Self-Neglect and Hoarding: A Guide to Safeguarding and Support

Citation

Preston-Shoot, M. (2019), "Self-Neglect and Hoarding: A Guide to Safeguarding and Support", The Journal of Adult Protection, Vol. 21 No. 1, pp. 65-68. https://doi.org/10.1108/JAP-02-2019-052

It is my experience as an Independent Adult Safeguarding Consultant that practitioners and managers across health and social care, and in agencies as diverse as environmental health, police, fire and rescue and social housing, find cases of adults who self-neglect and hoard to be amongst the most complex and challenging. The number of safeguarding adult reviews (SARs) and, prior to implementation of the Care Act 2014, of Serious Case Reviews (SCRs) that feature adults who self-neglect and hoard is further evidence of the complex challenges involved. These challenges comprise features of direct work with the individual concerned but also of the organisational and inter-agency context of adult safeguarding (Braye et al., 2015; Preston-Shoot, 2016, 2017, 2018). Consequently, practitioners and managers will welcome a book that offers guidance on how to work effectively with adults at risk of self-neglect.

Besides an introduction and conclusion, the book mainly comprises seven chapters that begin with defining self-neglect and hoarding before moving on to discussion of how self-neglect affects people’s lives and the themes that emerge from the aforesaid SCRs and SARs. There are then chapters on safeguarding, therapeutic interventions, assessment and engagement and finally supporting the practitioners. A preface and epilogue offer observations that address ethical questions and implicitly if not explicitly address the six principles (DH, 2017), especially prevention, protection and proportionality. This, then, is definitely a book mainly for practitioners and their immediate supervisors and managers. Its primary focus, returning to the challenges that emerge from SCRs and SARs, is on direct practice, with some much more limited focus on the organisational and inter-agency context for effective practice. Ensuring that practitioners have the knowledge and skills to work with adults who self-neglect and hoard is crucial. However, workforce development, to which this book will contribute, has to be accompanied by workplace development (Braye et al., 2013). Put another way, for practitioners to be able to practise by drawing on the best research, review and practice evidence available, brought together in work such as this book, organisational and inter-agency systems must be aligned to facilitate this. All too often practitioners report that they are required to work within systems that frustrate and impede rather than promote best practice.

A commitment to Making Safeguarding Personal, either explicitly or implicitly, resonates throughout this book. It is reflected, for example, in an important acknowledgement of the emotions that individuals may bring to encounters with statutory services, and of the importance of understanding the meaning behind the self-neglect and hoarding for interventions to be effective in the longer term. There is a strong focus on the values that practitioners bring to this work and on the ethical considerations that must be given space in decision making. There is a strong focus on accountability, for instance regarding practitioners and their managers being able to give a defensible account of their decision making.

The book tends to focus more on hoarding than self-neglect, for example when exploring definitions. Nonetheless, the chapter that draws on research to understand what is self-neglect and hoarding does provide an insight into what might lie behind these behaviours. Similarly, the chapter that covers the impact of self-neglect and hoarding on individuals and those they live with once again tends to focus more on hoarding. However, it emphasises some of the risks that should be included in any assessment and it correctly stresses the importance of “thinking family”. Not all individuals who self-neglect and hoard live alone. The dynamics between carers and cared-for people can be complex. Children and other adults in the household might be at risk of harm. In this chapter is a case illustration drawn from the author’s own practice experience. Cases can be illuminating and it is perhaps disappointing that more use is not made of the cases, including material drawn from specific SCRs and SARs.

One example where cases would be illuminating and thought-provoking is the ethical dilemma between self-determination and prevention of foreseeable harm. There is an appropriate acknowledgement of the need to challenge assumptions of lifestyle choices but perhaps links could have been made to published sources that have explored the values, knowledge and skills that might help practitioners and managers to navigate the challenges here (see, e.g. Preston-Shoot and Cornish, 2014; Braye et al., 2017). There are SCRs and SARs that have highlighted this dilemma and, whilst these reviews do not necessarily provide clear answers for practitioners, they do highlight the components of good practice, including discussion with the person concerned, multi-agency meetings, detailed mental capacity and risk assessments and consideration of all available legal options.

The chapter that focuses explicitly on drawing out themes from SCRs and SARs would have been one place where specific illustrative case examples could have been used. Frustratingly, however, readers are only told that the chapter has been informed by a consideration of 30 SCRs/SARs and Domestic Homicide Reviews since 2010. Readers are not informed which reviews were accessed and none are used for illustrative purposes. This is a missed opportunity. There is also no reference to the database and thematic analysis of SCRs and SARs involving self-neglect that has been compiled since 2015 (Braye et al., 2015; Preston-Shoot, 2016, 2017, 2018), now numbering 134 cases. What follows in the chapter is, however, an exploration of ethical decision making, including the tension between autonomy and duty of care. Brief case scenarios are described but not linked then to what the thematic analysis of reviews might indicate would be good practice in such instances.

This same chapter then moves on to explore the six principles of empowerment, prevention, proportionality, protection, partnership and accountability in the context of working with adults who self-neglect and hoard. This is done mainly in the format of lists; an approach subsequently applied to a number of areas including Section 42 enquiries, risk assessment, carer assessment, mental health and substance misuse, capacity and consent, information-sharing, management support and imposed compliance. The content is all appropriate and very relevant for practitioners working with adults who self-neglect and hoard, but some case examples would enhance the guidance being given, especially if they were to focus on where the six principles might appear to conflict one with another. Furthermore, although the discussion of imposed compliance is appropriate, since it is not always possible to negotiate a way forward, perhaps more guidance could have been offered about what skills to employ in an endeavour to avoid imposed interventions and how to manage situations when such interventions become inevitable.

The same focus and approach is taken in the following chapter on safeguarding adults who self-neglect under the Care Act 2014. Section 42 enquiries and the six principles of safeguarding are explored, followed by information-sharing and an important, highly relevant discussion of defensible decision making. There is much that is useful as guidance for practitioners and managers herein to enable them to maintain practice that is lawful, ethical, knowledge informed and careful. Once again, however, more detail would be helpful. For example, there is a short section on case law judgements with respect to information-sharing but these are not explicitly referenced. Once again, the assumption is that the six principles dovetail neatly and further that all the rights guaranteed under the Human Rights Act 1998 similarly mesh together. In reality there will be cases where the right to life, for example, has to be balanced against the right to private and family life, and where the principle of empowerment, for instance, has to be balanced against that of protection. A decision-making framework must show how principles and rights, when they conflict, have been balanced in each unique case.

The following chapter focuses on therapeutic interventions. Once again, there are useful pointers for building a rapport and exploring trauma and loss, with an important acknowledgement that care management structures may impede effective work by imposing unrealistic timeframes on practitioners. There is a link that should be made here to the importance of emphasising workplace development, as highlighted above.

There is a welcome but brief section on systemic approaches. Here and elsewhere there are welcome references to asking miracle questions but unfortunately the potential of other components of systemic practice is omitted. Hypothesising and circular questions, for instance, can prove helpful in enabling exploration of what might be driving self-neglect and hoarding behaviours. Greater space is given to the cycle of change and solution-focused assessment, offering practical guidance that is informed by theoretical perspectives. Once again, the dominant focus is on hoarding.

The order of the chapters is, arguably, somewhat confusing. Following the chapter on therapeutic interventions is the chapter on assessment and engagement. Once again, often in the form of lists, there is much helpful guidance therein, for example on risk assessment, capacity assessment and comprehensive assessment. There could have been greater emphasis on assessing executive alongside decisional capacity but the templates provided will be helpful to practitioners when structuring assessment. Discussion of the safeguarding response appropriately identifies the range of professionals and agencies that may need to be involved. There is some discussion of the barriers that might block change and an illustrative extended case study is used to illustrate the dynamics and components of assessment.

The final major chapter considers support for practitioners. This should be essential reading for those occupying supervisory and managerial positions, and for members of Safeguarding Adults Boards. There is appropriate acknowledgement of the impact of financial austerity but perhaps more space could have been given to how, at strategic and operational levels, workplaces might be aligned to enable practitioners in their organisational and inter-agency context to work effectively with adults who self-neglect and hoard.

The book is underpinned by the law in England. There is no reference to the legal rules that now apply to adult safeguarding in Wales and adult protection in Scotland. This is something of a missed opportunity although the guidance on assessment, agency support and therapeutic interventions should resonate with readers outside England.

There are a few inaccuracies regarding references and perhaps greater use could have been made of research conducted in England and Ireland to underpin the practical guidance being offered in the book. In summary, then, for hard-pressed practitioners, especially across health and social care organisations, this book provides helpful pointers to the components of effective and sound practice. It is person-centred and informed by research, knowledge and practice experience. The lists and templates offered are useful. That said, working with adults who self-neglect and hoard is often complex and frequently challenging. Illustrative and detailed case studies would have given a sense of how to manage in just those situations.