Key characteristics of self-neglect
There are a number of indicators which, when combined, may indicate the presence of self-neglect. There is no clear point at which lifestyle patterns become self-neglect, and the term can apply to a wide range of behaviour and different degrees of self-neglect. The following list is not exhaustive and should be considered in conjunction with the Multi-Agency Self-Neglect and Hoarding Risk Assessment and Guidance Tool [Word Document] and all information within this document:
- Living in very unclean, sometimes verminous circumstances, such as living with a toilet completely blocked with faeces
- Neglecting household maintenance, and therefore creating hazards within and surrounding the property
- Portraying alternative lifestyles which some may perceive or judge to be eccentric behaviour
- Obsessive hoarding
- Poor diet and nutrition. For example, evidenced by little or no food in the fridge, or what is there, being mouldy
- Declining or refusing prescribed medication and/or other community healthcare support
- Declining to allow access to health and/or social care professionals in relation to personal hygiene and care
- Declining to allow access to other organisations with an interest in the property, for example, staff working for utility companies (water, gas, electricity), housing services
- Repeated episodes of anti-social behaviour – either as a victim or source of risk
- Being unwilling to attend external appointments with professionals in social care, health or other organisations (such as housing)
- Very poor or lack of personal hygiene or personal hygiene resulting in poor healing or sores, long toenails, unkempt hair, uncared for facial hair, body odour, unclean clothing, unkempt appearance
- Social withdrawal or Isolation from family, friends, community support network; either of an individual or of a household or family unit
- Failure to take medication
- Repeated referrals to Environmental Health
It is important for practitioners to understand poor environmental and personal hygiene may not necessarily always be a result of self-neglect. It could arise from a cognitive impairment, poor eyesight, functional and financial constraints. In addition, many people, particularly older people who self-neglect, may lack the ability and/or confidence to come forward to ask for help; and may also lack the support of others who can advocate or speak for them. They may then refuse help or support when offered or receive services that do not actually adequately meet their needs.
Models of self-neglect
There is a consensus in research on the main characteristics of self-neglect and the approach practitioners should take when working with people who are deemed to be self-neglecting. There is less consensus as to why people self-neglect. Self-neglect is usually a symptom of other problems including:
- Deteriorating physical health
- Onset of depression or other mental health need
- Response to trauma
- Change in social networks or income
- Personal identity and philosophy
Self-neglect and hoarding has to be understood in the context of the individuals life experience.
Research in Practice for Adults (RiPFA) outlines how self-neglect arises from an unwillingness or inability to care for oneself, or both. It is interlinked where inability arises from the care and support needs of the individual.
Braye et al (2014) identified five overarching themes in their research with people who self-neglect:
- Demotivation stemming from other factors;
- Other priorities
- Different standards
- Maintaining self-care
- Uncertainty about reasons and inability to self-care
Health difficulties, homelessness, loss and social isolation were repeatedly cited as reasons why self-care had come to seem comparatively unimportant. This in turn could impact on self-image, further demotivating them and entrenching negative cognitions:
“I would sit here and not even have a wash. I got it in my head that I’m unimportant, so it doesn’t matter what I look like or what I smell like.”
Self-neglect had led some interviewees to fail to take steps to care for their health; the resulting deterioration or new diagnosis came as a shock that further worsened their tendencies to self-neglect.
Executive dysfunction – the inability to perform activities of daily living, even though the need for them may be understood, is seen as significant, and when this is accompanied by an inability to recognise unsafe living conditions, self-neglect may be the result.
The perceptions of people who neglect themselves have been less extensively researched. However, where they have, emerging themes are pride in self-sufficiency, connectedness to place and possessions and behaviour that attempts to preserve continuity of identity and control. Traumatic histories and life-changing events are also often present in individuals’ own accounts of their situation.
Differentiation between inability and unwillingness to care for oneself, and capacity to understand the consequences of one’s actions, are crucial determinants of response.
Identification and intervention in potential situations of self-neglect is not dependent on any diagnoses of a physical or mental health condition, however hoarding is now recognised as a mental disorder by the Royal College of Psychiatrists.