Relationship-based practice and service delivery in self-neglect

A key challenge in social work decision-making lies in balancing two potentially competing mandates: respect for individual autonomy, and a duty of protective care. Nowhere is this challenge more acute than in work with people... [ view full abstract ]

A key challenge in social work decision-making lies in balancing two potentially competing mandates: respect for individual autonomy, and a duty of protective care. Nowhere is this challenge more acute than in work with people who, through their own choice, live in circumstances posing severe risks to their own health or safety – either through neglect of their personal care or health, or through neglect of their domestic environment by hoarding or living in squalor. While self-determination may be approached in different ways in different countries, in some national contexts its recognition is both a professional and a legal obligation, yet such situations can result in death or serious harm to the service user if no intervention can be agreed, and social workers are criticised for failing to protect. Thus self-neglect severely exercises practitioners’ decision-making discretion, and requires creative approaches to service delivery.

This paper draws on an evidence base from 3 studies conducted by the authors over 4 years (2010-2014), combining systematic review of the international literature with empirical evidence from England on social work practice and service delivery to people who self-neglect. It prioritises findings from the most recent 2014 study, which explored - from the perspectives of service managers, professionals and service users themselves - what makes for effective practice. Drawing on the analysis of a large qualitative data set of 91 interviews across 10 different municipalities, the paper discusses, first, how self-neglectful behaviour arises, situating it within service users’ life stories and relationships. Second, it identifies the significance of practice approaches that build trust-based relationships; these emerge as the single most effective means of engagement and intervention to mediate risk. Finally, the organisational policy implications are outlined, emphasising the value of workflow pathways that support relationship-based practice rather than time-limited care management in achieving positive outcomes.