Test your knowledge - Self neglect

If someone who self-neglects or hoards, refuses support or services that would protect their safety and wellbeing, this should never be dismissed this as a ‘lifestyle choice’. People’s circumstances, life histories or their reasons for not seeking or accepting help, may not always be clear, but it will often be the case that people didn’t really choose to live in this way.

Self-neglect: Is it really a choice, when:

• You don’t see how things could be different? 
• You don’t think you’re worth anything different? 
• You didn’t choose to live this way, but adapted gradually to circumstances 
• Your mental ill-health makes self-motivation difficult? 
• Impairment of your executive brain function makes your decisions difficult to implement?

Consider these real-life quotes:

“I get tired because daily routines are exhausting me, to do the simple things like get washed, put on clean clothes, wash my hair”. “
“I don’t have time to make a note of everything in the paper that has an interest to me and so I’m very fearful of throwing something away”.
“I’m drinking, I’m not washing; I wouldn’t say I’m losing the will to live, that’s a bit strong, but I don’t care, I just don’t care”.
“I got it into my head that I’m unimportant, so it doesn’t matter what I look like or what I smell like”

Self-neglect may arise in circumstances where the person at risk has a mental health condition, but it should not be assumed that this is the case, or that it is the cause of the self-neglecting behaviour. 

Self-neglect can arise due to a range of mental, physical, social and environmental factors. 

It may be a longstanding pattern or a recent change 

It may be linked to loss, past trauma and/or low self-esteem 

It may be associated with:

• 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 
• addictions
• traumatic life change
• Or something else

As the reasons for self-neglect behaviour will vary from person to person, we must not make assumptions. We need to be professionally curious. We need to look for the person behind the behaviour, to understand their life history, what is important to them, and work with them towards reducing risk. Only in this way can we tailor our approach and support in a way that responds to their unique individual needs.

No, it’s not that simple. If someone who self-neglects declines support essential to their health and wellbeing, it is not the end of the matter 

‘Talk to me, hear my voice’ is the citizen-led practice principle adopted in Leeds. Sometime, however, this voice will say ‘I don’t want your help’. This can be a huge challenge for practitioners when working with adults who have self-neglecting behaviours, as they may refuse to engage or accept support.

The challenge is to get alongside and work with people, support them to make informed decisions, and to engage with them in ways they feel able to accept. 

If a person is declining support or services:

• Consider if the person has been provided with all the necessary information in a format they can understand
• Assess the risk as far as is possible given the person’s limited engagement
• Be open and honest; share concerns about these risks with the person self-neglecting
• Check as far as possible, if the person has understood the options and the consequences of their choices 
• Listen to and show understanding of the person’s reasons for mistrust, disengagement, refusal and their choices and consider if there are ways to provide support in the way the person feels able to accept 
• Where the person is willing, ensure there is the time to have conversations over a period of time to develop a trusting relationship
• Check out your concerns with other relevant agencies in accordance with the Safeguarding Adults Board: LSAB Information Sharing Policy
• Consider who (whether family, advocate, other professional) can support engagement with the person at risk. You may not be the best person. 
• Formally assess a person’s mental capacity if there is evidence to indicate this is lacking in relation to these specific decisions. Where a person lacks mental capacity in relation to relevant decisions, those decisions will need to be made in their best interests.
• Formally record decisions, actions, attempts to engage and peoples responses.

Where there is a significant threat to the person’s health and wellbeing, practitioners and services should seek to provide continued support and take further actions in accordance with the LSAB Self-neglect policy

• Where there is limited or partial engagement and risks are low, seek to provide continued engagement and support in to help the person to identify and overcome barriers they may experience in accepting support.
• Where there is a significant threat to the persons health and wellbeing, consider whether a multi-agency meeting is needed to understand the issues, concerns, and assess and respond to the risks.
• In circumstances where the person appears to be unable to protect themselves from the self-neglect they are experiencing; concerns should be reported in line with multi-agency safeguarding adults policy and procedures.

Read the LSAB Self-neglect policy in full, for more information and guidance

There is a lot of useful research about how to support people who self-neglect. We have sought to include as much as possible within our LSAB Self-neglect policy. For example: 

When working with people who self-neglect, the research identifies key practice messages for practitioners that can lead to improved relationships, engagement and positive outcomes for the person at risk: 

1. Take the time to build rapport and a relationship of trust through persistence, patience and continuity of involvement 
2. Seek to ‘find’ the whole person and to understand the meaning of their self-neglect in the context of their life history, rather than just the particular need that might fit into an organisation’s specific role 
3. Work at the individual’s pace, spot moments of motivation that could facilitate change, even when the steps towards it are small 
4. Ensure you understand the nature of the individual’s mental capacity in respect of each specific self-care decision
5. Be honest, open and transparent about risks and options 
6. Understand and consider the legal mandates providing options for intervention 
7. Be creative with flexible interventions, including family members and community resources where appropriate 
8. Engage in effective multi-agency working to ensure inter-disciplinary and specialist perspectives, and coordination of work towards shared goals.

Suzy Braye et al: Self-neglect policy and practice: research messages for practitioners  

(SCIE: March 2015)
 

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