Self-Neglect: A Practitioner’s Perspective

Paula M. Mixson, BA, SWA

ABSTRACT. The practitioner’s concern in cases of self-neglect is not with definitions, but rather with the conflict between the societal imperative to protect the vulnerable from harm while honoring individual autonomy. After touching briefly on informed consent, the causative factors of neglect, and patterns among clients who refuse care, the author discusses methods for enhancing trust and support with resistant clients to increase the likelihood of their accepting intervention.

The scarcity of research data about self-neglect and the lack of consensus about its appropriateness for inclusion as a category eligible for adult protective services (Coleman & Karp. 1989; Pillemer & Finkeihor, 1982) are not reflected in the practice arena, where such cases do occur with varying rates of frequency (Anderson & Theiss, 1987; Dolon and Blakely, 1989; Roe. 1977: Talara, 1989). Although the conceptual complexity of defining elder or adult abuse for research purposes is compounded when self-neglect is included. As is evidenced by Hudson’s analysis (1989), for practitioners the concern lays not so much with the definition of elder abuse and neglect as with the delineation of best practice when dealing with adults who need protection from harm.

Recognizing the need for protection from harm as “the single, universal factor in all protective cases,” Blanton (1989, p. 31) argues for a holistic view of adult abuse in which the identification of a perpetrator, an actor committing abuse or omitting vital care, becomes secondary to alleviating the adverse conditions in which the victim is found contingent upon the individual’s willingness to accept services. There is always cause for concern that protective practitioners will disregard the individual’s right to refuse services and employ intrusive measures to “impose different values and conditions on an individual’s freedom” (Coleman & Karp, p. 54). However, objecting to the category of self-neglect solely on these grounds ignores the existence of legitimate justification for paternalistic intervention (Carroll, 1980) and provides a rationale for condoning societal neglect.

Integral to the concept of informed consent is the idea that consent, and therefore refusal, is not valid unless the individual giving it is able to understand the situation and its consequences (Drane, 1985). When the person refusing protective services is incapable of understanding the consequences of ‘‘the failure to provide for one’s self the goods and services which are necessary to avoid physical harm, mental anguish, or mental illness’’ (Texas Human Resource Code, 1981), the practitioner is thrust into a value-laden appraisal of the degree of the client’s impairment versus the potential for harm which may result from failing to intervene. The exercise in judgment may culminate in social work behavior which ranges from non-intervention through stages that can be described as ‘‘advocacy . . . empowerment . . . persuasion . . . and making decisions on behalf of the patient’’ (Moody, 1988, p. 66).

The bases for decision-making at either end of this spectrum are relatively clear. In the first, the refusing client is capable and understands the consequences of refusal. Regardless of the degree of danger or harm to the client, the client’s right to self-determination must be honored; and services are not provided (Rathbone-McCuan & Bricker-Jenkins, 1983). At the other end of the continuum, the client is mentally or physically incapable of understanding and is in imminent danger of irreversible harm, so that involuntary intervention is justified (Carroll, 1980). The challenge to the practitioner in this case lies in the middle ground, in maximizing the opportunity for advocacy, empowerment, and persuasion in situations in which some degree of danger or harm is present and the individual is (a) capable but resistant or (b) resistant but somewhat (i.e. not legally) impaired.

In dealing with self-neglect the first element of good practice is a thorough understanding of the underlying factors which lead to such behavior. Rathbone-McCuan and Bricker-Jenkins summarize these factors as follows: “(1) individual conditions, such as mental impairment, which make the person unable to handle basic decisions and activities without help from others, (2) interpersonal conditions in which neither the individual nor caretakers have knowledge about or ability to obtain needed resources, or (3) environmental conditions which make it impossible or difficult for the person to receive necessary assistance’’ (p. 301).

Not discounting the importance of an extensive base of knowledge in gerontology, disabilities, and resources to effective casework, this article focuses on a phenomenon not specifically included in the above summary, i.e., the reluctance of a legally competent (but not necessarily fully capable) individual to accept the assistance needed to alleviate conditions of neglect, and more specifically, to discuss caseworker practices which, without violating the individual’s right to sell-determination, may help move the client from reluctance to acceptance.

Rathbone-McCuan and Bricker-Jenkins emphasize the importance of understanding the ‘‘dimensions of the adaptive process for self-care’’ (p. 306) as a framework for assisting incapacitated individuals in their adjustment to losses without threatening their human rights and their needs for self-esteem and independence. This approach recognizes that “self-care activities may be the last area of functioning over which an impaired adult can exert control” (p. 310). In self-neglect cases this control may be the impaired adult merely saying ‘‘no’’ to offers of assistance.
In an analysis of Texas neglect cases, Dubin, Lelong & Smith (1988) found six patterns among adult protective clients who refused care. They are as follows: (1) persons who were near death; (2) persons who were despairing; (3) persons who were wrongly despairing due to depression or anger; (4) persons who were denying or were adapted to their incapacities; (5) persons who mistrusted others, particularly authority figures; and (6) persons who were too proud to accept help. Although Dubin et al. found that ‘‘interventions and their outcomes vary with the reasons for resistance’’ (p. 8), they note that situations in which caseworker intervention was most successful were accomplished by ‘‘first establishing trust and allying with the person, focusing on the rapport rather than the problem. The more personal the role the caseworker took, the better were results’’ (p. 8).

If establishing a foundation of trust and rapport between the caseworker and client is indeed the first step in working toward success in intervention in self-neglect cases, then it necessarily follows that a closer examination of ‘‘the skills of rapport technology” (Brooks, 1989, p. 13) is in order for caseworkers who wish to become more effective. M. Brandwein (personal communication, October 30, 1989) explains that we trust people who:

go slow
explain (things) simply
don’t surprise us
trust us, ask our opinion, confide in us
care about what we care about or we know about
who are more like us
have flaws and tolerate them in others
like themselves
do things they don’t have to do

Brandwein’s assertion that we trust people “who are more like us’’ sums up Brook’s primary theme that “people have rapport with others because of the reflection of themselves they perceive’’ (p. 20). Brooks holds that consciously achieving rapport is a matter of recognizing the physiological states of others (e.g., posture, respiration, body movements) and their verbal signals (such as tone of voice, word choice) and then matching, or being congruent with, one’s communication style in response.
In the language of neurolinguistic programming from which Brooks has derived his rapport technology, this process is called “mirroring” and “matching” (Brooks, 1989, p. 123). Always useful and often practiced unconsciously, this process consciously applied can greatly enhance the practitioner’s effectiveness in situations in which rapport is not spontaneous, as well as build on the individual’s natural abilities in this area. A few days of self-observation by the practitioner will reveal how unconsciously, but consistently, we physically reflect the non-verbal behavior of others in our social interactions (Brooks. 1989, p. 128).

The methods employed by Fell (1982) for verbal and non-verbal communication with the disoriented old-old incorporate mirroring and matching. A thorough knowledge of Fell’s Theory of Validation can enhance communication with confused and disoriented elderly persons, who may present as self-neglect cases. When working with depressed individuals, familiarity with the behavioral manifestations of depression in autonomous versus dependent personality types—and the responses suitable for each (Emery & Lesher, 1982)—can guide the caseworker to more successful strategies for intervention.

Robbins (1986) stresses the importance of metaprograms, another concept from neurolinguistic programming, in enhancing communication. He defines metaprograms as “the keys to the way people process information. They are powerful internal patterns that help determine how we . . . direct our behavior . . . [and] that we use in deciding what to pay attention to’’ (p. 254). Examples of metaprograms are: whether individuals look for differences or similarities, whether they are oriented primarily to themselves or others, or whether they’re motivated by probability (the potential for varieties of experience) or necessity. Also significant is how the person becomes convinced that something is true (e.g., do they have to experience it, hear it, see it, feel it themselves, or does someone else have to confirm it as well?). In this context, changing the form of the message so that it is congruent with the client’s internal motivational processes may mean the difference between closing a case because the client is refusing services versus effecting what seems to be miraculous change in the individual’s life.

Change can also be brought about by the application of exchange strategy, a simple form of negotiation (Berlew, 1986). “Exchange strategy takes advantage of the Eastern idea that ‘an idea that does not have to be defended is most likely to be changed’” (Berlew, p. 2) and can effectively replace what Berlew calls the “overdependence on logical persuasion” (p. 1). According to Berlew, logical persuasion works best when neither party has vested interest in its position and when one party has the special expertise necessary to present a convincing argument to the other. When the parties have vested interests to protect, however, each push in one direction elicits an increasingly firm counter-reaction, rather than a move toward accord. Berlew suggests, instead, “the use of an exchange strategy that requires you to (1) state exactly what you want or need (an expectation), (2) ask about and then listen carefully to any problems your request causes for the other person (active listening), and (3) find ways to help resolve those problems and/or satisfy any other needs the other may have so as to gain that person’s cooperation (offering incentives)” (p. 2).

The practitioner, of course, must take care that the implementation of exchange strategy does not smack of bribery. Berlew admits that exchange strategy may be less natural and more difficult to use than logical persuasion. However, skillfully used, this technique can produce mutually acceptable solutions while conveying the intent on and purpose of the influencer and at the same time demonstrating that he or she is sensitive to the needs of the other person.

Ultimately, building trust and rapport depends on the caseworker’s making a one-on-one connection with the client in some manner. In addition to the methods outlined above, another key can be for the practitioner to offer the individual one concrete piece of assistance, regardless of its relation to what the practitioner may view as the presenting problem (Lustbader, 1990; Rathbone-McCuan & Bricker-Jenkins, 1988). This action may evoke in the client the attitude reflected in Brandwein’s primer listed above: “we trust people who care about what we care about and who do things they don’t have to do.’’ Regardless of the method in which the connection is made, the practitioner who attempts intervention without first having established this basis of trust and rapport is sabotaging the potential for success.

Handling self-neglect cases, far from being an unjustifiable social work practice, is one of the most challenging and rewarding exercises undertaken by practitioners. The need to handle these cases is especially critical in states which may not otherwise manifest legislative intent to support adult social services. Deleting this category from statutory definitions would condone an unconscionable neglect of vulnerable adults who lack either the capacity to act on their own behalf or the social resources to meet their needs, at a time when the size of the vulnerable population is at the beginning of a precipitous rise.

The competing demands that practitioners face when asked to deal with persons found in states of self-neglect will not ebb during the discussion of definitions and the debate over the legitimacy of its classification as a category of adult abuse. This paper is not meant to deny the importance of that discourse, but to begin to speak to the needs of practitioners for methodologies that can increase the frequency of successful outcomes in self-neglect cases, thereby helping to resolve the practice dilemma of honoring individual autonomy while at the same time preserving the equally important social goal of caring for dependent adults (Dudovitz. 1985: Weinberg, 1987).

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