Working with Self-neglecting Clients - eLearning Transfer of Learning Guide

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Self Neglect

3

work with this difficult population. Have them read the handout “Ethical Principles” which defines some ethical terms. Some follow up questions may include:

• What do you see as the mostchallenging dilemma for APS workerswhen dealing with self-neglectingclients (balancing the client’s autonomywith our beneficence….responsibility toprotect)

• How do you see an APS workercausing harm to a client while tryingto protect her/him? (removal of clientfrom family home to a LTC facility maycause quicker deterioration, - stressthat workers must weigh theconsequences of their actions beforemaking a decision)

• What privacy issues may get in theway of your being able to provide aservice to a self-neglecting client?(refusal to allow worker access, refusalto share income info, refusing to sharenames/phone numbers of familymembers)

Explain that there may be conflicts between the client’s wishes and your commitment to protect. As long as clients understand risks and make choices voluntarily, their wishes must be respected. When victims do not understand the risks they are taking or are operating under coercion AND the threat is substantial, we may be obligated to take actions. Ask:

• When might a self-neglectingperson’s behavior constitute acrime? (animal cruelty, firehazard, condemned home)

Written Activity:

Define self-neglect, its prevalence, risk factors and indicators:

Assess self-neglect in the 5 domains

n this activity, new staff will be able to explain the 5 domains of assessment and will begin to

examine the indicators of self neglect under each domain.

The following page is a worksheet that workers will use to identify self-neglect indicators in the five domains. Have them write as many as possible on the sheet. If you have more than one new worker, have them exchange papers and discuss the differences.

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Self Neglect

4

Ethical Principles

The 5 Domains of Assessment

For each domain, list as many possible indicators of self neglect as you can think of:

Domain 1: Physical/Medical Factors:

Domain 2: Psychological/Mental Health

Domain 3: Environmental

Domain 4: Financial

Domain 5: Social and Cultural

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Self Neglect

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Answer Sheet

Case Vignettes: Assess self-neglect in the 5 domains

1. Joe Smith, age 82, lives alone. He is diabetic and is not keeping his diabetic diet.Sometimes he forgets to take his insulin. He has been having pain in his foot aswell. He has a 2nd grade education and has minimal reading and writing abilities.

What may be the impact? (complications of diabetes, amputation, inability to understand the medications or inability to read the prescriptions or diet, malnutrition 

2. Maria Rodriguez, age 74, has moderate dementia. She believes that there arepeople in her attic who are trying to kill her. She calls law enforcementfrequently to complain, but she doesn’t speak enough English to make herselfunderstood. She sometimes runs out of the house and knocks on neighbor’sdoors in the middle of the night.

What may be the impact? (neighbors filing charges, mental health commitment, client refusing to return home) 

3. Hanna Rupinkska, age 80, is an animal lover, taking in stray cats. Presently shehas 45 cats. She believes she is taking good care of them and preventing themfrom being euthanized. She has some vision problems and her home isextremely cluttered. The smell has reached the neighbor’s home.

What may be the impact? (cruelty to animal charges, health and safety hazards, falling, house may be condemned leaving client homeless

4. Harriet Demone, age 79, is a recent widow. Her husband always managed thefinances and paid the rent. She does not open the bills and has been avoiding thelandlord. She says her daughter comes every so often to help her. Herdaughter lives 500 miles away.

What may be the impact? (utility shutoff, eviction, privacy issues, shame issues)

5. Lakshmi Patel, age 88, lives with her son Proful. She is frail and almost bedbound.She will not allow her son to assist her with bathing and she refuses to letstrangers near her.

What may be the impact? (bedsores, illness resulting from lack of hygiene, son may become frustrated and neglect her) 

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Self Neglect

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Answer Sheet

Functional Assessment

• Mrs. F is a frail 85 year old woman. She recently fell and hurt her wrist. Thedoctor doesn’t want her lifting anything weighing more than 5 lbs.

o What assistance might she need? (laundry- can’t lift the basket, shopping- can’t carry bags, some cooking- can’t lift pan of water, making beds- can’t liftcorner of mattress, depending on leg strength she might even need help risingfrom a chair.)

o How severe or urgent is this situation? (not severe or urgent, but in need ofhome health services.)

• Mrs. S. is 76 and a recent widow. She is depressed and has not paid her utilitybills. Her home is in disrepair. She says she has never handled money and herhusband used to take care of everything. She has isolated herself from others.She does not drive.

o What assistance might she need? (money management, companionservices, reassuring calling, reconnect with friends and/or family, handymanservices, mental health treatment, medication, transportation)

o How severe or urgent is this situation? (moderate. If client doesn’t getmental treatment, her depression may worsen and the self neglect also.

• Mr. G. age 80 has some dementia and is taking Coumadin, Aricept, bloodpressure medication. He often forgets to take his medications and is unsteadyon his feet. His home is full of clutter and trash. There are newspapers stackedto the ceiling. He is dirty, his clothing is soiled and ill-fitting and he is wearing hisboxer shorts over his pants. There is little food in the house.

o What assistance might he need? (medication monitoring, home healthservices, meal prep or delivery, assistance with dressing and bathing, cleaningservices)

o How severe or urgent is this situation? (risk may be imminent and becomean emergency if services aren’t provided.  Client may also require a capacityassessment.)

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Self Neglect

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3) The Self Interested CaregiverDefinition: Someone has responsibility for providing but the care is inadequatebecause the caregiver is really just in it for the money.Examples:

∗ Caregiver is being paid or stands to inherit. ∗ Caregiver is concerned or preoccupation with their own interests.

• Accounted for the fewest number of cases• Prognosis: Interventions are relatively simple if caregivers were removed as

responsible parties.• Promising Approaches: Guardianship. Money management.

4) The Elder AloneDefinition: Elders who have no one to provide care. Since the neglect in thesesituations can not be attributed to anyone other than the elders themselves,these cases are often referred to as self neglect.Examples:

∗ Elder recently lost close friends or relatives, or spouses who were providing care and alternative arrangements haven’t been made.

∗ Elders who have chosen to be alone or to live with animals. ∗ Debilitated couples where neither member is capable of providing care to the

other. • Prognosis: Depends on the reason that the older person or couple is alone. Many

older people and their families don’t know about services. Some may agree toservices when they hear about them.

• Promising Approaches: Educate seniors and their families about services.

5) Elders who Refuse CareDefinition: Same as above but senior has refused help.Examples:

∗ Senior is depressed. May be close to die and wants to die ∗ Senior doesn’t want to have their affairs scrutinized ∗ Senior is committing slow form of suicide.

• Prognosis: Poor but depends on reasons that clients are refusing help. If theyreally want to die, there may be little that can be done.

• Promising approaches: If judgment is shaded by depression, it may be treatable.Bringing services in to home. Crisis may precipitate change.

* Dubin, T., Garcia, R., Lelong, J., & Mowesian, R. (1986). Family neglect and self-neglect of theelderly: Normative characteristics and a design for intervention. Austin, TX: Hogg Foundationfor Mental Health, Family Eldercare, Inc.Transfer of Learning: Describe risk assessmenttools used for evaluating self-neglect

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Self Neglect

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Self Neglect

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Role Play: escribepromisingmethods for

working with self-neglecting adults Develop safety and risk reduction interventions for self-neglecting adults,

In this role play, new workers will have the opportunity to practice interviewing a difficult self-neglecting client. The goal is for them to develop rapport with the client and get a sense of who the client is and how she sees the world and the presenting problem. You the supervisor can play the role of client or ask an experienced worker to play the role so you can observe. To prepare for the role play, ask them to read handout “Using Empathy to Counter Resistance.” Stress that their purpose is to connect with the client and try and understand the self-neglecting behavior. They are not expected to solve the case…

Client Role:

You are Florence Maccio. You are 80 and live alone in a 2nd story apartment where you have lived for 45 years. You had been a nurse and always took care of yourself and your own things. You have never been married and always wanted to do things your own way. You never asked anyone for anything. You never wanted anyone in your business. You love animals, especially birds. You have 5 birds and don’t like to see them caged up, so you let them fly around the apartment. They give you a lot of pleasure and comfort.

5 years ago you had a stroke which left you weak on one side. You take lots of different medications and sometimes it is confusing which ones to take at which time. The doctor you used to have has died and some young doctor has taken over the practice. He doesn’t know you and gets mad when you don’t make it to your appointments.

It has been difficult for you to clean the apartment but you do the best you can. Last year the landlord sent an exterminator, but you didn’t want to have all those poisons in your house. They might hurt your birds. A few months ago the building manager sent you a notice that you had to clean or you would be evicted. Imagine that! After all these years! They sent some kind of social worker to talk to you but she was really pushy and criticized your housekeeping… and told you to get rid of the birds. You kicked her out. Now the landlord is really angry and called some other social worker to come see you.

After the role play ask the worker the following questions:

• How did it feel to be confrontedwith a resistant client?

• What do you think caused theresistance?

• What were some of thechallenges in connecting with thisclient?

• What would be your next stepsin this case? How would youdecrease risk?

D

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Role Play

To prepare for this role play, review handout “Using Empathy to Counter Resistance.”

The Case:

You have been assigned the case of Florence Maccio, age 75. She was referred by the landlord of her apartment because she may be evicted due to the condition of her apartment. Landlord reports that Ms. Maccio had a stroke and cannot do anything for herself. She hasn’t cleaned the apartment in years and has birds flying around loose in the apartment. He also reports that Ms. Maccio is confused and has been resistant to anything she has been offered – exterminator, help from the office on aging. He believes that Ms. Maccio is not realistic about her situation and probably needs to go into a nursing home.

Your assignment:

• Make an initial visit to Ms. Maccio

• Use empathy to try and understand her perception of her situation

• Try to understand where her resistance comes from

After the role play, think about the following:

• How you handled any resistance

• How you showed empathy

• What you did well

• What would you do differently

• What would your next steps be in this case

Self Neglect

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Using Empathy to Counter Resistance

Causes of Resistance

• Dementia

• Anxiety

• Grief

• Depression

• Lack of insight

• Personality problems

• Shame

• Distrust

• Fatigue

• Fear

• Pain

• Anger

Express Empathy

• Listen• See the world through the client’s eyes• Think about things as the client thinks about them• Feel things as the client feels them• Share in the client’s experiences• Respect the client’s perceptions• Take your time• Do not rush to judgment

Benefits to using empathy

• Lessens resistance and denial• Helps you get more information• May make client more open to suggestions and incremental change

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• Exploration of personal issues relating to the work with APS clients: workingwith this population may arouse feelings in all workers, especially new ones.Self awareness is critical for workers in APS – is it the client? Is it the worker?Where is the issue coming from? Some topics for exploration may include:

o Independence/dependenceo Loss/grief/deatho Ageism and attitudes towardo Isolationo Illness: physical and mentalo Reframing situations from a strengths perspective (instead of seeing

issues as problemso Countertransference: linkage between the worker’s personal feelings

and professional interventions and behaviors. Signs may includeDepressed or uneasy feelings during or after contact with certainclients or family membersForgetting/avoiding appointmentsStrong or sharp comments relating to a client or family memberDoing more for certain clients due to very positive/affectionatefeelingsDoing less than what is required or available due to negativefeelings about a client/situationOngoing arguments with certain clients or family membersSudden increase or decrease of interest in a certain caseRush to terminate

References:

Burack-Weiss, Ann and Coyle Brennan, Frances. Gerontological Social Work Supervision Haworth Press (New York, 1991)

Genevay, Bonnie and Katz, Renee S. Countertransference and Older Clients Sage Publications (California, 1990)

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Transfer of Learning: Identify community partners in self-neglect cases

Share Handout “Community Partners in Self-Neglect Cases” with new workers. This handout identifies community partners.

Have workers research who the most appropriate community partners are for their particular caseload/area. They can do this by asking coworkers or colleagues for recommendations, by calling other agencies and developing their own contacts. When they have completed the worksheet to follow, they should discuss their findings with you and then keep that worksheet as a resource list that they can use in the future.

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Community Partners in Self-Neglect Cases

Professional, entity or group Who Do I Call? 

Mental health professionals, including county geriatric mental health program personnel or professionals in private practice (geriatric psychologists, psychiatrics, etc.)

Geriatric physicians and nurses

Conservators, including private professionals

Public Guardians

Clergy

Local law enforcement, including police and sheriffs

Animal Welfare Organizations (municipal animal care and control agencies, humane societies and SPCAs, and rescue organizations

Ethics Committees (most are convened by hospitals and nursing homes)

Multidisciplinary teams, including elder abuse multidisciplinary teams and death review teams.