Self-neglect: the tension between human rights and duty of care

Self-neglect was written into safeguarding procedures for the first time under the Care Act 2014, but has the change helped social workers?

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Photo: Gary Brigden

Just four days before Robert Crane died in a fire at his flat, social services closed his referral.

Robert had refused a community care assessment and a social worker had deemed his hoarding “a lifestyle choice” that he had the capacity to make.

The 61-year-old had a history of mental illness and was known to services for regularly lighting fires and stockpiling flammable items in his home. Care teams and housing officers would arrive to find broken furniture and electrical speakers piled high inside. Sometimes the only way to get in was climbing over a broken sofa that partially blocked the front door.

An inquest held last month found Robert’s death was accidental. However, a serious case review identified missed opportunities to intervene. Services had failed to take Robert’s mental health history into account when assessing his capacity. They had also failed to recognise that his inability or unwillingness to engage with services was a risk in itself.

Robert’s son, Alexander, accused social services and the mental health trust of “ignoring and downplaying” his father’s medical history and failing to take responsibility for his care.

The safeguarding board’s chair warned the review contained lessons around handling the “complex issues” of self-neglect and mental capacity. In response, commissioners said the inclusion of self-neglect in the Care Act 2014 had given agencies “clearer” duties to intervene.

Robert’s case occurred before the implementation of the act in April 2015 and his referral to social services was for a community care assessment, not a safeguarding intervention. The then guidance on safeguarding adults in England, No Secrets, excluded self-neglect.

The Care Act’s statutory guidance lists self-neglect as a category of abuse or neglect that may prompt a safeguarding enquiry. Under section 42, councils must make whatever enquiries they think necessary where an adult has care and support needs, is experiencing or at risk of abuse or neglect, and is unable to protect themselves because of their needs.

Social workers say the change has led to a spike in self-neglect referrals. But are services any clearer on how to handle these cases when they arrive?

‘Limited options’

Gary Fitzgerald, chief executive of Action on Elder Abuse, says the way self-neglect has been written into the Care Act guidance is flawed – “it was an afterthought” – but acknowledges that the safeguarding route has added to the fairly limited options already available to services.

Prior to the Care Act coming into force, he explains, section 47 of the National Assistance Act allowed for the removal of an older or disabled person from their home, if they were deemed to be living in insanitary conditions and not able to care for themselves.

But this was only used in extreme circumstances and was repealed under the Care Act on the basis that it was incompatible with human rights law. More often, services would look to set up some home care support and an “in-depth clean-up” with the person’s agreement.

“This was basically getting someone’s living conditions and personal care back up to a level that was not a public health risk, before withdrawing again. But in terms of intervening and encouraging people to live differently, there were not many other options. People just existed in the community and neighbours complained, which wasn’t very satisfactory.”

Adi Cooper, safeguarding lead at the Association of Directors of Adult Social Services, remembers commissioning high numbers of these cleans in her days as a team manager.

“Six months later we saw the same level of hoarding – now we know why,” she says.

“We weren’t looking at the underlying causes of why someone might hoard, and what might help them deal with it. We were only looking at the presentation and trying to deal with that.”

‘Building trusting relationships’

Cooper says social workers have historically struggled with self-neglect cases because an evidence base for intervention has only emerged fairly recently.

A Social Care Institute for Excellence briefing last year by leading self-neglect researchers Suzy Braye, David Orr and Michael Preston-Shoot highlighted some of the key issues facing practitioners. These included different thresholds for intervention between agencies, uncertainty over the law and the fact that self-neglect did not fit neatly into local authority workflows because of the time needed to build relationships.

“What we know now is that building up a relationship of trust, helping the person early to reduce the things that are causing them harm and to improve resilience and self-protection so they do not place themselves at risk of harm anymore, is more likely to work,” says Cooper.

Cooper welcomes the Care Act guidance and feels it has offered a much clearer framework for working with self-neglect, with the safeguarding system potentially beneficial where social workers identify a serious risk of harm.

“Often these cases require input from the fire service or environmental health, for example, and we know that having a safeguarding approach in terms of multi-agency engagement and involvement, when supporting someone at considerable risk, is more effective.”

‘Duty of care vs. choice’

The research by Braye, Orr, and Preston-Shoot also highlighted the challenge self-neglect poses to professional values and the conflict between duty of care and promoting choice.

This tension is present in the Care Act guidance, which says any concerns about self-neglect “do not override” the principle, set out in section 1 of the act, that any restriction on an individual’s rights should be kept to “the minimum necessary”. A decision on whether a response is required under safeguarding should be made on a case-by-case basis and “will depend on the adult’s ability to protect themselves by controlling their own behaviour,” it adds.

Mark Harvey, principal social worker at Hertfordshire council, says the case-by-case approach is vital because the term self-neglect “covers a thousand different scenarios”.

“I think in the last three years we’ve moved a little bit into a world where the person is seen as the source of the problem, but we know they’re not – it’s wider societal factors.

“These impact on the individual and then they develop choices from that, or they get driven down a route where they have no choice – it could be substance misuse, poverty, crime, abuse, the list is endless and that’s why you can’t define it.”

‘Good social work’

The first thing Harvey says he’d ask a social worker is “whose problem is this?”

“Nine times out of 10 the referral hasn’t come in from the person saying ‘I’m hoarding and I’d like to stop’ – it will have come from the ambulance service, a health visitor, a neighbour.

“They think that because the Care Act now says self-neglect is a safeguarding issue that we can just accept control and people will have a much nicer life.

“That’s not the reality and that’s not the reality of social work. There will be cases where we do need to effect some change but again you do that through good social work and use of the tools you have. You don’t necessarily do it through safeguarding.”

For Harvey, the key is building relationships and making sure the person is “absolutely” at the heart of any process, even if they lack capacity to make relevant decisions.

“You need to understand how they got to that position and what they would have done prior to lacking capacity. Has this only come about because they’ve lost capacity? That’s a very different thing to if they’ve always lived like this.”

The line where you have the problem, he feels, is in cases where the person has capacity to make relevant decisions, chooses to continue living in a certain way and is unwilling to engage.

“Then that’s human rights, isn’t it? I think part of the problem is everyone just thinks ‘refer it to social work and they can do some of that Mental Capacity Act stuff’. There is a perception that you must lack capacity if you are living like that, and that’s just not true.

“You have to accept that there are certain people who have capacity and will decide not to engage. However unpalatable that is to the community and society as a whole, it’s a reality.”

‘Two different scenarios’

FitzGerald says social workers would’ve been helped in this regard if there had been greater debate over how self-neglect should be included as a safeguarding issue under the Care Act.

“There are two parts to self-neglect and I think this is what causes the difficulty and anxiety.

“The first scenario involves a person who is self-neglecting not through a life choice, but through their circumstances. An older person may have lost their partner, for example, and is starting to deteriorate. Or a person may not have enough money to care for themselves.

“This would clearly be a scenario that would benefit from intervention from adult protection.”

The second scenario involves the “life choice” and that is a human rights issue, he adds.

“I think what we’re struggling with here is less the issue of self-neglect and more how far does the choice and control debate take you – where is the balance?

“I would not have put self-neglect under adult protection – or if I did, I would have narrowly defined it to that first scenario, where it’s a result of those outside factors.”

‘Thorough capacity assessment’

The issue is further complicated where there are concerns about the impact of the adult’s self-neglect on other people, where it is considered to be anti-social behaviour or where it puts a person’s tenancy at risk. All three of these issues were present in Robert Crane’s case.

The serious case review concluded that agencies had underplayed the risks Mr C’s behaviour posed to others and this meant that decisions were made predominately on the basis of his willingness to comply, or assumptions about his capacity to choose how he lived.

“Mr C’s circumstances were seen as lifestyle choice, but insufficient attention was paid to the threat his behaviours posed to others, particularly in relation to the accumulation of rubbish in his flat and his propensity to start fires. This behaviour, together with his diagnosis of bipolar disorder, should have led to a thorough assessment of his mental capacity,” the report said.

It added that staff needed to be able to challenge and work assertively with the level of self-neglect being shown by Robert, in the context of his history of mental health problems.

Harvey says that if the risk is so significant it poses a wider risk – and “we can’t just say well that’s a choice” – then you should involve the person in any decision-making that might result in more instructive intervention. “The classic one everyone talks about is fire risks,” he says.

“Social workers aren’t the ones to deal with that really, it’s got to be a collaborative approach with the individual, the fire service, maybe the housing department if they’re involved…

“The social worker I think is the key in allowing those relationships between everyone concerned to hopefully get a resolution, rather than just stepping in.”

‘The jury’s out’

For Harvey, the jury is still out on whether the Care Act changes will have the desired effect.

“My view is that I don’t actually see what value bringing self-neglect into the safeguarding framework gives it. An investigatory meeting is going to give you nothing. You’re just going to ask the social worker to do some good social work, which they would have done originally.

“But I don’t think we should just drop it – let’s evaluate it and see if it does bring value to people’s lives by having it within those safeguarding arrangements.”

 

 

14 Responses to Self-neglect: the tension between human rights and duty of care

  1. Maharg November 23, 2016 at 11:53 am #

    Self-neglect. If this individual cannot be detained under the mental health act, are not breaking any laws, and have the mental capacity to make a decisions, unwise or other. What piece of legislation can be use to promote changes in their situation and environment. If individuals are not willing to engage based on our concerns. I perceive Injurious detention is not going to be regularly used?.

    Good old-fashioned social work and building a relationship may be the best option. However, with local authorities busy cutting the legs off of social work team, with an expectation that people can pick up and fill the gaps. Concern is ongoing promotion intervention on self-neglect cases .

    “It can be difficult to safeguard people who are busy sawing the branch off, the one they are sitting on, whilst saying safeguard me . I have capacity. !”

    This is not to say that we don’t try, but failure has highlighted above often results to serious case reviews and enquiries.

  2. Yvonne Bonifas November 23, 2016 at 1:26 pm #

    I argued in authority for self neglect to be brought within safeguarding. At the very least it ensures the problems are formally discussed – it was always too easy to ignore under the heading of lifestyle choice.
    I’ve never come across a self neglecter who requests to go back to living in filth and squalor.

    • Tracey November 23, 2016 at 8:26 pm #

      I disagree with that statement. In my experience, not all except that they are living in squalor. There is often a level of denial and they do refute help. One argument that I received when working with a service user was and I quote “I have lived into my 90’s without your help. Why do I need it now? “. He clearly understood the situation he chose to live in. It is so frustrating. The Care Act is wooly at best and often clashes with Human Rights Act

    • Toconclude December 9, 2016 at 8:57 pm #

      I have, many times. The idea that everyone knows what’s good for them “really” is naive. Some people do make repeated choices to live in appalling conditions for a variety of reasons – and more in conditions other people turn their noses up at but are just not “nice”. Formal discussion is fine, but how this guarantees anything improves beats me. It just means that families, at the end of their own resources to change the situation or sometimes not wanting to stay involved, have someone they can take pot shots at because social services “must” be able to “do something” – usually involving magic, if experience is anything to go by.

  3. Ilanit Aharoni November 23, 2016 at 1:38 pm #

    It needs to be addressed also that people do continue to self neglect even when put into care and there is a thin line between abuse and neglect so sometimes care homes have no choice but to allow a certain level of self neglect and intervene at a later stage . There are people who refuse eg to be changed after they have been incontinent . The important thing is to monitor and encourage that person until they do consent even if it may be an hour later rather than abuse their human rights and force them to conform there and then but of course there is a line and for those in the community it may be they need regular people checking in on them so the line of neglect is not crossed as allowing someone to self neglect is corporate neglect which is itself abuse.Thorough risk assessments with controls in place do need to be written for each individual addressing each aspect of self neglect and the repercussions on themself and others if not addressed and for how long it is only then that you can really see if its an Adult Safeguarding issue or not but nevertheless these adults do need some support.

  4. Social Worker November 24, 2016 at 1:09 am #

    it’s got to be a collaborative approach

  5. anon November 24, 2016 at 4:56 am #

    this article doesn’t really address the situation where a client is actively asking for help with self neglect but services incessantly intone that it is a ‘lifestyle choice’ because they’ve ‘got capacity’.

    It’s bizarre that mental health professionals go on so much about working with symptoms not labels/diagnosis but if someone can’t explain why they are unable to maintain housework then they are ordered to agree that they are making a /lifestyle choice’ to live in squalor – even as they actively express their dislike of it and are asking for help.

    It’s also bizarre that there isn’t more acceptance and knowledge about the difficulties many people with severe mental illness have with housework (planning/decision making/executive functions) even when they aren’t in an acute episode. I know so many people whose lives are blighted by endless struggle, and failure, to maintain reasonably clean and tidy houses but services just blame the client and litter their interventions with sanctimonious comments about ‘promoting responsibility’, ‘encouraging independence’ blah blah blah

    • Ellie November 24, 2016 at 3:00 pm #

      A very insightful comment that addresses a genuine concern. I totally agree that people who have mental health problems may have issues with maintaining a clean and tidy house (i.e. housework). As you say, this can be down to problems with executive function, planning, or decision making. It can also, for instance in depression, be down to poor motivation levels and mood fluctuations that leave a person feeling incapacitated. With problems like dementia, it may be due to agitation, disorientation or forgetfulness. I doubt it’s easy to keep on top of the housework when you have become forgetful, get easily lost or confused, and struggle to remember where things like dusters or cleaning products are or how you use them!

      We should remember, too, that people who have learning disabilities may find themselves in a similar situation. Some struggle with housework because they struggle with motivation, others because they are routine-obsessed and this gets in the way. Some may have a mental age that is far younger than their physical age, and their “childlike” behaviour as a result may mean that they are unaware of the need for housework, or struggle with it in some other way. Sadly, a lot of people who have learning disabilities also have comorbid mental health problems (i.e. they have BOTH learning disabilities AND mental health problems). They, too, could well struggle.

      See my reply, below…

  6. Martin Porter November 24, 2016 at 8:40 am #

    This is an issue in which the Care Act contradicts itself. Under the new procedures people with mental capacity have to consent to be Safeguarded and choose the outcomes they want. A bit tricky to get a compulsive hoarder to agree to be evicted from their own home. Even more tricky If you can’t even get in and you’re doing the assessment through the letterbox.

  7. Ellie November 24, 2016 at 2:50 pm #

    It’s about time that issues such as this were addressed. It seems to me that Social Care is becoming too much about doling out pre-prescribed packages of one-size-fits-all “care” in order to save money, than it is looking at cases on an individual basis and trying to work out what’s going on, and what can be done to genuinely improve a service-user’s situation.

    I can totally identify with the sense of tension, of horror, and of impotence that comes with having to deal with cases like the one described. Believe me, if you get a case like this, it is absolutely draining, and soul-destroying. I should know!

    I had a very similar case whilst working in Adult Services as a Social Worker. I was the first Social Worker to get the case, and by the time it reached me it was already absolute chaos. The service-user was referred to me because the Social Housing where they lived were serving an eviction notice. I was utterly gobsmacked that a case could be allowed to get this bad before a Social Worker was called to intervene. I spoke to a Housing Officer, and was told the service-user had been “in dealings” with them over rent arrears and neighbour complaints for about six months at least. HOW could anyone let that go on for six months without attempting to get help for the person? I got the impression I had only been contacted as a “formality” prior to forcing through the eviction.

    Anyhow, I made a home visit and the service user was understandably anxious. It took time to gain their confidence, just to be allowed into the flat. They thought I was just another Housing Officer there to threaten eviction. The true state of the service-user’s living conditions truly horrified me. We are talking, here, about an elderly vulnerable person living in a first floor flat despite obvious mobility problems. The flat was filthy (I am NOT being judgmental here – it truly was filthy – there were flies swarming about, and refuse on the floor, plus mildew on the walls). The smell on opening the front door was terrible (so I could understand why the Housing Officers said neighbours had complained). It was clear that the service user was a compulsive hoarder, who stockpiled everything from broken electrical gadgets, to old magazines and newspapers. Even mouldy food was hoarded. The bathroom and one other room in the flat (I think the bedroom) were inaccessible because so much was piled and hoarded there (even the bath had boxes of newspapers in it). The service user did not bathe, and slept on the sofa under an old blanket.

    Worse was to come. During my assessments (which I did in stages because the service user was so confused, agitated and anxious that it was almost impossible at times to hold a conversation) it became clear that the service user never left the flat. Nor did they have a bank account, or appear to be registered with a GP. The service user was emaciated and very frail, and my regular visits showed that the service user rarely changed clothes (I got the impression they may even be sleeping in the same clothes). They did not know how to use the central heating, or – more disturbingly – the refrigerator, which it turned out was not even switched on. The service user had a cooker (which was filthy, but never used), but instead was boiling up canned soup in an electric kettle (risk of fusing the electrics, or setting fire to the flat, VERY high)! The kitchen was buzzing in flies and smelled of grease. The service user had a hacking cough.

    I really DID believe that this frail and clearly vulnerable individual needed – deserved – assistance. After speaking to one concerned neighbour, I became aware that the service user had no family support, and did not leave the flat for fear of “threatening youths” (it seems they may have been assaulted in the past). The service user asked this neighbour to do the shopping. I also became aware that the service user had no bank account and stashed money at home; also the service user did not appear to be registered with a GP. The neighbour described the service user as skeletal, confused and poorly – which was the exact impression I got, too.

    Personally, I do NOT believe that it is at all acceptable, or excusable, to leave individuals to fend for themselves and live in such a state. Where a Social Worker comes across a service user living in concerning conditions – especially where that service user presents as confused, possibly lacking capacity, vulnerable and poorly – the Social Worker should explore every avenue to ensure that the service user receives the correct assessments (ones that will hopefully uncover the cause of the problems), and assistance.

    I tried as hard as I could to do the above, despite a complete lack of care or empathy from others involved. The Housing Officers showed little compassion – they were more bothered about the inconvenience caused by the mess the flat was in, and by the fact that the flat was due to have new windows installed, but the double-glazing salesmen refused to enter the premises because it was so dirty and cluttered. They did not willingly visit with me, and the only time a joint visit was undertaken, the female Housing Officer insisted on wearing a plastic apron, Marigold rubber gloves, and stood holding her nose all the time! She barely spoke to the service user at all. Just HOW insulting can a professional be to a service user’s dignity? HOW do you gain someone’s trust if you are not treating them with respect? I had to try to argue to hold off the eviction whilst I attempted to sort the service user out.

    I did attempt to get assistance from Mental Health Services, because the service user showed clear signs of possible dementia – including forgetfulness, disorientation, mixing up past and present when speaking (talking about a dead person as though they were still alive), and confabulation. A worker from Mental Health Services did a joint assessment with me, and afterwards uncaringly told me that although the service user “showed clear signs of mental health problems, probably demetia-related” there was “nothing that could be done” because the service user “chose to live this way”. I was gobsmacked! To this day, there is NO way that I could possibly be persuaded to believe that any service user chooses to live with confusion, anxiety, memory loss, emaciation, compulsive hoarding and clear evidence of an untreated chest infection! I don’t think people CHOOSE to be seriously poorly, and vulnerable.

    Fortunately, after a lot of hard work, I did manage to register the service user with a GP, who kindly agreed to an urgent home visit. I am eternally glad of this, because it tuned out the service user had Pneumonia and required medication that could not be bought over the counter. I also managed to secure meals on wheels, so the service user no longer had to cook in the dirty kitchen, or cook meals in a dangerous manner. This, at least, prevented the consumption of mouldy food, which could now be disposed of. It became possible to work with the service user towards change.

    I cannot describe just how much hard work cases like this can be. They are not quick-fix cases – anything but. It often takes considerable time just to build trust with service users who self-neglect, because the underlying causes of self-neglect can be highly complex, and may involve issues that service users are desperate to hide. Besides, self-neglect is often a long, drawn out process that begins slowly, and (without assistance) gets gradually worse (especially if it is caused by progressive mental or physical dysfunction). The really frustrating thing for Social Workers is that timescales mean we are supposed to move cases on, which can be really hard with cases like this – they do not fit into regular timescales at all. They truly are LONG HAUL!

    I firmly believe that the role of the Social Worker in cases such as these is to, first and foremost, weight the likelihood that the person chooses to self-neglect. If it seems possible that lack of capacity, or serious mental/physical health problems are impairing a service user’s ability to care for themselves, then it makes sense to investigate further and to try to build a relationship of trust with the service user which may promote change, or at least encourage them to seek aid. This is NOT abusing a person’s human rights, it is acting from a position of concern, compassion and empathy whilst understanding that there is a duty of care for vulnerable people. If it is evident that a person CAN make informed choices, and chooses clearly to self neglect, then perhaps the safest approach is to back off, but to agree that assistance will be offered again at a later set date (to give the service user time to weigh options). SOME people may decide to accept help, once given the chance to think things over (like a comment says above, “monitor and encourage until the person does consent to have assistance”). Sometimes, refusal to accept help may be down to a service user’s personal experiences in the past (e.g. fear of hospitals, or poor care in the past), which it may help to talk through with them. Or, it could be that refusal is just because they don’t understand the nature of the help you are offering. Perhaps with some service users you maybe have to reinforce what you have said to them, to make it really clear that they understand?

    Maybe it will be useful bringing self-neglect under the umbrella of safeguarding. At least it may have the benefit of preventing some lazy or uncaring workers from acting like Pontius Pilate and “washing their hands” of the whole affair! Cases that spark concerns will then trigger the need to investigate further, and to discuss appropriate action – which HAS to be better than just fobbing potentially vulnerable service users off with the excuse “it’s a lifestyle choice”!

  8. Miles Taylor November 28, 2016 at 10:40 am #

    Clearly the key to working with ‘hoarding’ and self neglect has to be a multi disciplinary approach where ever the issue sits, Care Act or Safeguarding. Everyone needs to want to work together for the individual.

  9. chrissie November 29, 2016 at 10:29 am #

    Ellie I think your post and experiences have such impact and a case study like this should be publicised and used for teaching. There is such a lack on understanding//interest around hoarding and consequent neglect that it is frightening. It is because of society and the approach of professionals that these people become isolated – it is all so judgemental and based on time processes that human beings don’t stand much chance. Thank goodness for social workers like Ellie – thank you.

  10. Martin Porter November 30, 2016 at 2:28 pm #

    This issue raises huge philosophical questions about what ‘mental capacity’ actually means. Can anyone who does anything ‘compulsively’, whether it be hoarding, gambling, drinking or smoking, be considered to have ‘full mental capacity’? And we accept that they don’t, then who does that leave who does indeed have ‘full mental capacity’? Very few of us.

  11. Ellie December 10, 2016 at 12:36 pm #

    It has somewhat restored my faith in (some of) humanity to see that there are people such as those above (Miles, Chrissie, Martin) who understand that behind the issues of mental capacity, safeguarding, hoarding and self-neglect lie a huge range of as yet undiscussed philosophical, moral and other debates. Martin Porter is spot on to suggest that the matter raises very important philosophical questions about what “mental capacity” actually means.

    What disturbs me immensely is to consider the FACT – and I emphasize FACT – that it appears neither the Government, nor employers of Social Workers have stopped to consider such questions until now; such philosophical, moral, social debates. These should have been considered well BEFORE they ever introduced legislation, protocols and procedures pertaining to safeguarding, mental capacity and suchlike into the sphere of social care. It strikes me very much as putting the cart before the proverbial horse! IF such debates have NOT taken place… IF such questions HAVE not been raised, and satisfactorily answered… then just HOW can anyone expect the average Social Worker (such as I was) to get matters right when working on cases that involve service-users in situations such as that discussed in the article? These are matters that ought to be fully debated and ironed-out at the very HIGHEST (i.e. Government and Managerial) levels long BEFORE any “grass roots” Social Worker has to grapple with them – and with the piecemeal, ill-thought-out legislation, or knee-jerk-response-styled protocols that may be hastily rushed into place as an attempt to address such issues, but never in full. IF, as seems clear, there exist NO accurate guidelines or legislation for workers to refer to, then it can only be expected that Social Workers struggle with the correct response to such cases. Furthermore, absence of guidelines and legislation also mean that multi-agency working is unlikely – perhaps impossible – because nobody knows just what their remit and responsibilities ought to be.

    Matters such as this annoy me intensely (and that is putting it VERY politely), for I sense that if our managers and superiors are NOT asking such questions, and are NOT having such debates, Social Work as a profession can only deteriorate. Furthermore, it begs the very important question… Just WHAT are we paying our managers and superiors to do, if they exhibit such a lack of knowledge, discernment or interest, that they DO NOT ask such questions, or spark such debates? Those in positions of leadership, authority and management are supposedly there to lead, to manage. IF, as it would appear, they cannot do this effectively then it is little wonder that the Social Work professions are now in the state that they find themselves in. I am NO genius, NO Stephen Hawking or Albert Einstein… but IF, as I did when only a basic, on-the-job Social Worker, I can raise such debates and ask such questions then WHY cannot those in charge?

    Issues such as those raised here are central to the problems that the Social Work profession faces. I have the distinct impression that Social Work remains deeply misunderstood. It is NOT – contrary to Government and public opinion – a profession in which “snap” decisions can be made in short spaces of time, in which one-size-fits-all care packages can be routinely doled out like sticking plasters or “Prozac” (care packages that do not meet the needs of service-users, because there was simply not the time, money or inclination to do better). Social Work deals with PEOPLE, and with all the deeply personal, and hugely variable, issues that real people experience. It deals with issues that may have been a LONG time in the making; issues which are complex and multi-faceted. Issues which encompass the public and the private, the social, the criminal, the moral and immoral, the ethical and unethical, nature and nurture… Issues such as mental ill health, homelessness, crime, abuse, old age, infirmity… THESE are not issues to be entered into lightly by Social Workers, and with a minimum of forethought. THESE are issues that require careful consideration, questioning, gathering of information, weighing of evidence, assessment, planning… THESE are issues that may take considerable time to resolve, and so cannot be subject to arbitrary time constraints, funding constraints, or otherwise.

    I have long argued that the whole issue of “mental capacity” requires further thought. It is nothing so simple and clear-cut as we might like to believe. Indeed, even to suggest that capacity may be “variable” is putting matters lightly! Mental capacity is, as I see it, completely unique and individual to each person. At any given time, each and every one of us may have capacity, or may lack it. The circumstances determining our mental capacity may be as variable as our life circumstances. Here, I would add that the point Martin Porter raises in asking whether any of us could be considered to have “full mental capacity” is highly pertinent. To give a (hypothetical) example…

    Imagine we have a woman (let’s all her Jackie). Jackie has no known diagnosis of mental illness, or learning disability, so we might assume she is possessed of full mental capacity. However, Jackie has a real weakness when it comes to buying shoes and handbags – to the extent that she would even go without food for a day in order to make a purchase. In other respects, Jackie can weigh information and make reasonable decisions for herself. However, her desire to have the latest fashion trends in terms of shoes and handbags means that she may compulsively buy, that she may risk running up debts, and that she may forfeit other more practical purchases (even necessary ones such as food, cleaning products) in order to buy a pair of shoes or a handbag that she desperately wants. Besides, she can never resist a bargain, and will automatically buy shoes and handbags that she sees in the sales!
    Based on the above scenario, if I were to ask whether Jackie has full mental capacity in respect of spending and finances, then does she?

    There are many issues which may be said to impact upon mental capacity, not least of which is a person’s compulsion to do something – which could be due to mental health issues (e.g. Obsessive-Compulsive Disorder), due to an addiction (e.g. gambling or alcohol), due to ingrained habit (e.g. ritual such as always requiring to smoke a cigarette after a meal), or due to misinformation (e.g. always buying labelled or branded items in the mistaken belief that they are better than non-branded items). Each and every one of us may be affected to differing degrees by such matters. For instance, even people who have no known mental health issues or learning disabilities may behave in ways that are suggestive of lack of mental capacity, or of compulsion – such as obese people who refuse to diet and exercise, but instead continue overeating but then demand a gastric bypass; or people who rush headlong into extramarital affairs, only to find it destroys their marriage. Just HOW responsible, and HOW reflective of full mental capacity is such behaviour? And any of us could be culpable! IF, as it would appear, THIS is the case, then just what can be meant by “mental capacity”? WHAT does the term mean in relation to the whole of humanity? And then… WHAT does self-neglect imply? WHAT context does it occur in? WHAT conditions must be present to make it self-neglect? WHAT implies a lifestyle choice?

    Given the above, ought we not all to pause for thought?

    Social Work is all about BIG questions such as these. It is SO NOT about snap decisions, trite responses, and one-size-fits-all “Happy Meal” care packages! It is, as Chrissie rightly says, SO NOT about judgementalism and arbitrary time constraints! Social Work should be about marrying ones understanding of social, psychological, developmental, cultural… of various human dimensions and processes… and of using this understanding to work with people. It should be about understanding the human condition – in all its variety – as best we can. It should be about trying to understand why humans end up sometimes facing difficult predicaments… how they end up homeless, or committing crime, or taking illicit drugs, or being abused… THIS is NOT something that can be subjected to ill-thought-out legislation, or half-baked practices and procedures, or random timescales. It is something that requires an inquiring mind, an ability to ask questions (including difficult ones), an ability to collect and sift information (including unpalatable facts), and ability to be tolerant, empathic… to work with people from ALL walks of life irrespective of what others might think. Social Work is SO NOT about superficial, shallow decision-making, or stylized process – it should be DEEP. Implying deep thought, deep learning, deep reflection, deep understanding.

    As to the issue raised by Chrissie – of case studies. Whilst I agree that these are very useful for training people, I would add that case studies should only ever be publicised and used for teaching once the full consent of all involved (i.e. worker and service-user, plus any others) has been given. Otherwise, to use a case as training material represents a violation of both the worker’s and the service-user’s privacy. Furthermore, it should be made fully understood that NO Government department, and NO employing organization has any right to use either a worker (or group of workers), or a service-user (or group of service-users) as a “test case”, “pilot” or “guinea pig” without their full knowledge and express consent. To do so is a violation of dignity, respect, and of human rights. To do so would involve deception, collusion, lies or other duplicitous practices. Would any of us want to be treated in such a manner? And if, as I suspect, such things are already taking place, ought not the Social Work profession to be asking why? And whether it should be considered acceptable, or not? Here, the old adage should apply…

    “Do only to others as you would wish done to yourself”!

    Besides, each and every Social Worker has numerous case studies – their own cases! As far as I understand, the correct usage of SUPERVISION is to engage in REFLECTIVE PRACTICE. This is the process of looking back upon, and re-engaging with ones own casework; asking why and how one did as one did. Asking what one did well, what not so well, what changes could have been made, what different resources could have been used… This provides an opportunity to learn, to re-evaluate. Also, to discuss ones work with ones seniors (who ought to have more experience and more expertise and therefore be role-models to learn from {I say OUGHT!}), and to learn about new resources or styles of working. However, from what I have seen, SUPERVISION is a huge problem in the Social Work profession. This is because some employers (like my previous) are failing to provide it; others are not undertaking it correctly. Where supervision and reflective practice do not take place, or are done incorrectly, Social Workers fail to thrive, fail to provide satisfactory outcomes for service-users, fail to learn, and fail to improve. This is yet another failing on the part of management.

    It seems to me that NOW is as good a time as any to commence debate. IF, as seems to be desired, Social Work is to change into the profession it so wants to be, then why not use the present to make it so? To ask important questions. To debate significant issues. Rather it be done now, than not at all. Better late than never! The whole point in respect of making improvements and changes for the better is that, first, one has to recognize that change for the better is needed. Then, one has to learn what is required in order to facilitate such change. Is not this what Social Work could now be doing?

    I will add one caveat… BUT Social Work will NOT, can NOT change for the better whilst people who ask questions, who seek to make improvements, who raise debates – people who are whistleblowers, or pioneers of different practices – are (like myself) bullied, harassed and picked-on to the point where they leave their jobs (or are pushed out). Such an environment could never be considered healthy, or conducive to improvement.