create a facade of reasoned response, but beneath the surface, our brains are wired for safety and belonging. Trauma, power dynamics, coercion, and the complexity of systems often leave us overwhelmed or lacking the information needed to make informed decisions.

While I can mechanically follow the processes outlined in the Mental Capacity Act, my humanity often grapples with discomfort over the decisions. My emotional intelligence reminds me of my care for these individuals, pushing me to consider alternative approaches. However, this internal conflict leaves me feeling as though I am disempowering individuals and acting against legislation, leading to confusion.

It is crucial to remember that the purpose of the Mental Capacity Act is to protect human rights while serving as a decision-making tool. The notion of mental capacity as a binary concept, either having it or not, has left many practitioners, including myself, feeling uneasy. This approach appears to have led us to forget our duty of care, the principles of advocacy, and has enabled professionals to avoid making challenging decisions, such as addressing suicidal ideation.

These situations often raise profound ethical and moral questions:

Autonomy vs. Protection: Balancing an individual’s autonomy with the duty to protect them from harm is a complex challenge.

Ethical Deliberations: Difficult situations often give rise to deep ethical deliberations, which are rarely documented.

While the Mental Capacity Act recognises this complexity and provides principles and frameworks to navigate it, understanding the underlying value sets alongside the rules is crucial to avoiding poor decision-making. Neglecting these considerations can lead to compassion fatigue, toxic work cultures, and a failure to notice critical nuances.

Constructing this blog has been an intricate journey. While I can describe the Mental Capacity Act (MCA) in specific contexts, its nuances become more challenging when applied in complex circumstances. Each revisit brings forth new contradictions, compelling me to acknowledge the paradox within the Act.

I’ve chosen to delve into the intricacies of the MCA over a series of three blogs:

• The first examines the uneasy interplay between the Mental Health Act and the MCA.
• The second highlights the dilemma of defining capacity using a binary system, especially for individuals experiencing hyperarousal or trauma. Given that our cortex may not function optimally during these instances, how might this influence capacity assessments?
• The third discusses the power dynamics inherent within the MCA.

The significance of the MCA cannot be understated. Its primary intent is to safeguard and empower those who lack the mental capacity to decide for themselves. By ensuring decisions made in their best interest reflect their genuine feelings and beliefs, we aim for a more inclusive and empathetic approach, leaning on the principle of minimal restrictiveness.

Yet, history paints a grim picture. Numerous instances highlight individuals being detained against their will for supposed medical ‘treatment’ or undergoing paternalistic practices where decisions were imposed rather than informed by their personal experiences and perspectives.

The Intersection of the Mental Health Act and the Mental Capacity Act

The Mental Health Act primarily focuses on circumstances that permit the detention of an individual in a hospital for assessment or treatment without their consent. It seeks to ensure that those with severe mental disorders receive treatment when it is vital for their health, safety, or for public protection.

Criteria for Detention under the Mental Health Act dictates:

• The individual must be diagnosed with a mental disorder severe enough to justify detention for assessment or treatment.
• Detention must be necessary for the person’s health, safety, or to protect others.

The Act guarantees specific rights for detained patients, including:

• The right to contest their detention.
• The right to be informed of their rights.
• The right to seek legal counsel.
• The right to have their situation reviewed periodically.

The Act defines roles for various professionals. Approved Mental Health Professionals (AMHPs) and section 12 approved doctors play critical roles in the assessment process. Following an assessment, a person may be detained based on the criteria mentioned, admitted voluntarily with their consent, or, if they pose no significant risk, might be directed to local services for support.

Clearly one of the challenges, where beds are scarce, services overwhelmed and the criteria for treatment still unclear, the exact nature of a mental disorder is problematic and the threshold of risk to themselves and others, difficult to quantify.

While the Mental Health Act seems tailored specifically for addressing mental health, risk, and treatment, there has been an observed overlap with the Mental Capacity Act. Notably, the language of the Mental Capacity Act has been increasingly employed in discussions of risk management, particularly in cases of suicidal ideation, eating disorders, addiction, and other behaviours deemed by society as problematic.

Misinterpretation of the Mental Capacity Act: A Hindrance to Care

A compelling webinar underscores the pitfalls of misapplying the MCA, cautioning against its misuse as a shield to protect professionals from litigation—especially surrounding the contentious issue of capacity to make ‘unwise decisions’, including suicide.

View the webinar with Dr. Chloe Beale here. https://www.mentalcapacitylawandpolicy.org.uk/suicide-and-the-misuse-of-capacity-in-conversation-with-dr-chloe-beale/

There’s an alarming trend where the Mental Health Act is bypassed, often relating to those with personality disorders and other expressions of emotional distress. While these are not always considered grounds for detention or voluntary admission, sidelining them as mere “choices of behaviour” is deeply problematic. Those of us attuned to the complexities of the human psyche understand the limitations of the conventional medical model of mental health. As professionals, we’re bound by our ethical and moral duties to “Do no harm” and respond with care.

Yet, barriers persist. While we pride ourselves on evidence-based methodologies, the absence of a thorough understanding of the mind’s physiological processes creates rules and protocols, where much of the diagnosis and treatment is not understood. Traditional care models and systemic prerequisites to address emotional distress often sideline intuitive and empathetic responses. In this context, the ‘Open Dialogic Model’, which prioritises open conversations and patient involvement, offers a refreshing alternative.

It’s disheartening when I hear of individuals labeled as “non-contactable” or deemed to have made a “capacitated decision” not to seek care. From my experience, when genuine efforts are made to walk alongside these individuals, they are reachable. Instead of recording that they didn’t show up, we must ask: How can we effectively reach out to them? It’s not just about setting an appointment; it’s about creating an environment where they feel heard.

In our quest for holistic care, psychologists and therapeutic modalities often find themselves vying with medication and interventions. But considering the emerging evidence surrounding trauma, adverse childhood experiences, addiction, and personalities, I strongly advocate for a participatory model. Building connections, instilling hope, and fostering a sense of purpose can significantly alter an individual’s trajectory, steering towards healing and growth.

Let’s Prioritise Compassion and Understanding

I advocate for deeper and more meaningful conversations, rooted in understanding. We must Listen actively, Believe genuinely, and Respect unconditionally. It’s time we cultivate safe environments where individuals can navigate the tumultuous waters of hope and despair. If mental health is the primary concern, lets use the Mental Health Act and rather than defaulting to Mental Capacity Act that might pigeonhole individuals into categories of care declination, let’s shift our focus. Let’s genuinely notice those in distress, understand the pivotal role of advocacy, and present genuine opportunities for care and support.

Understanding the Essence of Paradox

Philosophers and thinkers have long been fascinated by paradoxes. They challenge our ingrained beliefs, forcing us to confront our knowledge’s limitations and the intricate nature of our surroundings. By breaking free from conventional thought patterns, paradoxes encourage innovative solutions and open the doors to unintended outcomes.

In Taoism, reality arises through the interaction of opposites: light and dark, life and death, unity and separation. Like the flow of water, decisions should move harmoniously with these contradictions. Currently, a prevalent mindset promotes the existence of one correct answer or viewpoint. However, to evolve, we must nurture a relationship with diverse possibilities.

The Paradox in Decision Making

Often, we see decision-making as a linear path, assuming a single opportunity to select an option. But decisions are seldom so straightforward. We must consider moving ahead slowly, continually evaluating our journey, and being open to modifications. By finding ways to engage both in divisive topics and complex matters, while maintaining respect and connection, we find harmony in the opposing perspectives.

Creating Spaces for Discussion

Establishing space to communicate about polarizing discussions is paramount. These dialogues, should be held in a manner that allows psychological safety, inclusion, and authenticity and should be fun and respectful to allow the best conversations.

These diverse dialogues aid mutual understanding. They let participants reflect on their values and biases while also examining unfamiliar perspectives. The crux of these conversations should be to discover a shared idea, emphasising collaborative progression rather than mere differences and like an orchestra play a symphony rather than a single note.

Embracing Paradox in Leadership and Organizational Growth

Successful leaders understand that paradoxes aren’t mere puzzles; they disrupt the status quo, promoting connection, shared opportunities, and a shift from rigid processes. Paradox theory indicates that past successes can breed complacency and resistance to change. To counter this, we need to constantly reinvent the idea of success by harmonising our rule-based, evidence-based, and values-based practices. By blending experience, emotion, intuition, instinct, and diverse perspectives, we foster confident decision-making even when definite answers elude us.

The Road Ahead

In essence, paradoxes aren’t just intellectual exercises. They are powerful tools that deepen our understanding of the world. As we strive to engage in difficult conversations, we must craft safe, inclusive environments. By celebrating differences and facilitating open discussions, we enable collaboration, empowering individuals and communities to embrace the multifaceted nature of existence and debate the paradox “Less is more.”