Challenges of Self-Neglect - What works Best?

Self-neglect is challenging for Practitioners because:

Every case is different, influenced by a complex mix of personal, mental, physical, social and environmental factors.
The high risks it poses, both to the adults and sometimes to others (e.g. fire risk).
The possibility that any outside intervention may not be welcomed by the individual, making engagement difficult.
The complexities of assessing mental capacity.
Ethical dilemmas between respecting the adult's autonomy and right to make choices and agencies fulfilling their duty of care.
Limited resources that can lead to short-term, task-focused involvement rather than developing long-term relationships with adults.
The need for coordinated interventions from a range of agencies and the difficulties involved in achieving this.

Building a relationship with the adult

Because of these challenges and because all cases are different there is no one set approach which will always work. However, a supportive approach based on building a trusting relationship with the adult has been shown to be more likely to achieve a positive outcome. Supportive intervention relies on multi-agency co-ordination and risk management.

At the heart of good self-neglect practice is a complex interaction between knowing, being and doing:

Knowing, in the sense of understanding the person, their history and the significance of their self-neglect, along with all the knowledge of resources that underpin professional practice.
- Being, in the sense of showing personal and professional qualities of respect, empathy, honesty and reliability, care, being present, staying alongside and keeping company.
- Doing, in the sense of balancing hands-off and hands-on approaches, seeking the tiny element of latitude for agreement, doing things that will make a small difference while negotiating for the bigger things, and deciding with others when enforced intervention becomes necessary.

Knowing (understanding the individual's experience of self-neglect

You are unlikely to build a trusting relationship and achieve a positive outcome unless you can gain an understanding of the adults’ experience of self-neglect from their point of view.

Here are some points to consider helping you find out:

Consider the person's own view of the self-neglect.

Is the self-neglect important to the person in some way?
Have you considered if the person has mental capacity in relation to specific decisions about self-care and/or acceptance of care and support?
Is the self-neglect a recent change or a long-standing pattern?
Has there been a recent significant life event such as bereavement?
What strengths does the person have - what is he or she managing well and how might this be built on? What motivation for change does the person have?
Are there links between the self-neglect and health (including mental health) or disability?
Are there care and support needs that are not being met?
Is alcohol consumption or substance misuse related to the self-neglect?
Consider how the person's life history, family or social relations are interconnected with self-neglect?
Does the self-neglect play an important role as a coping mechanism? If so, is there anything else in the person's life that might play this role instead?
Are there any concerns for others in the property, i.e. other residents including children or animals?
Who owns the property?

Being (considering your own reactions when you interact with a person who self-neglects and the impact this could have).

Did you realise that when you enter a hoarded or neglected home you will have a very strong reaction, but you won't know you are having it as it happens subconsciously? You need to understand this in advance to prepare yourself because the adult may see this reaction, and this could damage your chances of building a positive working relationship.

When we enter any enclosed space, we look for symmetry as symmetry is memorable. We need to remember the layout since, if we feel threatened, we need to know how to escape. In hoarded properties there often is no escape route, and this can fuel your feelings of claustrophobia, discomfort, or the desire to clear the property. This feeling can have a very negative effect on you and this effect might influence how you perceive the person you are working with, which will influence how you then work with that person. You may also have a strong physical reaction to strong smells that may be present.

What you can do about it

If you know this normal reaction is going to happen; you can prepare yourself for this and think of strategies to help overcome it. For example, try imagining the environment is not cluttered and focusing your sight upon the person's face.

Noting your own feelings is helpful in reports and helps to build an understanding of the reactions of others that may have compounded a sense of isolation or helplessness about the individual's circumstances. The effect of strong smells can be reduced by carrying a strong counter acting smell e.g. using a cold remedy or having a mint.

Doing (the things that tend to work best)

No one approach always works but there are a number of things or different approaches that can be done that have been shown to be successful. The below outlines examples of what this might mean in practice:

Building Rapport - Taking the time to get to know the person; refusing to be shocked
Moving from rapport to relationship - Avoiding knee-jerk responses to self-neglect; talking through with the person their interests, history and stories
Finding the right tone - Being honest while also being non-judgemental; expressing concern about self-neglect, while separating the person from the behaviour
Going at the individual's pace - Moving slowly and not forcing things; showing concern and interest through continued involvement over time
Agreeing a plan - Making clear what is going to happen; planning might start by way of agreeing a weekly visit and developing from there
Finding something that motivates the individual - Linking to the person's interests (for example, if the person is hoarding because they hate waste, link them into recycling initiatives)
Starting with practicalities - Providing small practical help at the outset may help build trust
Bartering - Linking practical help to another element of agreement (for example, 'If I can replace your heater, would you go to see the doctor?')
Focusing on what can be agreed - Finding something to be the basis of initial agreement, which can be built on later
Keeping company - Being available and spending time to build up trust
Straight talking - Being honest about potential consequences
Finding the right person - Working with someone who is well placed to get engagement - another professional or a member of the person's network
External levers (Legal Framework) - Recognising and working with the possibility of enforcement action - See guidance on possible legal interventions