Items appear useless to others Identifying value Instrumental Sentimental Intrinsic This results in the growth of items and interferes with the functionality and use of living spaces. 80% of what we own we never use 1.4 million Americans suffer from chronic hoarding and clutter. Inability to discard items despite apparent uselessness. Reasons for saving items can be classified into three types of values that individuals places on possessions. First, items are believed to have instrumental value and are saved because they are viewed as practical items that are useful. Secondly, possessions are seen as having sentimental value (i.e., the individual attributes emotional meaning and attachment to the item, and their possessions are seen as extensions of the self. Third, possessions can have intrinsic value , where the item may not necessarily be useful or meaningful, but rather these items are saved because they are believed to have some characteristic that makes them too valuable to be thrown away.
Elements of Acquisition: Free samples Items discarded by others Compulsive shopping (“Retail Therapy”) On-line Infomercials “ Good Deals” Hand-Me-Downs Items left behind by family Gradual accumulation over years Individuals who hoard are more likely to engage in compulsive buying and will buy more of one item to keep on hand. People who hoard will also acquire possessions through the compulsive acquisition of free items, by taking free samples, handouts, or items others have thrown away. Possessions are acquired with the intention to use the item in some way. However, items that are acquired often go unused due to the quantity of possessions. The compulsive acquisition behaviors resemble behaviors of OCD. Individuals often experience intrusive and recurrent urges to purchase or acquire, which are accompanied by discomfort that is relieved by acquisition or avoidance of situations where they are tempted to acquire Addictive component - Intense emotion in the moment that gradually fades over time. If re-exposed to the opportunity, the intensity spikes again.
Difficulties with decision-making is a hallmark feature of hoarding. Individuals with hoarding problems tend to have difficulty making decisions in general, not only decisions regarding their possessions: what to clothing to wear, what to order in a restaurant, and what products to buy at a grocery store. Perfectionism: The difficulty with decision-making is thought to be related to perfectionistic fears of making mistakes, which form the foundation for compulsive saving and buying behaviors. Explain that people with this disorder will purchase many items that they do not need because of a fear that they might need the item in the future or that someone they know could use the item. These urges are especially strong with items that are on sale. Hoarders feel that they must buy the item now because it may not be on sale again, or they will not be able to purchase the item in the future. These behaviors are fueled by obsessional thoughts of making a mistake by not purchasing the item immediately. Perfectionism in categorization: Perfectionism in decision making also contributes difficulties in the categorization and disposal of possessions. Discarding and organizational behaviors are often avoided by people who hoard because the decision making process is complicated by fears of discarding a needed item, or placing an item in a category that it may not perfectly fit into. When discarding hoarders think mostly of the benefits of saving possessions and attend less to the costs of saving. Decision-making is painful and timely for people who hoard and is often avoided by saving possessions, or putting items to the side. By avoiding decisions making, the person does not have any regrets or pain over their decisions, but their clutter in the home continues to accumulate.
Explain that in addition to the information processing deficits in compulsive hoarding, hoarders tend to have problems with emotional attachment. Compulsive hoarders have an overly sentimental view of their possessions and may save items as reminders of relatively unimportant events. Possessions as extensions of themselves: Compulsive hoarders attach much more sentiment to their possessions. This excessive attachment to possessions also results in a tendency toward excessive purchasing behavior. Often they feel comforted by their possessions, but are often uncomfortable with the amount of clutter in their home. When hoarders attempt to de-clutter their home and discard possessions, they often feel that they have lost part of themselves or their identity. Exaggerated loss: Most hoarders experience some type of exaggerated loss when discarding possessions and tend to have grief-like reactions and ruminations about the discarded objects. The emotional discomfort of discarding is avoided through the saving possessions, or repurchasing items they previously threw away.
Hoarding presentation 2
Hoarding Assessment andIntervention at HOC HOC Housekeeping In Service 1
Training Objectives Understand the complex reasons for hoarding Learn to identify hoarding behaviors Learn about effective and ineffective intervention strategies when treating hoarding Have a better understanding of roles of all HOC staff involved, as well as outside agencies. Be able to effectively communicate with other staff and across the agency regarding specific situations. HOC Housekeeping In Service 2
Compulsive Hoarding:Proposed DSM-V Criteria Persistent difficulty discarding or parting with personal possessions, even those of apparently useless or limited value, due to strong urges to save items, distress, and/or indecision associated with discarding. The symptoms result in the accumulation of a large number of possessions that fill up and clutter the active living areas of the home, workplace, or other personal surroundings (e.g., office, vehicle, yard) and prevent normal use of the space. If all living areas are uncluttered, it is only because of others’ efforts (e.g., family members, authorities) to keep these areas free of possessions.
Compulsive Hoarding:Proposed DSM-V Specifiers Specify if with Excessive Acquisition If symptoms are accompanied by excessive collecting or buying or stealing of items that are not needed or for which there is no available space. Specify whether hoarding beliefs and behaviors are currently characterized by: Good or fair insight: Recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic. Poor insight: Mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. Delusional: Completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.
Failing to Discard Items Items appear useless to others Identifying value Instrumental Sentimental Intrinsic This results in the growth of items and interferes with the functionality and use of living spaces.
Why is hoarding a problem? Safety of individual:1. Fire2. Falls3. Health hazards4. Increased social isolation Safety of the community1. Fire2. Infestations Legal: Violation of code and HUD regulation. Financial: Cleaning up is expensive, buying items create debt HOC Housekeeping In Service 6
Illustrations….. Where is the stove????? HOC Housekeeping In Service 7
Bedroom I am sure my bed was somewhere in this room! HOC Housekeeping In Service 8
Stairwell Goat path… HOC Housekeeping In Service 9
Estimated Prevalence Rates 26 in 1000 - Whole Spectrum of Hoarding 169,000 estimated cases in Massachusetts 16,180 estimated cases in Boston HOC has 50 cases “on record” in its residences .5 in 1000 - Diogenes Syndrome Gross self-neglect, domestic squalor, hoarding of trash 3250 estimated cases in Massachusetts 310 estimated cases in Boston(Based on overall populations of 6,500,000 for MA and 622,351 for Boston)
Co-Morbid Diagnoses Major Depression (57%) Social Phobia (29%) Generalized Anxiety Disorder (28%) Obsessive Compulsive Disorder (17%) Specific Phobia (12%) Post-Traumatic Stress Disorder (6%) Dysthymia (4%) Panic (2%) No Other Diagnosis (8%) Frost, Steketee, Tolin, & Brown, 2006
Conceptual Model of Compulsive HoardingPersonal & Family Vulnerability Factors Information Processing Problems Thoughts & Beliefs Emotional ResponsesEfforts to Obtain Pleasure by Saving Escape & Avoidance of Unpleasant Emotions(Positive Reinforcement) (Negative Reinforcement) Cluttering and Difficulty Discarding Steketee & Frost, 2007
What can be done? Each situation is different An accurate assessment is essential In most situations, hoarding does not have a cure – it is a chronic condition. Research show that a multidisciplinary approach is the most effective method of intervention. Some therapy techniques have been successful in reducing hoarding behaviors. This is a long term treatment, which requires insight and motivation. HOC Housekeeping In Service 13
Thoughts: Decision Making Perfectionism All-Or-Nothing Fear of making Cluttered Space mistakes Spartan Room Missed opportunities Decisions are Being caught complicated by fears unprepared Distorted perception of Avoidance of regrets, others’ spaces pain, or mistakes Focus on benefit of “But what if…” saving and risk of letting go
Emotional Attachment Possessions as Reaction to losses extension of self Grief-like reactions Attach greater Ruminations sentiment Emotional discomfort Comforted by possessions Fear of losing part of oneself or one’s identity
Evaluation Process:Assessment of Individual Appearance Cognitive status Executive functioning ability Medical and mental health symptoms Insight into hoarding behaviors Motivation to address hoarding behaviors Relations with others Family history - mental health and hoarding behaviors Ability to consent to and participate in treatment interventions (Capacity-Risk Model; Soniat & Micklos, 2010)
Who should be involved? Housing Management (inspectors, managers) Federal Programs Resident Services County’s Health & Human Services (e.g., CPS, APS, case management) County’s Code Enforcement and Fire Department Community mental health providers HOC Housekeeping In Service 17
Housing ManagementHousing Management Mission Description The Housing Management Division is responsible for managing the affordable properties in HOCs housing portfolio that receive State, Federal and local subsidies.Through both in-house management and contractual arrangements, the division: Ensures occupancy by qualified households under numerous Federal, State and local affordable housing programs. Ensures that all dwelling units are maintained at or above community norms, and in compliance with Federal housing programs. Enforces the terms and conditions of residents leases. Performs preventive maintenance on all units and building systems in order to extend their useful life. Conducts frequent resident surveys. HOC Housekeeping In Service 18
Roles I: Housing Management1. Conduct annual inspection.2. Respond to complaint from neighbors.3. In known cases of previous violations, inspections are done, when possible, together with on-site RS staff.4. Managers have a relationship with residents and express concerns directly to resident5. Follow up with a letter and request an office conference, usually within two weeks.6. Time frame for re-inspection will be decided, usually within 30 days.7. A service agreement will be used to define the necessary steps to resolve situation.8. If service agreement is not effective, a referral is made to FP for a supervisory conference.9. Close collaboration between Housing Management and Resident Services is KEY to success. HOC Housekeeping In Service 19
Roles II: Inspectors for HCV1. Conduct an annual inspection. Residents with a history of late inspection get 180-day notice.2. Respond to landlords, community or HOC staff’s complaints.3. Determines the degree of violation.4. Verbally explains to resident the nature of the violations and follows up with a letter copied to landlord.5. Notifies RS, usually via email.6. Do not refer to Disability Services directly. This will be decided by RS staff.7. Give 30 days to remedy violations, then follows up with another inspection.8. If situation not resolved, refer to Federal Programs9. If resident can provide documentation for inability to follow up with inspection process, inspector may grant extension.10.Communicate with RS and FP staff to ensure follow up and positive outcome. Collaboration is KEY. RS will update inspector on status of progress. HOC Housekeeping In Service 20
Resident Services Resident Services links HOC clients to a widerange of services intended to allow individualsand families to achieve self-sufficiency, gainindependence, assimilate into the broadercommunity and to successfully retain theirhousing . Resident Services also provides counselingsupport and service linkage to assist elderlyand disabled residents to live independently incomfort and with dignity. HOC Housekeeping In Service 21
Role IV: Site-Based Counselors1. Conduct a home visit (routine visit or in response to a complaint/referral). A complaint home visit is often conducted with onsite Housing Management.2. Perform an assessment of the severity of condition and mental status of the resident, using a hoarding scale when applicable.3. Identify available resources for resident.4. Determine which referrals need to be made and which agencies need to be involved (e.g. Adult and child Protective Services).5. Participate in an Office Conference with Housing Management and resident.6. Assist in establishing a plan of action (e.g. Service Agreement) and follow up on plan in collaboration with other HOC staff and outside entities.7. Send a formal letter to resident to address issues subsequent to the Office Conference.8. Monitor weekly/bi-weekly/monthly to ensure progress is made toward goals.9. If progress is not made, collaborate with Housing Management. Referral to FP.10. Prepare a Social Summary & Chronology for the FP Supervisory Conference.11. If notice to vacate is recommended, the counselor will continue to work with resident in an attempt to resolve the issue and to avoid eviction.12. If termination is enforced, the counselor will seek to engage resources and services toward a safe alternative housing plan. HOC Housekeeping In Service 22
Roles V: Federal ProgramsFor HCV Residents:1. Becomes involved after 2nd failed inspection.2. Assigns an investigator to begin termination process.3. Send termination letter to resident. Copy RS manager/supervisor. Resident has 10 days to request an informal hearing.4. Resident Services will attempt to contact resident to offer supportive services.5. If appeal is not received FP notifies HRD to terminate.6. If resident requests a hearing, investigator will schedule and notify resident and RS staff.7. Hearing Officer will render decision within 30 days.8. If hearing officer upholds termination resident has the right to request a hearing board.9. Hearing board will render decision. HOC Housekeeping In Service 23
Roles V: Federal Programs cont.For Public Housing:1. Becomes involved if resident does not follow through with recommendations from case conference .2. Supervisory conference scheduled. RS, HM and resident invited. It is held with or without the resident.3. Staff in supervisory conference attempts to reach a consensus decision.4. Recommendations range between a service agreement, consent judgment or Lease Enforcement Panel (LEP).5. LEP may decide to send case back to FP with recommendation or may agree to issue a notice to vacate.6. If a notice to vacate is issued resident can request a hearing board.7. Hearing board will render decision. HOC Housekeeping In Service 24
Role VI: County Fire, Inspection & Police: Respond to calls from neighbors and Housing Management. If entry is permitted by the occupant, by administrative search warrant or due to an emergency incident where chain of custody is maintained, enter the premises and inspect for compliance of all fire and life safety codes. This would include proper smoke detection, access to and operation of “Escape” windows, as well as the “safe” operation of all water, heating and cooking appliances. Inspect all the common areas and act on a concern found there. Can condemn a unit if conditions are deemed unsafe. Work with property management to address issue. HOC Housekeeping In Service 25
Role VII: Health & Human Services The role of Adult and Child Protective Services:APS and CPS only intervene in extreme cases of abuse or neglect and/or when loss of home is imminent for a vulnerable adult. Resident Counselors are mandatory reporters, but anyone can make a referral. HHS has resources for services in the face of imminent eviction and offers emergency shelter. County Social Services to adults may also be involved. They provide case management and assistance in accessing resources. They are limited in capacities and have a wait list. HOC Housekeeping In Service 26
HOC goals for working with chroniccases:1. Prevent repeated crises.2. Improve collaboration internally.3. Collect data on prevalence and severity.4. Foster a long term plan for stability. HOC Housekeeping In Service 27
Now, let’s look at some casestudies.. HOC Housekeeping In Service 28
How to de-clutter1. Select target area2. Assess possessions3. Create categories4. Select a starting spot5. Start sorting and de-cluttering6. Continue until target area is cleared7. Use space appropriately8. Prevent new clutter HOC Housekeeping In Service 29
Do Be safe (gloves, wash hands, look where you touch) Be positive Make supportive comments Foster self determination Be creative Let the person lead the process Come ready for hand on experience Believe in the client’s ability Highlight strengths Stay calm Take care of yourself Stay in touch with other staff and work as a team HOC Housekeeping In Service 30
Do not Touch items without the person’s explicit permission Be judgmental Give negative comments Let the amount of stuff overwhelm you De-clutter behind the client’s back Minimize the challenges faced Make decisions Equate the clutter with the person Argue or try to persuade HOC Housekeeping In Service 31
Challenging, not Confronting How many do you already have? Is that enough? Do you have enough time to use, review, or read it? Have you used this during the past year? Do you have a specific plan for this item? By when? Does this fit with your values and needs? Is it important because you’re looking at it now? Is it current, of good quality, accurate, reliable? Would you buy it again if you didn’t already own it? Do you really need it? Could you get it again if you really needed it? Do you have enough space for this?