Although abuse of carers by the people they care for is rare, social workers need to be able to spot the risk factors. A recent good practice paper from the Association of Directors of Adult Social Services (Adass) said practitioners operated a rule of optimism, whereby they overestimated families’ ability to care, which can lead to them missing this form of abuse. Denial, guilt and fear on carers’ part can also account for abuse going unnoticed. Below, Natalie Valios looks at four indicators of possible abuse highlighted by Adass and what social workers should do when confronted with them.
EXCESSIVE CARE NEEDS
Indicator: when the service user has care needs that exceed the carer’s ability to meet them.
Practice example: Crossroads Care was called in to support an 83-year-old man caring for his wife who had severe dementia. “He didn’t grasp the extent of her incontinence problem, even though the bed and sofa were soaked in urine,” says Sandy Caley, assistant director of support services.
“He couldn’t lift her into the bath so was standing her in a large tray in the lounge and pouring buckets of water over her.
“He was terrified that if he asked for help she would be taken away, but it was just too much for him. His health was affected, he wasn’t sleeping and was beside himself with anxiety.”
What social workers should do: Sometimes social workers think only of the service user’s needs. If the carer is emphatic that they can cope, it’s human nature for a busy social worker to move on to the next case. But common sense should make you question a carer’s assertions – in this case, says Caley, anyone who sat on the sofa could not fail to realise the extent of the problem.
“She needed protection, but so did he,” she says. Her dementia was such that she had little idea who he was and could become distressed by his treatment of her. In such a situation, distress can turn into abusive behaviour out of fear or confusion.
In this case, the social worker called Crossroads Care because the husband was scared of social services. “Partnership working is important,” says Caley. “Working together, we were able to get a carer’s assessment, urgently review the care plan and access bathing and continence services.
“He needed emotional support, respite care and training in moving and handling and dementia awareness. Consequently her final few months were more comfortable and she was able to die at home as they both wanted. Social workers need to look at the whole package and not look at the service user’s needs in isolation.”
REJECTION OF SUPPORT
Indicator: when the service user is abusive or aggressive.
Practice example: A 73-year-old man became resentful of his limited capabilities due to chronic airways disease. His wife, who cared for him, was terrified of his temper outbursts but was reluctant to tell anyone out of fear. Consequently her mental health deteriorated. This continued for several years, hidden from family visits, and it was only a casual word from a neighbour to a daughter that uncovered the issue. The daughter phoned Action on Elder Abuse’s helpline. The outcome was a carer’s assessment, domiciliary care and the involvement of a mental health nurse.
What social workers should do: People can drift into a situation where interaction between the two becomes fraught, says Gary FitzGerald, Action on Elder Abuse’s chief executive. “Social workers sometimes don’t see the complexities of the relationship so need to spend time with them to understand what’s happening. They may think it is just part of the family dynamics and are reluctant to interfere, but we need to challenge that.
“It can be hard for social workers to know what goes on behind closed doors, which is why they should interview the carer and service user separately.
“If that is done as a one-off it is not likely to elicit the information: social workers need to spend time building up trust for an abusive relationship to be revealed.”
Also, social workers can sometimes build up a picture of what’s going on from others, such as a domiciliary care worker, the warden in sheltered housing, or neighbours, FitzGerald adds.
Indicator: when the service user has sought help but did not meet thresholds.
Practice example: A 63-year-old man with a degenerative illness wanted practical assistance with housework, gardening and shopping, leaving his wife to carry out his personal care. But while personal care could be provided, the other tasks were assessed as falling below the threshold for support, so he declined.
As his health deteriorated his wife struggled to get him out of bed, dressed and washed, and sometimes he slipped and was injured. He would then be abusive. She became depressed until a friend phoned Action on Elder Abuse which advised about a carer’s assessment, respite support and safeguarding.
What social workers should do: A good social worker will know which voluntary organisations to direct service users to if they can’t provide a direct service.
“Social workers need to think wider than a narrow checklist of statutory services,” says Gary FitzGerald, chief executive of Action on Elder Abuse. “The pressures they are under may make it difficult for them to stand back and look holistically at situations, but they need to.
“If they are concerned about a deteriorating relationship, [the family] should be referred to adult safeguarding. This should be seen as a preventive measure. An abusive relationship can push people into the critical category which overrides the original thresholds they didn’t meet.”
ABUSE AND AGGRESSION
Indicator: when the service user rejects external help or support, including breaks.
Practice example: A woman caring for her father called Carers UK for advice when she reached breaking point. She worked full time and didn’t live with her father so was doing a 20-mile round trip daily to carry out personal care, clean the house, prepare meals and work. He didn’t agree that he needed support and refused to let social services into the house.
What social workers should do: This can happen when someone wants to remain independent; they think they are, but in fact are relying heavily on their family. Occasionally it is the result of a controlling relationship, says Emily Holzhausen, director of policy at Carers UK.
“A social worker may be able to skilfully broker an honest conversation between the two and say [to the person cared for] that their daughter/son is under extreme stress and they are worried about their health,” she says.
“That won’t work for everybody, particularly if there is an element of control in the relationship, but will for those who haven’t realised the impact they are having.
“The biggest risk is to the carer’s mental health. In this situation we still haven’t been able to get anyone into the house so all we can do is provide advice.”
Advice can come in the form of practical help, such as benefits assistance, or putting the carer in touch with the local carers’ support groups or centres, says Jill Manthorpe, director of the Social Care Workforce Research Unit at King’s College London.
“Setting up a support plan for the carer may need to be a multi-professional activity,” she says. “Some professionals may find it useful to think about co-working, with one person thinking more about the carer and another about the service user.”
“The common mistake,” says Holzhausen, “is to believe that the service user’s rights trump everything, but the Human Rights Act is clear that one person’s rights cannot override another’s.”
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