Any social worker working with vulnerable adults will be familiar with the issue of self-neglect, which is estimated by some studies to be a factor in about 20% of cases in mental health and older people’s services (May-Chahal et al, 2011: Day et al 2012). Self-neglect has not traditionally been treated as a safeguarding issue, yet these cases can be the most alarming and challenging on a social workers’ caseload, often involving serious difficulties and competing interests and really bringing into question one’s own value base.
Local communities are often very aware of individuals who are self-neglecting, and it is neighbours who commonly make referrals to social services, often very vociferously. A study by May-Chahal and Antrobus (2011) found evidence of “highly negative and abusive standpoints” by the wider community, particularly younger people, towards self-neglect.
Although participants were ambivalent about whether they would become involved in supporting someone who was self-neglecting, they all agreed that after a certain point, “someone should do something”, though they were also critical of health and social services because of resource constraints.
The study suggests that community tolerance and support can be important factors in whether the self-neglecting person will be able to remain living as they choose. Where neighbours are willing to become involved, social workers may have an important role in mobilising their support.
Some of the dilemmas for practitioners working with self-neglect are explored by Day et al (2012), an Irish study exploring social worker views. One theme was the idea of a “continuum of severity” with low level concerns (e.g. refusing services) potentially escalating to more troubling problems (e.g. living in squalor), rather than distinct categories of self-neglect. Participants stressed the importance of building therapeutic relationships with service users and gave vivid descriptions of the strategies that they use in building relationships to try to avoid being intrusive.
The ethical challenges are brought into sharp focus by Scourfield’s analysis of a serious case review following the death of JK, a 76-year-old woman, where the issues of choice and risk became dangerously confused in the way that services responded. He questions issues the idea of living in squalor being described as “lifestyle” choice and what is described as JK’s “eccentric”, “reclusive” lifestyle.
He notes how unhelpful such labelling can be. Scourfield considers the legal framework that may support social workers in self-neglect cases, but concludes that it offers no clear solutions. His points out that self-neglect is not a decision that people have arrived at, but something that has often come about by default, for “most people do not, at some clear point in their lives, choose to live in squalor and danger”. He discusses the importance of skilled, thorough risk assessment that sets out to understand what the risks mean from the service user’s perspective.
Questions for practitioners
- Using the concept of a continuum, how bad are the problems at this point? Do risk assessments clearly incorporate the service user’s perspective?
- Are you seeing the picture clearly or are your views being swayed by the labels this service user has acquired, or their historical reputation? Is it really the person’s ‘choice’ to live in the way that they are? What has brought them to this ‘choice’?
- Is pressure from neighbours making you act in a way that may not necessarily be in the service user’s best interests? Alternatively, have the neighbours got a point?
- What other professionals need to be involved? Can recourse to the law help?
- How can a trusting relationship be built up? How can resources be identified and mobilised to support the service user?
Day, M. R., McCarthy. G., & Leahy-Warren, P. (2012) Professional Social Workers’ Views on Self-Neglect: An Exploratory Study. British Journal of Social Work, Volume 42, pp725-743.
May-Chahal, C. & Antrobus, R. (2011) Engaging Community Support in Safeguarding Adults from Self-Neglect. British Journal of Social Work, advance access, published 17 November 2011.
Scourfield, P. (2010). Reflections on the serious case review of a female adult (JK) Journal of Adult Protection, Vol 12, Issue 4, pp16-30.
A guide to self-neglect assessments