Self-neglect at a glance
At a glance 71. Published October 2018.
Self-neglect is an extreme lack of self-care, it is sometimes associated with hoarding and may be a result of other issues such as addictions. Practitioners in the community, from housing officers to social workers, police and health professionals can find working with people who self-neglect extremely challenging. The important thing is to try to engage with people, to offer all the support we are able to without causing distress, and to understand the limitations to our interventions if the person does not wish to engage.
What is self-neglect?
- Lack of self-care to an extent that it threatens personal health and safety
- Neglecting to care for one’s personal hygiene, health or surroundings
- Inability to avoid harm as a result of self-neglect
- Failure to seek help or access services to meet health and social care needs
- Inability or unwillingness to manage one’s personal affairs
What causes self-neglect?
It is not always possible to establish a root cause for self-neglecting behaviours. Self-neglect can be a result of:
- a person’s brain injury, dementia or other mental disorder
- obsessive compulsive disorder or hoarding disorder
- physical illness which has an effect on abilities, energy levels, attention span, organisational skills or motivation
- reduced motivation as a side effect of medication
- traumatic life change.
Sometimes self-neglect is related to deteriorating health and ability in older age and the term ‘Diogenes syndrome’ may be used to describe this. People with mental health problems may display self-neglecting behaviours. There is often an assumption that self-neglecting behaviours indicate a mental health problem but there is no direct correlation.
Hoarding is now widely considered as a mental health disorder and appears in the US ‘Diagnostic and statistical manual of mental disorders’ (5th Edition). Hoarding can sometimes relate to obsessive compulsive disorder but hoarding and self-neglect do not always appear together and one does not necessarily cause the other.
Self-neglect: what are the issues?
People who neglect themselves often decline help from others; in many cases they do not feel that they need it. Family or neighbours can sometimes be critical of professionals because they don’t do anything to improve the situation of the individual. But there are limitations to what others can do if the adult has mental capacity to make their own decisions about how they live. Sometimes, even when all agencies have done everything in their power to support an individual, they may die or suffer significant harm as a result of their own action or inaction. It is therefore vital that all efforts to engage with and support an individual are clearly recorded.
The inclusion of self-neglect in the Care Act statutory guidance with regard to safeguarding focused attention on the issue and led local authorities to develop new approaches to working with people. In some cases, where the adult has care and support needs, safeguarding responses may be appropriate. However, the inclusion of self-neglect in statutory guidance does not mean that everyone who self-neglects needs to be safeguarded.
Safeguarding duties will apply where the adult has care and support needs (many people who self-neglect do not), and they are at risk of self-neglect and they are unable to protect themselves because of their care and support needs. In most cases, the intervention should seek to minimise the risk while respecting the individual’s choices. It is rare that a total transformation will take place and positive change should be seen as a long-term, incremental process.
Barriers to good practice
- Working with people who self-neglect can be alarming and very challenging.
- People who self-neglect may refuse support or fail to acknowledge the problem.
- The risks associated with self-neglect can be high and the options for intervention are limited.
- There can be pressure on professionals to take action, but often very little they can do.
- There is often a lack of clarity about who should take responsibility for supporting people who self-neglect.
- Work patterns and resources don’t support long-term, relationship-based work.
- Individuals don’t always have care and support needs – so safeguarding responses may not be appropriate.
- Where the Safeguarding Adults Board isn’t appropriate there may be no alternative decision-making forum.
- Information sharing is sometimes problematic, particularly when the person refuses help.
- Limited legal literacy – professionals may not have a good understanding of the law that can be utilised in relation to self-neglect.
- Application of the Mental Capacity Act can be very complex in relation to self-neglect.
- Lack of resources can prevent appropriate service responses.
- The Care Act (2014) statutory guidance – self-neglect is included as a category under adult safeguarding.
- Article 8 of the Human Rights Act 1998 gives us a right to respect for private and family life. However, this is not an absolute right and there may be justification to override it, for example, protection of health, prevention of crime, protection of the rights and freedoms of others.
- Mental Health Act (2007) s.135 – if a person is believed to have a mental disorder and they are living alone and unable to care for themselves, a magistrate’s court can authorise entry to remove them to a place of safety.
- Mental Capacity Act (2005) s.16(2)(a) – the Court of Protection has the power to make an order regarding a decision on behalf of an individual. The court’s decision about the welfare of an individual who is self-neglecting may include allowing access to assess capacity.
- Public Health Act (1984) s.31-32 – local authority environmental health could use powers to clean and disinfect premises but only for the prevention of infectious diseases.
- The Housing Act 1988 – a landlord may have grounds to evict a tenant due to breaches of the tenancy agreement.
A strategy for good practice
Local authorities should work with partners to ensure:
- strategic and operational infrastructure and coordinated interdisciplinary involvement overseen by the Safeguarding Adults Board or equivalent
- there is agreed policy and guidance on self-neglect that includes clear referral routes and strategy for dispute resolution
- a multi-agency approach from strategic level to work on the ground, including shared ownership, risk assessment and management
- the Mental Capacity Act is well understood and implemented in the context of self-neglect; making sure that the presence of mental capacity is not used as a justification for inaction
- a clear record is made of interventions, decisions and rationale
- relationship-based working and time for long-term work is supported
- pressure from others (agencies/family/neighbours/media) is managed
- training, supervision and support for staff dealing with people who self-neglect to help them understand the complexities of this area of work, the possibilities for intervention and the limitations.
Positive engagement and best practice
The research on self-neglect suggests beneficial approaches and a range of options, levers and practical measures that could help engagement with individuals.
In the past we may have intervened in ways that prioritised the views of others rather than trying to work from the perspective of the individual. Research has shown that those who self-neglect may be deeply upset and even traumatised by interventions such as ‘blitz’ or ‘deep cleaning’. When developing an approach it is important to try to understand the individual and what may be driving their behaviour. There are some general pointers for an effective approach:
- Multi-agency – work with partners to ensure the right approach for each individual
- Person centred – respect the views and the perspective of the individual, listen to them and work towards the outcomes they want
- Acceptance – good risk management may be the best achievable outcome, it may not be possible to change the person’s lifestyle or behaviour
- Analytical – it may be possible to identify underlying causes that help to address the issue
- Non-judgemental – it isn’t helpful for practitioners to make judgements about cleanliness or lifestyle; everyone is different
- Empathy – it is difficult to empathise with behaviours we cannot understand, but it is helpful to try
- Patience and time – short interventions are unlikely to be successful, practitioners should be enabled to take a long-term approach
- Trust – try to build trust and agree small steps
- Reassurance – the person may fear losing control, it is important to allay such fears
- Bargaining – making agreements to achieve progress can be helpful but it is important that this approach remains respectful
- Exploring alternatives – fear of change may be an issue so explaining that there are alternative ways forward may encourage the person to engage
- Always go back – regular, encouraging engagement and gentle persistence may help with progress and risk management
- Risk assessment – have effective, multi-agency approaches to assessing and monitoring risk
- Assess capacity – ensure staff are competent in applying the Mental Capacity Act in cases of self-neglect
- Mental health assessment – it may, in a minority of cases, be appropriate to refer an individual for Mental Health Assessment
- Signpost – with a multi-agency approach people can be signposted to effective sources of support
- Contact family – with the person’s consent, try to engage family or friends to provide additional support
- Decluttering and cleaning services – where a person cannot face the scale of the task but is willing to make progress, offer to provide practical help
- Utilise local partners – those who may be able to help include the RSPCA, the fire service, environmental health, housing, voluntary organisations
- Occupational therapy assessment – physical limitations that result in self-neglect can be addressed
- Help with property management and repairs – people may benefit from help to arrange much needed maintenance to their home
- Peer support – others who self-neglect may be able to assist with advice, understanding and insight
- Counselling and therapies – some individuals may be helped by counselling or other therapies. Cognitive behaviour therapy, for example, may help people with obsessive compulsive disorder, hoarding disorder or addictions
Resorting to enforcement action should be a very last resort with people who self-neglect. There are some options that can be used in extreme circumstances but often the threat of enforcement can encourage and individual to accept help and support. Levers may include housing enforcement options based on tenancy or leasehold breaches and environmental health enforcement based on a public health risk. Local authorities also have powers relating to anti-social behaviour that may be relevant in a minority of cases.