by Deborah Barnett
Are you, or is one of your colleagues, struggling to work with someone who hoards or self-neglects?
If so that’s unsurprising: engaging with, assessing and providing support to such people can be complex and frustrating, and often requires a clear understanding of the law to ensure actions taken are defensible. Many dedicated, compassionate practitioners are left struggling with cases, feeling alone and isolated.
In 2011 the Law Commission undertook a series of scoping studies in adult social care. This identified a historic lack of understanding of self-neglect, resulting in inconsistent approaches to support and care.
In an effort to address this, the Care Act statutory guidance 2014 formally recognises self-neglect as a category of abuse and neglect – and within that category identifies hoarding.
A clear basis for intervention
This enables local authorities to provide a safeguarding response, including the duty to share information for safeguarding purposes; the duty to make enquiries (S42) and the duty to provide advocacy, where a person has no one to advocate on their behalf.
The change in eligibility criteria for social services and the focus on wellbeing, create a clear basis for social work intervention with people who hoard/self-neglect.
Safeguarding duties apply to:
- any adult who has care and support needs (whether or not the local authority is meeting any of those needs); and
- is experiencing, or at risk of abuse and neglect (including self-neglect); and
- as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse and neglect.
The duties apply equally whether a person lacks mental capacity or not. So, while an individual’s wishes and feelings are central to their care and support, agencies must share information with the local authority for initial enquiries to take place.
Enquiries may take place even when the person has capacity and does not wish information to be shared, to ensure abuse and neglect is not affecting others, that a crime has not been committed, or that the person is making an autonomous decision and is not being coerced or harassed into that decision. Safeguarding duties have a legal effect in relation to many organisations and the local authority may request organisations to make further enquiries on their behalf.
Better safe than sorry
The updated Care Act guidance issued this year identified that not all cases of self-neglect need to go to a S42 enquiry – perhaps the situation is not impacting on the person’s wellbeing, does not impact on others, or is not a result of abuse or neglect.
I would argue that someone hoarding is not going to share intimate details of themselves straight away. It can take time to develop trust and unless further enquiries are made (often requiring a multi-agency response to information gathering and capacity assessments) we may be leaving someone vulnerable, and making assumptions that cannot be justified later.
The purpose of a safeguarding enquiry (S42) is initially for the local authority to clarify matters and then decide on the course of action to:
- Prevent abuse and neglect from occurring
- Reduce the risk of abuse and neglect
- Safeguard in a way that promotes physical and mental wellbeing
- Promote choice, autonomy and control of decision making
- Consider the individual’s wishes, expectations, values and outcomes
- Consider the risks to others
- Consider any potential crime
- Consider any issues of public interest
- Provide information, support and guidance to individuals and organisations
- Ensure that people can recognise abuse and neglect and then raise a concern
- Prevent abuse / neglect from re-occurring
- Fill in the gaps in knowledge
- Coordinate approaches
- Ensure that preventative measures are in place
- Co-ordinate multi agency assessments and responses
These responsibilities apply to people who hoard / self-neglect and whose health and wellbeing are at risk as a result. People may not engage with professionals, or be aware of the extent of their self-neglect.
For social workers this provides a significant challenge in developing relationships that empower the individual, or safety plans based upon what makes a person feel safe and well cared-for yet respect autonomous decision making, while juggling other duties and responsibilities.
Different causes and effects
Self-neglect manifests in different ways. It might be that a person is physically or mentally unwell, or has a disorder, and cannot meet their own care needs as a result. They may have suffered trauma or loss, or be receiving inappropriate support from a carer. The person may not recognise the level of self-neglect.
Self-neglect can occur as a result of dementia, brain damage, depression or psychotic disorders. It may be down to substance use, including misuse of prescribed medications.
According to the 2012 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), hoarding disorder is described as a pattern of compulsive behaviour, involving accumulating numerous possessions that are not really needed. This identifies those who severely self-neglect or hoard as in need of care and support – therefore meeting adult safeguarding criteria.
Symptoms of hoarding disorder can include emotional attachment and distress over parting with possessions, regardless of value or usefulness, allowing possessions to interfere with day to day life and relationships, and social isolation.
Often these attachments can begin with trauma and loss, parental attachment and control issues and information processing deficits. Often people who hoard suffer from anxiety.
No quick fixes
It is important to explore with the person their history; listen to the way they talk about their life, difficulties and strategies for self-protection.
By doing this social workers can begin assessing why the person self-neglects and offer support in replacing attachment to objects with interaction and relationships with people and the community. Distress may lead people to seek comfort in having possessions; when faced with isolation they may seek proximity to things they’re attached to and when faced with chaos may seek to preserve predictability.
Early relationships can have quite an effect on how a person perceives the world and may not recognise their self-neglect – and may even find comfort in the situation. Deep-seated emotional issues, which have evolved as coping strategies, cannot be undone in an instant.
My upcoming session at Community Care Live London won’t wave a wand and make the complexities disappear, but will offer practical tools and advice, and clarity on defensible decision making and recording, and suggest ways agencies can support each other in addressing the complex safeguarding issues around hoarding and self-neglect.
For further information please contact firstname.lastname@example.org.