Refusing help


The tragic case of Stephania and Sam Wolf has been in the news over the last day. Without knowing anything but the most cursory details of this particular case, it raises some issues and dilemmas that I am very familiar with and wanted to explore for a moment or two.

There is the issue of the overstretched carer who has little external supports. Yes, help was offered but help was also turned away. One can also speculate about the pressures that being a sole carer in a small community might bring and how much effort was made by services to actively engage with people who might find their presence stigmatising. One can also speculate about the kind of help that was offered and whether our systems are limited both in the type of help offered (day centres, home carers for example) and also by the ways in which help is offered.

These are the problems that may be created when social workers are berated by the press and in the public perception. An unrealistic image is engendered of the profession and people who might benefit and need social work interventions feel that there is a stigma attached to having a social worker or social services involved. For me, this is far more important an issue for the College to address than whether I feel comfortable telling people on the bus that I’m a social worker.

As long as ‘the social’ is seen as something wrong, unpleasant or something of a punishment, it will make people from all client groups – adults and children – reluctant to engage.

Now again, I want to emphasise that this is not a statement about this particular case, but there is a dilemma when a family member is a main carer of someone who may lack capacity to make a decision about their own personal care needs.

When would we, as social workers – as representatives of ‘social services’ challenge the carer as to whether they are acting in the best interests of the cared for and when does ‘refusing help’ need to be challenged?

This is one of the most troubling dilemmas as a professional. It is much easier to provide a service and to provide care when everyone agrees of course. When there is a clear capacitious statement by someone who may be entitled to a service that they do not wish for a service – again, that is clear, also  when there is blatant abuse it is a very clear judgement to make that the family member/carer is not acting in the best interests of the cared for – but when do we cross the line and demand services go in for the benefit of the person who might not be able to decide for themselves and whose family member is refusing help on their behalf.

Especially if the family member may be living in the same property. There is a risk of ‘upsetting the apple cart’ so to speak and ending up on the front page of the Sun or the Mail being accused of ‘dragging granny away from loving daughter’ or strong-arming services in.

A lot of times though,  services are refused, we can and often do have to walk away. People have the right to refuse.  Sometimes though, we need to assert the services more fully. Services don’t have to be removal to residential care – that is another myth that does enormous damage in the public perception of social care and often when services might be refused it is because people or their families are scared we’ll ‘put them into residential care’. Often I chuckle to myself that the last thing in the world we are going to do is put someone in residential care if they don’t need it as a  package of care at home is  infinitely cheaper.. but that’s not always as clear in thoughts and perceptions prior to arriving and being able to say this.

The problem with asserting roles and trying to engage slowly with a view to increasing or accessing services by slow introduction and the creation of a relationship of trust is the time factor that we are all subject to in our day to day work.

Fortunately, in the team I work in, being a CMHT, we are given more time to actively engage with users and carers and can often, even if it is over a period of months, gently prod towards a slow introduction of care services.

Just this week, I have finally, after working with someone for well over a year, persuaded her to give some formal care services ‘a try’. She could have done with those services for a good few years and granted the presence or not is a matter of quality of life rather than life and death but there is no way she would have agreed had we not had that previous relation of trust which had built up over time.

In the adult teams where I previously worked, there would be no time allowed for that. A refusal of services is one less assessment you need to do – and I don’t mean that to sound cruel, it isn’t meant to be – but just that the levels of workload don’t allow you to go back and try and catch anyone who might fall through the net.

Sometimes people don’t want what ‘professionals’ think they should have and that’s fine too. The Mental Capacity Act speaks explicitly about the right to make ‘unwise’ decisions although one persons’ unwise decision is another persons’ fully formulated plan. The provision of this clear statement is to ensure that professionals don’t become too prescriptive in making decisions about whether someone might have capacity or not. There are many decisions everyone makes on a day to day basis that aren’t scrutinised in the way that people whose mental capacity might be being questioned would be scrutinised and it is about shedding pre-made assumptions (apart, of course, from the assumption that everyone has capacity as a baseline).

But back to the Wolfs. If there is one thing that I hope can be taken from this it is that social isolation doesn’t just happen in big cities. It can happen in small rural communities too.

Keeping an eye out for neighbours and  acquaintances is worth more than formal care services.

About cb

Social Worker in the UK

Posted on 08/04/2010, in Disability, health, local authority, long-term care, MCA, mental health, old age, older people, personal, politics, social care, social issues, social work, work and tagged , , , , , , , . Bookmark the permalink. 10 Comments.

  1. The question about the refusal of help goes a lot deeper.

    In our situation we would now never be able to have help as we have been the victims of malicious allegations from NHS employees about whom we had complained. The result was that the SS held secret meetings(they still do!) without asking us for any input and stated that they have to believe the malicious employees of the NHS ‘because we have to work with them’ – they were not interested in the truth! This leaves us in a position where we can never access any help or support and the SS will be happy with that as it won’t cost them a penny.

  2. Pat, that sounds like an awful situation. I hope you manage to resolve the issue in some way and it sounds that you have been treated horrendously.

    • Thanks for sharing that. I can understand a bit better and will take some more time to read through the site more fully.

  3. ‘…one persons’ unwise decision is another persons’ fully formulated plan.’ I know that one intimately… I seem to be spending a lot of time at the moment dealing with a family member who spends a great deal of his time formulating very self-destructive plans. Or else I’m mopping up the fallout when he carries them out. Unfortunately I can only really be of any help if he wants to change the ways he makes decisions. That doesn’t seem very likely at the moment.

    On the plus side, that’s a wonderful idea for a story and as a professional writer I’ll probably file it away for a time when I can use it as a plot device!

  4. I did notice that the girl’s father had left them twenty years previously and I wondered if that was why the mother didn’t ask for help – it was a rebuke to him for abandoning his post. Desperately sad story and again, the carer goes before the patient.

  5. Yes, a tragic case and we don’t know all the facts yet. You make a good point about isolation not only happening in cities.

  6. The particularly difficult part of this for me is that if Sam did not have the mental capacity to accept or refuse different offers of day-care, respite etc. then was her mother acting in her best interests to refuse them on her behalf? My suspicion is that a parent or carer often makes these decisions for a person and that it is not challenged. I just don’t have the time to start investigating these complex issues of capacity when there are so many that we are actually ASKED to sort out. Papers like The Mail seem to have a perception of the law and what Social Services do that is so far removed from reality that I can only conclude that they wilfully mislead in pursuit of their political agenda.

    Something I have been thinking about recently too is the expectation that Social Services should be a safety net for all dimensions of a person’s life. Someone kills themselves and had contact with SS – it’s their fault. A person with capacity refuses care or help and dies of cold – SS must be to blame. To have this level of supervision and intervention would require SS to increase in size and funding vastly. A relative of mine recently said that SS had a poor reputation with the families of clients he sees because they are rarely in contact and have only fleeting contact with them. This is because they have a relatively low level of need and their needs are largely being met – the legal issues and degree of need I have to deal with in respect of my clients are at a level far above what a Daily Mail reader would expect.

  7. I can’t say anything other than that I entirely agree with you :) Thanks for the comment! My concern was about where the wishes of the carer overtake the needs of a user who does not have capacity. I think sometimes it is too easily forgotten.

  1. Pingback: This Week In Mentalists: The Slightly Sloppy Edition « Mental Nurse

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