From SN&H Practitioner workshop on 19/9/23:
What works well?
- Visiting the adult to see what this looks like in practice
- Talking, communication, support, understanding, not being judgemental
- Investigation, building a relationship, trust
- Being curious - how long has the property been cluttered/issues been going on? (history)
- Recent ill-health/trauma?
- See the service user's view
- What would be the individual's ideal situation?
- Let the person keep their own agency to resolve issues
- Utilise positive social support network
- Depends on risk - initial call to partners, e.g. social work, SFRS, NHS 24 - if needed, raise an ASP
- Deep cleaning and ongoing weekly housing support to maintain home environment
Sensitive and comprehensive assessment is important in identifying capabilities and risks. It is important to look further through a professional relationship into the possible significance of personal values, past traumas and social networks. Some research has shown that events such as loss of parents as a child, abuse as a child, traumatic wartime experiences, and struggles with alcoholism have preceded the person self-neglecting. The Ice-Breaker Form at Appendix 3 might be a helpful conversation starter.
The CoP (p21) notes that practitioners should be alert to the need to view behaviours that compromise health, wellbeing and safety as adaptations that may have played a useful role in the individual’s life in helping them to survive, and cope with, their experiences of trauma. Examples of such adaptations can include: maintaining contact with an alleged harmer; use of drugs or alcohol; self-harm; hoarding, and avoidance of places and people, including professional relationships and services, which may trigger reminders of prior traumatic experiences. In these circumstances, some people’s ability to take and action decisions about safeguarding themselves may effectively be compromised.
There may be a complex intersectionality of physical, social, personal and environmental factors based on each individual’s life experience. Practitioners should seek to understand any significance of self-neglect and harm based on the individual’s diverse life experience especially where they may have experienced forms of discrimination, trauma and life changing events.
It should be borne in mind that societal expectations of women vs men as caregivers, homemakers and placing value in their appearance, may lead to increased shame/guilt and reluctance to access support. Interconnected vulnerabilities may lead to more complex trauma for women, amplifying the challenges they face and making accessing support even harder. In addition, traditional gender roles may discourage men from seeking help which is also a negative outcome of gender inequality.
The CoP (p22) states that it is also essential to move from a position of looking at substance dependency in isolation and, instead, to see it in terms of relational causation and connection, i.e. a shift from the view that dependency causes self-neglect, to one that understands such dependency as an outward symptom or sign of deeper challenges and of self-neglect itself. As above, considerations of the impact of trauma on the individual’s ability to safeguard should be a thread throughout ASP activity [and any other intervention].
It is important to consider as part of the assessment if the individual has the skills and competencies, whether it is physical or mental, that can be applied and exploited. For example, an individual may be physically able to wash and dress and clean the house, but due to self-neglect they are not completing these tasks. Therefore, a significant risk to their health and wellbeing may arise. Where an individual may be able to do something for themselves but cannot due to self-neglecting behaviours, this may mean that they could be eligible for care and support.
The assessment process should include the person’s understanding of the cumulative impact of a series of small decisions and actions as well as the overall impact. Risk assessment and risk management (Appendix 4) is an essential part of the process and risk enablement is a core part of placing people at the centre of their own care and support. The focus should be on a person-centred approach to engagement and risk management leading to outcomes for the individual wherever possible.
The possibility of Gender Based Violence should be considered as part of any assessment of an adult at risk. Professional curiosity is essential, especially given higher rates of self-neglect/hoarding in older adults who may have different views/values around some forms of gender-based violence. Information about support services can be found online.
Professional curiosity and appropriate challenge should be embedded within an assessment:
- it is important that the practitioner does not make assumptions or accept the first, and potentially superficial response.
- do not accept things at face value.
- interrogate more deeply into how a person understands and could act on their situation.
- be honest about potential consequences while also being non-judgemental.
- separate the person from the behaviour.
- take time to get to know the person; and
- maintain contact and reliability.
The new Health and Social Care Standards: “my support, my life” are wide reaching and flexible and focused on the experience of people using services and supporting their outcomes. They are human rights based and underpinned by 5 principles: dignity and respect, compassion, being included, responsive care and support and wellbeing. They are no longer just focused on regulated care settings but for use in social care, social work, and health provision, and should be referred to when planning and delivering care. Find out more about Health and Social Care Standards.
Assessing mental capacity and trying to establish a root cause for self-neglecting behaviours is often a complex phenomenon. It is important that staff are familiar with and recognise the risk factors associated with this condition. Some people have insight into their behaviour, while others do not.
There are various reasons why people self-neglect:
- brain injury, dementia, or mental disorder;
- obsessive compulsive disorder or hoarding disorder;
- physical illness or disability which influences abilities, energy levels, organisational skills or motivation;
- alcohol or drug dependency or misuse;
- traumatic event or childhood trauma;
- social factors and diminished social networks;
- life-changing events such as bereavement and loss;
- fear, anxiety, or pride in self-sufficiency; and
- age-related changes.
Every adult has the right to make their own decisions and must be assumed to have capacity unless it is proved otherwise. Just because an individual makes what might be seen an unwise decision, they should not be treated as lacking capacity to make that decision.
Mental capacity is a key determinant of the ways in which professionals understand self-neglect and how they respond in practice. Where individuals lack capacity and there are concerns about self-neglect then the principles within the Mental Health (Care and Treatment) (Scotland) Act 2003 become relevant and anything done for or on behalf of the adult must be done in their best interests and should be the least restrictive of their basic rights and freedoms.
The Decision-Specific Screening Assessment Tool must be completed if an agency is in doubt that the adult lacks the ability to use and understand information to make an informed decision and communicate any decision made. It is also important to understand the function-specific nature of capacity, so that the apparent capacity to make simple decisions is not assumed automatically in relation to more complex ones.
Sometimes it may be necessary to override the person’s right to choose in situations where the adult has capacity to make informed decisions on the issues raised but refuses to engage and concerns continue to escalate. Such situations might include:
- Serious concerns for physical or mental health and wellbeing are adversely affected daily, including weight loss & pressure ulcers;
- When a services usual way of engaging with the adult at risk has not worked and no other options appear available;
- Enforcement is being considered using statutory powers.
Overlooking or dismissing these degrees of risk is not an acceptable solution and does not absolve any agency from their duty of care or professional responsibility. The agency should risk-assess and determine what intervention needs to be considered.
When engaging with an adult who is self-neglecting, and who may have difficulty with their executive functioning (the ability to plan, organise and complete tasks) consider whether:
- they have information in a format they can understand;
- conversations take place over time and the building up of a relationship;
- consider who can support you to engage with the adult;
- always involve attorneys or representatives if the adult has one;
- check whether the person understands their options and the consequences of their choices;
- ensure the adult is invited to attend meetings, where possible; and
- arrangements should be made for monitoring and making proactive contact with the adult at risk and, if they exist, extended family and community networks.