Updated: March 2024
Self-neglect
Self-neglect is an extreme lack of self-care, it is sometimes associated with hoarding and may be a result of other issues such as addictions. Practitioners in the community, from housing officers to social workers, police and health professionals can find working with people who self-neglect extremely challenging. The important thing is to try to engage with people, to offer all the support we are able to without causing distress, and to understand the limitations to our interventions if the person does not wish to engage.
What is self-neglect?
- Lack of self-care to an extent that it threatens personal health and safety
- Neglecting to care for one’s personal hygiene, health or surroundings
- Inability to avoid harm as a result of self-neglect
- Failure to seek help or access services to meet health and social care needs
- Inability or unwillingness to manage one’s personal affairs
What causes self-neglect?
It is not always possible to establish a root cause for self-neglecting behaviours. Self-neglect can be a result of:
- 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.
The inclusion of self-neglect in chapter 14 of the Care Act 2014 statutory guidance means that safeguarding duties apply where the adult has care and support needs and is at risk of self-neglect which they are unable to protect themselves from (due to their care and support needs). The nature of the potential harm is often a chronic risk that originates in quite deep rooted psychological issues (e.g. unresolved grief).
The adult often struggles to recognise the risks they are living with. They may lack mental capacity in relation to the care needs, but often very fine judgements are required to determine whether the adult has capacity but is making a choice about how they are living. Assessment of the adult’s ‘executive functioning’ (the ability to set goals and carry them out) is a key component in the assessment of their mental capacity in relation to specific decisions.
The most effective approaches are ones which allow a worker to get alongside the adult and work with their wishes as far as possible to build a relationships of trust. It is important for local partners to have a clear unified policy and process for when to raise a safeguarding referral in a situation of self-neglect, and when other approaches of support are more appropriate. A multi-agency approach to risk assessment and risk management in partnership with the adult is likely to be most effective, where it is possible.
In some more complex and high risk circ*mstances it may be necessary to consider using the Mental Capacity Act 2005 and Best Interests frameworks to provide vital care or support.
Self-neglect: what are the issues?
People who neglect themselves often decline help from others; in many cases they do not feel that they need it. Family or neighbours can sometimes be critical of professionals because they don’t do anything to improve the situation of the individual. But there are limitations to what others can do if the adult has mental capacity to make their own decisions about how they live. Sometimes, even when all agencies have done everything in their power to support an individual, they may die or suffer significant harm as a result of their own action or inaction. It is therefore vital that all efforts to engage with and support an individual are clearly recorded.
The inclusion of self-neglect in the Care Act statutory guidance with regard to safeguarding focused attention on the issue and led local authorities to develop new approaches to working with people. In some cases, where the adult has care and support needs, safeguarding responses may be appropriate. However, the inclusion of self-neglect in statutory guidance does not mean that everyone who self-neglects needs to be safeguarded.
Safeguarding duties will apply where the adult has care and support needs (many people who self-neglect do not), and they are at risk of self-neglect and they are unable to protect themselves because of their care and support needs. In most cases, the intervention should seek to minimise the risk while respecting the individual’s choices. It is rare that a total transformation will take place and positive change should be seen as a long-term, incremental process.
Relevant legislation
- The Care Act (2014) statutory guidance– self-neglect is included as a category under adult safeguarding.
- Article 8 of the Human Rights Act 1998gives us a right to respect for private and family life. However, this is not an absolute right and there may be justification to override it, for example, protection of health, prevention of crime, protection of the rights and freedoms of others.
- Mental Health Act (2007) s.135– if a person is believed to have a mental disorder and they are living alone and unable to care for themselves, a magistrate’s court can authorise entry to remove them to a place of safety.
- Mental Capacity Act (2005) s.16(2)(a)– the Court of Protection has the power to make an order regarding a decision on behalf of an individual. The court’s decision about the welfare of an individual who is self-neglecting may include allowing access to assess capacity.
- Public Health Act (1984) s.31-32– local authority environmental health could use powers to clean and disinfect premises but only for the prevention of infectious diseases.
- The Housing Act 1988– a landlord may have grounds to evict a tenant due to breaches of the tenancy agreement.
Direct work with people who may be at risk of self-neglect
The research on self-neglect suggests beneficial approaches and a range of options, levers and practical measures that could help engagement with individuals.
Approach
In the past we may have intervened in ways that prioritised the views of others rather than trying to work from the perspective of the individual. Research has shown that those who self-neglect may be deeply upset and even traumatised by interventions such as ‘blitz’ or ‘deep cleaning’. When developing an approach it is important to try to understand the individual and what may be driving their behaviour. There are some general pointers for an effective approach:
- Multi-agency– work with partners to ensure the right approach for each individual
- Person centred– respect the views and the perspective of the individual, listen to them and work towards the outcomes they want
- Acceptance– good risk management may be the best achievable outcome, it may not be possible to change the person’s lifestyle or behaviour
- Analytical– it may be possible to identify underlying causes that help to address the issue
- Non-judgemental– it isn’t helpful for practitioners to make judgements about cleanliness or lifestyle; everyone is different
- Empathy– it is difficult to empathise with behaviours we cannot understand, but it is helpful to try
- Patience and time– short interventions are unlikely to be successful, practitioners should be enabled to take a long-term approach
- Trust– try to build trust and agree small steps
- Reassurance– the person may fear losing control, it is important to allay such fears
- Bargaining– making agreements to achieve progress can be helpful but it is important that this approach remains respectful
- Exploring alternatives– fear of change may be an issue so explaining that there are alternative ways forward may encourage the person to engage
- Always go back– regular, encouraging engagement and gentle persistence may help with progress and risk management
Practical tasks
- Risk assessment– have effective, multi-agency approaches to assessing and monitoring risk
- Assess capacity– ensure staff are competent in applying the Mental Capacity Act in cases of self-neglect
- Mental health assessment– it may, in a minority of cases, be appropriate to refer an individual for Mental Health Assessment
- Signpost– with a multi-agency approach people can be signposted to effective sources of support
- Contact family– with the person’s consent, try to engage family or friends to provide additional support
- Decluttering and cleaning services– where a person cannot face the scale of the task but is willing to make progress, offer to provide practical help
- Utilise local partners– those who may be able to help include the RSPCA, the fire service, environmental health, housing, voluntary organisations
- Occupational therapy assessment– physical limitations that result in self-neglect can be addressed
- Help with property management and repairs– people may benefit from help to arrange much needed maintenance to their home
- Peer support– others who self-neglect may be able to assist with advice, understanding and insight
- Counselling and therapies– some individuals may be helped by counselling or other therapies. Cognitive behaviour therapy, for example, may help people with obsessive compulsive disorder, hoarding disorder or addictions
Self-neglect at a glance
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