Tuesday, 22 October 2013

Self neglect – Jackie Hodgkinson asks: when does a social worker say enough is enough?


Self neglect is a term that social workers are very familiar with. It often causes concern for both professionals and concerned neighbours and family. I can recall, within my social work career, many individuals who chose to live at home, in a condition that was considered by professionals as unacceptable. Was this their informed choice and was it in the best interests of the individuals? This depends on who you ask?

What is unacceptable? And who are we as a wider society to define how someone should or should not live, often those individuals had been what were considered as “eccentric” or “a bit different”. Using the definition of mental capacity as defined within the Mental Capacity Act 2005 would deem these individuals to have capacity to make what we may consider as unwise decision. Within society we make judgements based on how vulnerable we perceive a person to be.

Champagne lifestyle

If a young executive chose to spend their salary on a champagne lifestyle and then could not pay the bills at the end of the month would anyone pass judgement on this choice? If that person was a 79 year old man with motor neurone disease who enjoyed betting on horses and sometimes didn’t leave enough money for 3 meals a day, home care providers would instantly contact social workers with a safeguarding alert or his neighbours would be stating that he should be in a home! And asking how can we let someone live in this way.

The public expect that the adult social care department should protect all from harm and danger, regardless of the capacity of the individuals to choose how they live. Social work teams receive many phone calls from families or friends stating “it is a disgrace how you let people neglect themselves you should do something to stop it”. This implies we have the power to impose services and support on any unwilling recipient. A greater awareness of our statutory duties and the limitations of these perceived all-embracing powers is required to educate the wider public regarding when we need to intervene.

There needs to be more publicity on positive risk-taking, where social workers actively promote the human rights of the disadvantaged. We often see the potential in individual’s strengths or protective factors within them or their lives, where others see only problems.

Risk averse

In these risk-averse times, it is important to hold onto the concept of choice and respect for decision making. In my opinion as a social worker, it’s intrinsic to what social work should be about and is core to social work values. This requires a recognition at all levels of management and within wider society.

The Department of Health official definition of self neglect is the inability to understand the consequences of that failure. That definition of self-neglect excludes the individual who makes conscious and voluntary choices not to provide for him or herself. The person who denies themselves certain (accepted) basic needs as a matter of personal preference and who understands the results of that decision is ruled out.

Self-neglect implies a lack of wilful intent. Self-neglect is an act of omission. There is no perpetrator. Unlike perpetrator related abuse and neglect, self-neglect is not treated as a wrong-doing or a potential criminal act. Capacity is a highly significant factor in both understanding and intervening in situations of self-neglect. Decision-making autonomy by those who have capacity is widely recognised and respected. There is strong professional commitment to autonomy in decision making and to the importance of supporting the individual’s right to choose their own way of life, although other value positions, such as the promotion of dignity, or a duty of care, are sometimes also advanced as a rationale.

Research into self neglect

SCIE Report 46: Self-neglect and adult safeguarding: findings from research, examines the concept of self-neglect. The relationship between self-neglect and safeguarding in the UK is a difficult one, partly because the current definition of abuse specifies harmful actions by someone other than the individual at risk.

The perceptions of people who neglect themselves have not been extensively researched, but where they have, emerging themes are pride in self-sufficiency, connectedness to place and possessions and behaviour that attempts to preserve continuity of identity and control. Traumatic histories and life-changing effects are also present in individuals’ own accounts of their situation

What can we social workers take from research? Evidence demonstrates that self neglect is reported mainly as occurring in older people, although it is also associated with mental ill health in both older and younger individuals. Social workers when assessing levels of risk need to take into consideration both the inability to care for oneself as opposed to the unwillingness to self care. The other key determinant is the individual’s capacity to make the decision and understand the consequences of this action. The social work response will vary, dependent on these key risk determinants. Professionals will have a tolerance to someone who chooses to self neglect as a life style choice, perhaps that is how they have always lived. I once assessed an older person who chose to eat out of date food to save money even though they had £500.00 in the bank. Professionals, understandably, have a greater level of concern regarding those individuals who have made life style choices but due to onset of mental impairment struggle to understand the consequence of those actions.

Comprehensive risk assessments are core to all interventions. A balanced approach is required to ensure we are not foenough is enough.

cused simply on keeping people safe at all costs; all risk assessments should be person-centred, taking into consideration previous lifestyle choices. They should promote independence, choice and autonomy. They should also be reviewed regularly. Care plans should be lifestyle sustaining. Potential harm has to be balanced with potential benefit. Working in a multi disciplinary team, virtual or otherwise, enables us to gather evidence to make those decisions about when statutory intervention is required. We should check things through a mental capacity lens frequently. The profession needs to engage with the public about people’s rights, the wider duty of care and when

Jackie Hodgkinson is an independent social work practitioner and trainer

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