2. 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.
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3. 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.
4. 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.
5. 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.
6. Why is hoarding a problem?
Safety of individual:
1. Fire
2. Falls
3. Health hazards
4. Increased social isolation
Safety of the community
1. Fire
2. Infestations
Legal: Violation of code and HUD regulation.
Financial: Cleaning up is expensive, buying items
create debt
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8. Bedroom
I am sure my bed was somewhere in this
room!
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9. Stairwell
Goat path…
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10. 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)
11. 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
12. Conceptual Model of Compulsive
Hoarding
Personal & Family Vulnerability Factors Information Processing Problems
Thoughts & Beliefs
Emotional Responses
Efforts to Obtain Pleasure by Saving Escape & Avoidance of Unpleasant Emotions
(Positive Reinforcement) (Negative Reinforcement)
Cluttering and Difficulty Discarding
Steketee & Frost, 2007
13. 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.
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14. 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
15. 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
16. 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)
17. 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
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18. Housing Management
Housing Management Mission Description
The Housing Management Division is responsible for managing the
affordable properties in HOC's 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.
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19. Roles I: Housing Management
1. 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 resident
5. 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.
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20. Roles II: Inspectors for HCV
1. 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 Programs
9. 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.
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21. Resident Services
Resident Services links HOC clients to a wide
range of services intended to allow individuals
and families to achieve self-sufficiency, gain
independence, assimilate into the broader
community and to successfully retain their
housing .
Resident Services also provides counseling
support and service linkage to assist elderly
and disabled residents to live independently in
comfort and with dignity.
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22. Role IV: Site-Based Counselors
1. 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.
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23. Roles V: Federal Programs
For 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.
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24. 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.
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25. 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.
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26. 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.
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27. HOC goals for working with chronic
cases:
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
28. Now, let’s look at some case
studies..
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29. How to de-clutter
1. Select target area
2. Assess possessions
3. Create categories
4. Select a starting spot
5. Start sorting and de-cluttering
6. Continue until target area is cleared
7. Use space appropriately
8. Prevent new clutter
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30. 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
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31. 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
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32. 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?
Editor's Notes
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.