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Dealing With the Dirt
Working with people living in squalid conditions can be very difficult. What powers have we got to tackle the problem? Should we be intervening at all? You may hear health and care professionals say this is a lifestyle choice. If we decide to offer help, what happens if the person refuses, assuming they have the mental capacity to make that decision? What legal remedies are there? Again you may hear professionals telling you how cumbersome the law is in this area and the problem will not get resolved. Meanwhile, there may well be pressure from family and neighbours to make sure something does get done.
A colleague of mine has recently sent me a link to an e-book rather dramatically called ‘Vile Bodies’ (named after an Evelyn Waugh book about the antics of ‘bright young things’ in the 1920s). It is a very comprehensive document on the subject of human squalor that helps to work through the questions I have just outlined. It is written by Peter Bates who has done some excellent work with the National Development Team for Inclusion on the topic of self-neglect. I think this could be a valuable resource for home care agencies working with people who are hoarding, and living in insanitary conditions.
To explain the problem it is often given a term, such as Diogenes syndrome, or squalor syndrome, particularly where it occurs amongst elderly people. Diogenes was a 4th Century BC Greek philosopher who rejected the usual norms of daily living, and lived in a large ceramic jar. Diogenes syndrome is not listed as a mental disorder in the Mental Health Act Code of Practice. The problem of living in squalor may be as a result of mental health problems such as severe depression that stops the person looking after themselves and their home environment. What Peter Bates’ book length report does is to explore all the different aspects of the difficult issue of how you deal with people who are living like this.
Identifying the problem
The book starts with a useful checklist of indicators that might suggest dangerous self-neglect, a real warning we should be doing something. Is there evidence of the following?
- Ignoring bills and other important post
- Refusing healthcare
- Refusing help from care staff or utility suppliers
- Poor personal hygiene
These seven headings could be a very useful starting point in undertaking an assessment.
The book does not offer easy answers, but what it does do is have a whole range of useful information that can guide staff. The book looks at the history of personal hygiene, and how cultural factors have affected our view of this through the ages. The book also explores how recent policy changes and ways of thinking have made the work of care staff more difficult. On the one hand there is a focus on independence and choice for service users, but on the other a greater emphasis on protection of vulnerable adults.
Helpfully the book gives a brief outline of the laws that might be used in this area, and the questions that practitioners would need to ask to see if the law could be used. There’s also a useful paragraph in Richard Jones’ Mental Health Act manual on dealing with squalor. Where the person has a mental health problem, mental health legislation might offer a way of intervening that protects the person and resolve the problem, perhaps by taking a best interests decision under the Mental Capacity Act, or perhaps by using the Mental Health Act so that the person might be received into Guardianship. There are other laws outside the field of mental health such as the Environmental Protection Act 1990 which provides remedies for local authorities, so that wider public health concerns are met.
Building a team
The guide includes a useful section on joint working. Often care workers feel they are struggling alone with the person and their problem. The guide suggests a list of people and agencies you would draw into an assessment of the problem and a plan to resolve it. This offers other perspectives, as well as other powers. So we might be thinking about a team wider than a group of health and care staff, that includes safeguarding teams, housing officers, the police and fire brigade and more.
The guide also includes some references and links to scales and measures to establish how serious the problem is, such as hoarding rating scales, or matching against a range of sample pictures of rooms in varying degrees of clutter.
The guide includes an appendix which would be a very useful checklist of questions for workers to consider, divided into headings as follows:
- Getting to know the person – if intervention is going to be successful we need to establish a trusting relationship with the person. We need to know more about the person and how they have got into this situation. What has been their attitude to cleanliness? Has there been a recent change in the person’s attitude or has the person always been like this? What is the person’s view of the mess? To the person that pile of rubbish might have some significance.
- How serious is the problem – is the extent of the problem in terms of risk to the person or others such that we are going to have to intervene?
- Teamwork and procedures and arranging help - this is where you can identify the team of people and agencies who might be able to help.
- Supporting and developing staff – this is where you might be thinking about your own attitude to the problem. Different staff have different attitudes to cleanliness. However distasteful we might find the person’s situation we must remain respectful of the person themselves.
Finally three important messages that I’ve gleaned from this book:
- We might end up not actually being able to do anything for the person – but it is important that your assessment, and plan, and liaison with others is recorded in writing.
- Good quality assessments are important, and these include how you arrived at the assessment of the person’s capacity.
- Learn from incidents - review cases with staff – where things went well, and as will happen sometimes, where things went badly.