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Gregory Chasson - Family Support and Intervention for Hoarding


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For the 2016 Annual OCD Conference

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Gregory Chasson - Family Support and Intervention for Hoarding

  1. 1. Family Support and Intervention for Hoarding: Introduction to Family-As-Motivators Training Gregory S. Chasson, PhD Department of Psychology Illinois Institute of Technology Chicago, IL Alexandria M. Luxon Sophia Alapati Kristine Powers Priyanka N. Divecha Department of Psychology Towson University Towson, MD
  2. 2. Acknowledgments • The FAM Training trial is financially supported by Partners Healthcare, Inc. and Towson University. • Thanks to Ashley Carpenter, Brittany Gibby, and Jenna Ewing for helping with earlier drafts of FAM Training. • Thanks to Michael Jenike for project support. • Thanks to Jack Samuels and Gerald Nestadt for assisting with study recruitment.
  3. 3. An Origin Story • FAM Training stands for Family-As-Motivators Training • FAM was forged from the fires of helplessness • Continuous family cries for help for compulsive hoarding (CH) • But treatment ambivalence is a common feature of CH; how can you help somebody who isn’t willing to show up? • Plus, there are limited empirically-supported packages to offer families • Families and providers feel helpless
  4. 4. Domestic Disputes • Relatives report high levels of distress and rejection of the individual with CH • The loved one with CH often feels anxious and angry because of family involvement in CH matters • CH can lead to arguing, estrangement, hurt emotions, physical altercations, financial dependencies, legal battles, sovereignty violations (e.g., unscheduled cleanouts), among other problems
  5. 5. ♫ That’s the Power of Love ♫ • So much family emotion, usually driven by love and concern! • How can this power be harnessed to bring about change? • How do treatment providers encourage individuals with CH to get treatment without even getting a chance to speak with them? • Answer: Family
  6. 6. Something from Nothing? Hardly! • Integrating the help of family is not a novel concept • Michael Tompkins and colleagues1-3 have been trailblazing family approaches for hoarding for many years • Served as inspiration for much of FAM Training • FAM research supplements this work by establishing research evidence for a family program for CH • FAM Training was also inspired by family accommodation work in OCD and anxiety disorders4-6 , as well as motivational interviewing research and texts7 , particularly Rosengren8 ).
  7. 7. Three Birds with One Stone • FAM Training endeavors to 1. Increase treatment readiness and treatment-seeking behavior among individuals with CH 2. Increase wellbeing and decrease distress in relatives 3. Reduce family tension and fighting • The goal, however, isn’t necessarily to look like this family
  8. 8. The Skinny on FAM Training • FAM Training is 10-sessions (60 minutes each) • Manualized training program • 1:1 training session with a grad student trainer • Consists of four modules: 1. Psychoeducation 2. Motivational Interviewing Training 3. Harm Reduction 4. Family Accommodation Prevention
  9. 9. Psychoeducation Session 1 •First 20 minutes—reserved for introducing FAM Training, building rapport with the relatives, and allowing them to open up about their experience dealing with a loved one’s CH •Remainder of session focuses on instructing the relative on various CH info • Course and prevalence, main characteristics, how/why CH may develop, nature of insight, risk factors, and family and economic impact •Take-home handouts and list of local hoarding resources
  10. 10. Family Accommodation Prevention Session 2 •Family accommodation is defined; handouts of family accommodation model and process are provided and discussed Family Accommodation = A. Participating in and encouraging rituals or avoidance behaviors of those with CH9,10 B. Modifying personal and family routines as a result of trying to deal with CH
  11. 11. Family Accommodation Prevention Session 2 continued •Common types of CH family accommodations are reviewed; extra focus on 2-4 accommodations pertinent to the relative •Introduction of expressed emotion (i.e., criticism, hostility, and emotional overinvolvement)11-12 , with handout •HW: read a handout on family accommodation prevention tips and avoiding expressed emotion •Role Play 1: Expressed emotion
  12. 12. Family Accommodation Prevention Session 3 •HW discussed and questions answered about family accommodation and expressed emotion •Discuss and create an example behavioral contract based on guidelines from Van Noppen and Steketee11 •Introduce the concept of extinction bursts •Manage relative’s expectations of change •Role Play 2: Family accommodation and behavior contract
  13. 13. Motivational Interviewing Training Session 4 •Introduce the concept of motivational interviewing (MI). What it is, and what it is not. •Focus of module = in loved one with CH, addressing ambivalence about change and developing awareness of discrepancies •Explain the 3 components of MI8 1)Collaboration 2)Evocation 3)Autonomy
  14. 14. Motivational Interviewing Training Session 4 continued •Review MI pitfalls to avoid7,8 1) Trying to change all behaviors completely 2) The righting reflex 3) Too confrontational or directive 4) Don’t take sides 5) Avoid blaming 6) Premature focus trap •Complete MI Spirit exercises (worksheet adapted from Rosengren8 )
  15. 15. Motivational Interviewing Training Session 4 continued •Introduce and define Stages of Change, with handout (adapted from Whalley14 ) 1) Precontemplation 2) Contemplation 3) Preparation 4) Action 5) Maintenance •HW: Driving in Cars (adapted from Rosengren8 )
  16. 16. Motivational Interviewing Training Session 5 •Check in about Driving in Cars exercise •Introduce and define OARS Method of listening skills8 • O Open-ended questions • A Affirmations • R Reflective listening • S Summary statements
  17. 17. Motivational Interviewing Training Session 5 continued •Practice OARS Method with worksheets adapted from Rosengren8 •HW: 1) practice listening skills and 2) complete “Approaching Challenging Situations” worksheet8 •Role Play 3: OARS method
  18. 18. Motivational Interviewing Training Session 6 •Check in about Approaching Challenging Situations HW and practice of listening skills •Explain concept of ambivalence •Introduce concept of change talk statements reflecting8 1) Some desire or ability to change 2) Awareness of the benefits of change 3) Insights into the difficulties of the current situation 4) A willingness to commit to change 5) A recent history of taking steps to change
  19. 19. Motivational Interviewing Training Session 6 continued •Review examples of change talk specific to CH •In session, complete “Worksheet for Family Member Strengths” (modified from Rosengren8 ) •Review signs of readiness to change8 1) Decreased resistance 2) Decreased discussion of the problem 3) Sense of resolve 4) Increase in change talk 5) Questions about change 6) Envisioning life after change 7) Experimenting with change behavior
  20. 20. Motivational Interviewing Training Session 6 continued •Review ways of enhancing confidence to change8 • Asking about loved one’s success stories of change • Discuss strengths and supports • Brainstorm for problem solving • Reframing past difficulties or lack of success with change •HW: Reinforcing Change Talk worksheet8 and Value Exercise8 •Role Play 4: Change talk, readiness signs, and how to enhance confidence to change
  21. 21. Motivational Interviewing Training Session 7 •Check in about Reinforcing Change Talk worksheet and Value Exercise •Define and discuss the concept of resistance • Resistance is normal! •Define and discuss the concept of reversing
  22. 22. Motivational Interviewing Training Session 7 continued •Discuss ways of responding to resistance8 1) Be non-resistant with simple and double-sided reflections, amplified reflections 2) Reassure that you’re not moving forward too quickly 3) Reversing 4) Reframe problem 5) Acknowledge with a twist 6) Emphasize personal choice and control 7) Side with the negative 8) Encourage pacing 9) Feeling angry is okay, but try not to show it
  23. 23. Motivational Interviewing Training Session 7 continued •Complete in-session exercise  “Techniques for Responding to Resistance,” adapted from Rosengren8 . •Complete in-session exercise, “Real Life Reflections,” which involves role-playing reflections with the trainer •HW: 1) Complete “Resistance and Status Quo Statements” worksheet adapted from Rosengren8 and 2) practice using appropriate listening skills and reflections
  24. 24. Harm Reduction Session 8 •Check in about 1) “Resistance and Status Quo Statements” worksheet and 2) practice using appropriate listening skills and reflections •Introduce the concept of harm reduction Harm reduction = worldview about CH A. Priority = Decrease harmful consequences of high-risk behavior B. WITHOUT necessarily requiring the individual to stop CH fully1-3 .
  25. 25. Harm Reduction Session 8 continued •Introduce principles of Harm Reduction for CH, from Tompkins and Hartl3 1) Do no harm 2) Stopping all CH is NOT necessary 3) No two hoarding situations are alike 4) Loved one is essential member of treatment team 5) CH may not be the most pressing problem
  26. 26. Harm Reduction Session 8 continued •Discuss setting the stage for harm reduction 1) Letting go (with exercise from Tompkins and Hartl3 ) 2) Understand 3) Forgive and introduce the 4 A’s from Tompkins and Hartl3 • Acknowledge • Assign reasons • Assure patterns won’t be repeated • Ask for forgiveness 1) Grab hold with exercise from Tompkins and Hartl3
  27. 27. Harm Reduction Session 8 continued •HW: Read the following 1) “List of Forgiveness Resources” handout 2) Tompkins and Hartl’s3 “Do’s and Don’ts of Forgiveness” 3) Read as a primer, “Guidelines for Conducting the Home Assessment” (adapted from Tompkins and Hartl3 ) •Role Play 5: Setting the stage for harm reduction
  28. 28. Harm Reduction Session 9 •Check in about HW readings •Introduce concept of harm potential •Introduce guidelines of harm potential home assessment from Tompkins and Hartl3 1) Show respect and be honest 2) Be prepared 3) Explain assessment goals to loved one 4) Answer loved one’s questions 5) Complete the “Harm Potential Assessment Form”3 6) Leave time to chat
  29. 29. Harm Reduction Session 9 continued •Factors to assess during home visit • Level of support  “Assessing Level of Support” handout from Tompkins and Hartl3 • Insight and motivation  “Assessing Insight and Motivation” handout from Tompkins and Hartl3 • Other factors  “Assessing Other Factors” handout from Tompkins and Hartl3 1) Chronic or current medical conditions 2) Physical limitations 3) Alcohol or drug problems 4) Psychological conditions • Acquisition factors  “Assessing Acquisition Factors” handout from Tompkins and Hartl3
  30. 30. Harm Reduction Session 9 continued •HW: conduct an assessment of the loved one’s home using 1) “Harm Reduction Potential Assessment”3 2) “Identifying Harm Reduction Targets”3
  31. 31. Harm Reduction Session 10 •Check in about HW of conducting a home assessment •In session, complete “Harm Reduction Planning Worksheet” from Tompkins and Hartl3 •Identify harm reduction targets across certain categories3 • safety • health • comfort • medical, physical, memory, and sensory limitations • accommodations that may be required (e.g., removing name form junk mail lists) • financial harm
  32. 32. Harm Reduction Session 10 continued •Create a harm reduction plan, which includes 4 components3 • Realistic goals 1) Concrete and specific 2) Doable 3) Prioritized • Monitoring progress • Management strategies for 1) Reducing financial risk 2) Improving living situation 3) Facilitating saving and organizing • Harm Reduction Contract • Provide example contract
  33. 33. Harm Reduction Session 10 continued •Role Play 6: Creating the harm reduction plan •Wrap up FAM Training 1. Review of components 2. Seek feedback about the program
  34. 34. 1) Tompkins, M. A. (2015). Clinician's guide to severe hoarding: A harm reduction approach. New York, NY, US: Springer Science + Business Media 2) Tompkins, M. A. (2011). Working with families of people who hoard: A harm reduction approach. Journal Of Clinical Psychology, 67(5), 497-506. doi:10.1002/jclp.20797 3) Tompkins, M. A., & Hartl, T. L. (2009). Digging out: Helping your loved one manage clutter. Oakland, CA: New Harbinger Publications, Inc. 4) Stewart, S. E., Beresin, C., Haddad, S., Egan Stack, D., Fama, J., & Jenike, M. (2008). Predictors of family accommodation in obsessive-compulsive disorder. Annals of Clinical Psychiatry, 20(2), 65-70. 5) Steketee, G., Ayers, C., Umbach, A., Tolin, D., & Frost, R. O. (2013). Family response to hoarding: Assessment and features in an internet sample. Unpublished manuscript. 6) Amir, N., Freshman, M., & Foa, E. B. (2000). Family distress and involvement in relatives of obsessive-compulsive disorder patients. Journal of Anxiety Disorders, 14(3), 209-217. 7) Miller, W. R., & Rollnick, S. (2002). Motivational interviewing. (2nd ed.). New York: The Guilford Press. 8) Rosengren, D. B. (2009). Building motivational interviewing skills: A practitioner workbook. New York, NY: The Guildford Press. 9) Allsopp, M., & Verduyn, C. (1990). Adolescents with obsessive compulsive disorder: A case note review of consecutive patients referred to a provincial regional adolescent psychiatry unit. Journal of Adolescence, 13, 157-169. References
  35. 35. 10) Livingston-Van Noppen, B., Rasmussen, S. A., Eisen, J., & McCartney, L. (1990). Family function and treatment in obsessive-compulsive disorder. In M. A. Jenike, L. Baer, & W. E. Minichiello (Eds.), Obsessive compulsive disorder: Theory and treatment (pp. 325-340). Chicago: Year Book Medical Publishers. 11) Van Noppen, B., & Steketee, G. (2003). Family responses and multifamily behavioral treatment for obsessive-compulsive disorder. Brief Treatment and Crisis Intervention, 3, 231- 247. 12. Vaughn, C. & Leff, J. P. (1976). The influence of family and social factors on the course of psychiatric illness: A comparison of schizophrenic and depressed neurotic patients. British Journal of Psychiatry, 129, 125-137. 13) Whalley, M. (2008). Stages of change. Retrieved from assets/files/Worksheets/Stages_Of_Change.pdf References
  36. 36. Thank you!!! Gregory S. Chasson, Ph.D. Licensed Psychologist Associate Professor Department of Psychology Illinois Institute of Technology