To appreciate

This refers to inability to apply information (including consequences of the decision) to oneself or one’s situation, whether due to false beliefs such as delusions or confabulations, lack of insight into one’s condition or associated care needs, or other reasons. Notably, in referring to appreciation, the courts often use the term ‘understanding’ but in a broader sense than mere comprehension, as in ‘understands that X and Y apply to P.’ The key point here is that various terms can be used but the concept is the same: the ability to apply the relevant information to one’s own situation.

The broad category of appreciation was the most frequently used rationale in court practice (accounting for 41% of all rationales used), with subcategories of factors that can lead to loss of appreciation, namely, ‘delusions or confabulations’, lack of ‘insight into condition or care needs’, and other factors.

The (American) Appelbaum and Grisso criterion of appreciation in the Four Abilities Model has a similar definition – see here for an introductory comparison of this and the MCA.

Inability example quotes from court practice:

Delusions/ confabulations: [P] believes that the tumour was placed in her body by ‘screen things’ with the aim of influencing the doctors into stating that the operation was needed

Insight: [P] denies that she suffers from schizophrenia, that she needs to take medication to remain well and avoid consequent relapse of her illness and renal failure. As a result she does not understand the need for supported accommodation.

Other appreciation: The point is that despite the overwhelming evidence to the contrary, [P] does not begin to appreciate that [Q] will not, under any circumstances, look after him

Intact ability example quote from court practice:

Delusions/ confabulations: The view that [P} wishes to put forward is that she does not want the case to continue and she would prefer to stay where she is… I do not think her view is unreasonable or driven by delusion.

Insight: She demonstrated an understanding of and insight into her care needs and the reality of life if she returned home. She clearly understands that she is in need of total support and would need carers to visit four times a day. Although she said she could dress herself “if I had to”, I did not interpret this as indicating a significantly exaggerated or distorted view of her capabilities. On the contrary, I found her to be broadly realistic as to her physical limitations.

Other appreciation: She denied inappropriate use of social media (“I have kept away from social media … I don’t want to go back to square one”), showing an understanding that people contacting her through social media “might be a risk to me”

Link to MCA criteria in court practice:

In court judgments, this rationale is most commonly linked to either the MCA criteria Understand or the criteria Use or Weigh but we suggest that you link it to Use or Weigh. See here for why.

Link to impairments of mind or brain in court practice:

  • ‘Appreciation: delusions/ confabulations’ was most relevant to court judgments involving subjects with Chronic Psychosis
  • ‘Appreciation: insight into condition or care needs’ was most relevant to court judgments involving subjects with Eating Disorder and Chronic Psychosis.
  • ‘Other appreciation’ was most relevant to court judgments involving subjects with Personality Disorder, but numbers were small.

See here for more discussion of the court practice, and here for more discussion of our recommendations.

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