RCGP Safeguarding toolkit

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.

Self-neglect includes:

• 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 self-harm
• failure to seek help or access services to meet health and social care needs
• inability or unwillingness to manage one’s personal affairs.

Signs and indicators include:

• very poor personal hygiene
• unkempt appearance
• lack of essential food, clothing or shelter
• malnutrition and/or dehydration
• Living in squalid or unsanitary conditions
• neglecting household maintenance
• hoarding
• collecting a large number of animals in inappropriate conditions
• non-compliance with health or care services
• inability or unwillingness to take medication or treat illness or injury.

Self-neglect can be as 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.

It is not always possible to establish a root cause. Hoarding and self-neglect do not always appear together, and one does not necessarily cause the other.

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.

Barriers to working with and caring for individuals who self-neglect

• Can be challenging & alarming.
• Support/help may be refused.
• Risks are high.
• Intervention options limited.
• Lack of clarity on who takes responsibility including when help is refused.
• Resources and work patterns don’t support long-term relationship-based work.
• Lack of resources.
• Safeguarding responses not always appropriate if don’t have care & support needs.
• May be no decision-making forum.
• Information sharing can be problematic.
• Limited legal literacy.
• Assessment of capacity/ application of mental capacity legislation can be very complex (See Part 3 in the toolkit for further guidance on assessing capacity in self-neglect).

Best practice

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.

Other considerations:

• 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 Act 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.

References

• Social Care Institute of Excellence. Types and indicators of abuse. 2020.
• Social Care Institute of Excellence. Self-neglect at a glance. 2024.