What is the profile of people with mental health problems and modified legal capacity?
“Years ago, I was declared legally incapacitated, just in case, or to see if I could get some help.” In 2016, an independent woman, living at home without external support, caring for her grandchildren, and volunteering in various community activities, was talking to a neuropsychologist about participating in a research study. She couldn't do so without her guardians' permission. This woman had been diagnosed with schizophrenia and, despite her high level of functioning, had been legally declared incapacitated. What was striking wasn't just the statement itself, but what it reflected: measures designed to protect people might be applied in a way that was poorly suited to the realities and autonomy of some individuals.
And that opened up an uncomfortable but necessary question: how can it happen that someone with a high level of daily functioning has their ability to make decisions restricted in key areas of their life?
Modification of legal capacity
To understand this, we need to clarify a central concept: legal capacity. This refers to the right every person has from birth to make decisions and assume obligations in different areas of life. This includes everyday decisions like choosing where to live, and more formal ones like signing an employment contract, getting married, or exercising the right to vote.
Before 2021, in Spain, with the intention of protecting people with disabilities, procedures known as legal incapacitation were applied. This could be total (if the person was deemed incapable of making decisions in all areas of life) or partial (only in some areas of life, such as financial management). The term "disability" encompassed pathologies as diverse as neurodegenerative diseases, intellectual disabilities, and serious mental health problems, among others. However, in many cases, these measures focused less on providing support and more on limiting rights , which constituted a violation of fundamental aspects of personal autonomy.
In June 2021, Law 8/2021 came into force, bringing about a profound change in how the rights of people with disabilities are understood and protected. This reform aimed to guarantee that all people can exercise their legal capacity on an equal basis, with the necessary support to make decisions about their own lives. The law adopted the principles of the 2013 United Nations Convention on the Rights of Persons with Disabilities , which understands disability as the result of the interaction between the person and environmental barriers, and not as a fixed or immutable condition. From this perspective, a person's capacity can change over time, and the system must be flexible to adapt to these changes.
All people should be able to exercise their legal capacity on equal terms, with the necessary support to make decisions about their own lives.
With the new legal framework, legal incapacitation proceedings were eliminated, and a focus shifted to a personalized support approach . This support includes assistance with decision-making, communication aids, environmental adaptations, and guidance in complex situations. For example, just as we understand that information provided by a bank about a mortgage is complex and difficult to read, and we often consult a manager or lawyer to clarify it, materials such as informed consent forms or authorizations for medical procedures can be highly complex to read and understand. This does not mean that the person is incapable of making decisions. The goal is no longer to decide for the person, but to help them decide for themselves.
However, when we apply this legal change to the field of mental health, important questions arise for which we still lack clear answers. What profile do the people whose legal capacity is modified have? Are there diagnoses specifically associated with these processes? The lack of data made it difficult to understand how these measures were being applied and what adjustments are needed from the health, social, and legal perspectives .
Given this lack of studies in our context, and with the aim of contributing knowledge on such a sensitive and relevant topic, the RECAPACITA project emerged, aimed at better understanding the support needs of people with mental health problems in decision-making processes.
The RECAPACITA project: getting to know people to adjust support
The name RECAPACITA is a play on words in Spanish. On the one hand, it means to reflect or rethink something in depth; on the other, it refers to the possibility of regaining capacity. This double meaning aptly summarizes the spirit of this project, promoted by the Parc Sanitari Sant Joan de Déu : to critically review how legal decisions have been made regarding people's capacity and to explore alternatives more suited to their reality.
The RECAPACITA project, led by Dr. Elena Huerta and funded by the Carlos III Health Institute with support from the Agency for Management of University and Research Grants (AGAUR), has involved a multidisciplinary team of professionals in psychiatry, social work, psychology, and neuropsychology. Its objective from the outset in 2018 was to generate relevant knowledge from a health, social, and legal perspective, and to contribute to fairer and evidence-based capacity modification processes .
The RECAPACITA study reviews how legal decisions have been made regarding people's capacity and explores alternatives more in line with their reality.
To this end, between September 2018 and May 2022, 77 adults diagnosed with a severe mental disorder and a court order modifying their legal capacity were assessed. Sociodemographic, clinical, neuropsychological, and daily living functioning data were collected and compared with those of individuals with a similar diagnosis but without a legal capacity modification. In addition, the court orders were analyzed to see how the new procedures aligned with the guidelines of the United Nations Convention, evaluating both the reasons for modifying capacity and the language used to refer to the individuals.
As a result of this work, four scientific articles have been published to date, providing objective data and opening new avenues for reflection and intervention in an area of significant impact on people with mental disorders. This is a unique study in our country , using information that is difficult to obtain, which allows us to offer a rigorous and necessary perspective on this reality.
Main results of the RECAPACITA project
Description of the profile of the people
The first article of the RECAPACITA project (Marcó-García et al., 2023) focuses on describing the profile of people diagnosed with severe mental disorder whose legal capacity had been modified.
At the sociodemographic level , the results showed a fairly defined profile: the majority of those evaluated were 52 years old on average, male (74.7%), had a basic primary education, were single (74%), and had a diagnosis of schizophrenia (87%). Regarding their employment status, most were incapacitated for work (81.8%) and had low incomes, with monthly earnings not exceeding €1,000 (79.5%).
Clinically , negative symptoms such as apathy, lack of initiative, and difficulty initiating activities clearly predominate, with moderate to severe intensity. In contrast, positive symptoms, such as delusions and hallucinations, are generally mild, and depressive symptoms are minimal.
At a cognitive level , although they maintain a normal intellectual level and good attention, language, and working memory skills, they present mild cognitive impairment , which particularly affects executive functions (planning, organization, inhibition) and memory. In daily life, these individuals show moderate difficulties in their overall functioning , especially in leading an independent life, along with a low awareness of the disorder—a relevant aspect because it can prevent them from identifying their own difficulties and, therefore, from making decisions or asking for support when needed.
What is a support plan and how is it developed?
Differences between people with total and partial capacity modification
The second article (Marcó-García et al., 2024) analyzes the differences between people with a total capacity modification and those with a partial modification.
Compared to people with a partial impairment, people with a total impairment exhibit:
- Greater institutionalization.
- Lower income.
- More severe symptoms (especially positive symptoms).
- Worse overall performance.
- Less awareness of the disorder.
- Slightly lower cognitive performance in memory and executive functions.
In addition to comparing both profiles, a brief screening was included to assess the ability to make a decision in a specific situation: whether or not to participate in the research. The results showed that both groups had difficulties, although these were more pronounced in individuals with a significant impairment of overall capacity. This group had greater difficulty, particularly in evaluating and reasoning about the risks of participating in the research. These findings suggest that the degree of impairment of capacity does not depend on a single factor , but rather on a complex combination of clinical, functional, and social variables, beyond symptoms or cognitive performance alone.
Differences between people with and without capacity modification
The third article (Marcó-García et al., 2025) focuses on the neuropsychological profile and analyzes whether there are relevant differences between people diagnosed with severe mental disorder with and without impaired capacity. To this end, three groups were compared:
- People diagnosed with severe mental disorder without impairment of capacity.
- People with partial modification
- People with total modification.
All three groups exhibit mild cognitive dysfunction , particularly in executive functions, memory, and processing speed—a common pattern in severe mental disorders. Clinically, individuals with impaired cognitive abilities show poorer verbal learning skills , have more difficulty memorizing and freely recalling information, which may have impacted their previous work and family functioning.
Most people with mental disorder and capacity modification are men, diagnosed with schizophrenia, with completed primary education and work incapacity, with incomes below 1,000 euros per month.
In addition, an interesting positive relationship was observed: the better the ability to memorize, the better the ability to make decisions , suggesting that this cognitive function could act as a relevant preliminary marker in the processes of modifying ability or as a key area of intervention and support (e.g., adapting the way information is presented, repeating, summarizing, using memory aids).
Nevertheless, the cognitive differences between the groups are relatively small, which reinforces the idea that the modification of capacity cannot be justified by a cognitive profile alone, but rather requires a comprehensive evaluation that also takes into account clinical and social aspects.
Impact of the Convention on judicial rulings modifying capacity
Finally, the fourth article (Marcó-García et al., 2024) analyzes the impact of the United Nations Convention on the Rights of Persons with Disabilities and Law 8/2021 on judicial rulings modifying capacity, assessing whether they have led to changes in the criteria used and the terminology employed.
The data offers an initial glimpse into the direction the legal landscape in Spain is taking. More recent rulings tend to be more individualized, with a greater emphasis on the person's support needs . New proceedings no longer begin with generic concepts such as "the presence of a chronic and irreversible mental disorder," but are becoming more personalized, with increased references to more specific aspects, such as substance use or adherence to treatment.
The modification of capacity does not depend solely on psychopathological or cognitive factors, but on a complex combination of clinical, functional, social and contextual factors, which can vary over time.
However, the results also highlight areas for improvement . Future judicial procedures should more clearly describe how support needs are assessed and revise the terminology used, since in 100% of the judgments analyzed, the person is still described as "presumed incapable," a term that does not fully align with the spirit or guidelines of the Convention.
Conclusions and reflections on the results of the study
The RECAPACITA project has provided in-depth knowledge of the profile of individuals with severe mental illness and legal capacity modifications, as well as the clinical, cognitive, functional, and legal impact of these processes. The findings offer a solid foundation for guiding both clinical practice and judicial decisions , ensuring fairer and more personalized approaches.
General reflections:
- The severity of psychopathological symptoms is closely linked to decision-making capacity, regardless of the psychiatric diagnosis.
- The majority of people with mental disorder and capacity modification are men (74.7%) diagnosed with schizophrenia (87%), with completed primary education and work incapacity (81.8%), with incomes below 1,000 euros per month (79.5%).
- Clinically, they present moderate to severe negative symptoms , mild positive symptoms, and minimal depressive symptoms, with moderate impairment of overall functioning and low awareness of illness.
- Cognitively, they show mild impairment in executive functions and memory, intelligence quotient within normality, and attention and language in the low range of normality.
- Functionally, they have difficulties leading an independent life , especially those who reside in hospital environments.
- People with total capacity modification (tMC) usually come from hospital settings , receive lower incomes, present more severe symptoms, worse overall functioning, less awareness of illness, and lower cognitive performance in memory and executive functions than people with partial modification (pMC).
- The modification of capacity does not depend solely on psychopathological or cognitive factors , but on a complex combination of clinical, functional, social and contextual factors, which can vary over time.
- There is a positive correlation between memory coding and decision-making ability, which could serve as a preliminary predictive marker and guide personalized interventions.
- The UN Convention on the Rights of Persons with Disabilities and Law 8/2021 have had a positive impact on judicial procedures for modifying capacity , promoting a more individualized approach focused on support needs, although it is still necessary to review the terminology used in judgments, which continues to describe the person as "presumed incapable" in 100% of the cases reviewed.
- Current rulings reduce references to general concepts such as "personal autonomy" and place greater emphasis on specific aspects such as substance use and therapeutic adherence, among others.
Clinical implications of the study
The findings of the RECAPACITA project offer several key lessons for clinical practice:
- A comprehensive assessment of daily autonomy, awareness of the disorder, and cognitive abilities is essential to design personalized supports that enhance decision-making and autonomy, rather than being based solely on diagnosis.
- The needs of people with impaired abilities are heterogeneous, so the support must be adapted to each situation : support in decisions, aids for communication, adaptation of the environment or advice in complex situations.
- Early detection of vulnerabilities, such as increased institutionalization, low income, or severe symptoms, allows intervention before the person loses opportunities to control their life.
- Executive function and memory training can improve autonomy and decision-making ability, even in people with mild cognitive impairment.
- Adapting materials and content will be key to facilitating the first step: understanding the information. Having materials in health and other social areas available in easy-to-read formats will help people.
- Clinical and neuropsychological information should also be used to inform legal proceedings, avoiding unnecessary overprotection.
- The training and awareness-raising of professionals in Mental health, social work, and law are fundamental to ensuring that assessment and support processes are evidence-based, respectful, and person-centered.
