Home Improvement Agency - Hoarding Behaviour and Cluttered Homes

Transcription

1 Home Improvement Agency - Hoarding Behaviour and Cluttered Homes Version 1.1. July 2016 Copyright Astral PS Limited - All rights reserved No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without the prior written permission of Astral Public Services

2 Document History Revision History Date of this revision: 26/07/2016 Date of Next revision: Version number Previous revision date Summary of Changes Changes marked /07/2016 First draft /07/2016 Amendment to medical definition Approvals This document requires the following approvals. Signed approval forms are filed in the Management section of the project files. Name Signature Title Date of Issue Version P Smith Director..2

3 About Foundations Foundations is the National Body for Home Improvement Agencies and Handyperson Services in England as appointed by the Department of Communities and Local Government. Foundations remit is to: Engage with providers and commissioners to monitor the sector and enhance the quality and reach of home improvement agency services Arrange events and training Develop tools and resources News and publicity For me information visit: About Home Improvement Agencies Home Improvement Agencies (HIAs), sometimes known as Care & Repair or Staying Put schemes, help vulnerable people maintain independence in their own homes. Their services include: visiting clients at home or providing detailed telephone advice; setting out housing options to help clients decide what type of housing is best suited to their changing needs; checking entitlement to any financial help, including grants and charitable funding; project management, drawing up plans, getting estimates and liaising with others involved in any building work/adaptations needed, such as council grants officers and occupational therapists; provision of handyperson services, to carry out small jobs around the home, help with gardening, or coming home from hospital; and helping to make homes more energy-efficient. A searchable directory of accredited HIAs and handyperson services is available at: 3..

4 Introduction This guide is intended to help Home Improvement Agencies work with people who have behaviours that lead to cluttered homes and hoarding. It is not intended to be definitive, and draws on a number of studies and projects that work with people who live in homes that are dangerous, unsanitary or unusable due to excessive acquisition or failure or dispose of items. Hoarding behaviour can be a very complex issue, and is not, as is sometimes suggested, a lifestyle choice or simply down to laziness. Often, people who have difficulties in discarding items, or in obsessive acquiring have deep emotional reasons for their behaviour, and simply removing their stuff without understanding and working with those reasons can be traumatic and further entrench damaging behaviour. It is recommended that if your Agency has customers who need help with dealing with a hoarding condition, that you contact a specialist support service who can assist you and your customer find the most appropriate course of action...4

5 Hoarding Behaviour and Cluttered Homes What is Hoarding Behaviour? Hoarding behavour can be described as a persistent difficulty in discarding possessions, which results in obstructed living environments and functional impairment. This means that people who hoard live in homes that are difficult to get around or can t be used properly, and find it difficult to clear space for them. Rooms may only have a tiny space within them that can be used, and chairs, tables and other furniture may be completely covered in items which have been acquired, but not disposed of or stored appropriately. Sometimes, items can block or restrict access to doors and windows, into other rooms, or to bathing or cooking areas. Items which are hoarded often have little value when viewed from a monetary or purposeful perspective, but can have significant attachment for the person themselves. Hoarding behaviour could be a response to a traumatic event in the person s life, and as such, enforced removal of the items can cause extreme distress. Acquiring items can be a way that people try to deal with their emotional wounds. Hoarding is different to collecting. Some people like to collect memorabilia or other items that can take up large areas of their homes. However, the difference is usually that hoarding behaviour is more chaotic, often with items of little practical or monetary value, and disrupts a person s ability to live well. Collectors tend to be more organised, keep their collections clean and safe from damage, and live normally. However, it is a very fine line, and each case should be considered within its own context. 5..

6 A particularly distressing form of hoarding can be where significant numbers of animals are rescued but are often kept in squalid and dangerous conditions for both the animals and the householder. Often dead or diseased animals are found in these cases. In cases such as these, the RSPCA will need to be involved and may remove the animals from the home. Environmental health officers may be required to investigate whether vermin or other animal borne health risks may be present. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals in the United States. It contains a listing of diagnostic criteria for every psychiatric disorder recognized by the U.S. healthcare system, and in 2015 (DSM-5) it included Hoarding Behaviour as a diagnosis in its own right. Previous to this, it had been classified as a sub-diagnosis of Obsessive Compulsive Disorder. DSM-5 describes hoarding behaviour as: Persistent difficulty discarding or parting with possessions, regardless of their monetary value This difficulty is due to a perceived need to save items and distress associated with discarding them The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning The hoarding is not attributable to another medical condition or mental disorder Although the DSM-5 is not officially recognised in Britain, it is increasingly being used as a reference for the reclassification of hoarding behaviour, and it is expected that the WHO classification for the condition, which we use here, will soon follow suit...6

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8 Who lives in a cluttered home? Hoarding behaviour is estimated to affect around 2-6% of the general population. It is difficult to put a true figure to it, as many people with the condition do not engage with services readily. It is often only when neighbours or loved ones approach services for help, or there is a crisis such as a fire or fall, that the severity of the situation is realised. People who may be susceptible to hoarding behaviour come from all walks of life. They are just as likely to be educated, well-off home owners as social tenants on a low income. Living in a cluttered home can, and often does, lead to isolation and reclusiveness. This could be due to embarrassment about their home, or fear that people will take their things away from them. As a consequence, though, they can be very good at maintaining rent and other payments in order to not attract attention. Sometimes, they can be very successful in their public lives, and don t see their behaviour a problem, but don t let anyone into their private sphere or their homes. At the other end of the scale, however, some people may withdraw completely and not leave their homes at all, sometimes not even to buy adequate food, and may suffer severe deprivation and risk. Heating and hot water systems may not be serviced or repaired, or cooking and food storage may be inadequate or inaccessible for example. People with hoarding behaviour can be men or women, and it can affect people of any age, although most people who are identified tend to be older, and may have been living in an increasingly cluttered environment for many years. Early signs may have been overlooked as simply a phase or are attributed to other things, such as teenage messiness or being a shopoholic. Often, however, hoarding behaviour is triggered or exacerbated by a significant life event, such as an abandonment (divorce, or death of a parent or spouse for example), loss of a job or home, or abuse...8

9 Alternatively, sometimes a cluttered environment can be symptomatic of a different unrecognised condition such as dementia, depression or chronic pain, which leads to the individual not being able to cope with cleaning or disposing of rubbish, or aggravates feelings of loss or anxiety. Although there has not been a genetic link identified, research does indicate a familial correlation, which suggests that some hoarding behaviour could be a learned response. People are very complex and there is no simple or straightforward reason as to why they hoard. 9..

10 Working with people who have hoarding behaviour or who live in cluttered homes. Why is it important to work sensitively with people who hoard? Hoarding behaviour can be disruptive and damaging to people s lives, relationships and wellbeing. It is a creeping, pervasive condition and can escalate or exacerbate underlying mental and physical health conditions, and can lead to dangerous conditions within the home. Working with people who have hoarding behaviours can be time consuming and frustrating at times, but it is essential that patience and understanding are employed. Do not expect quick results. Pushing someone to declutter or discard possessions before they are ready to do so can prove counterproductive and may lead to further disengagement and entrenchment. It should also be remembered that for some, living in what to most people may be seen as a chaotic environment, may be their preferred way of living and does not cause them any discomfort or distress. As mentioned earlier, however, it is important to assess each case on its own merits before deciding what, if any, action to take. People who hoard may exhibit difficulty in making decisions, typically around what and how to dispose of items, or be fixated on the possible consequences of getting rid of things, such as feelings of extreme regret and loss (emotional attachment), needing it in the future and not having it (needless waste), or risk of contamination to others by throwing something away (obsessive thoughts). Cognitive Behavioural Therapy (CBT) is a widely accepted treatment method employed by mental health professionals to help people with hoarding behaviours to help them learn to deal with anxiety provoking situations, including throwing away their possessions, and establishing more helpful behaviours instead. Multi-disciplinary approaches to helping people to deal with their hoarding behaviours and underlying issues are now generally considered to be most effective, therefore, with support from mental health professionals working with occupational therapists, housing support or home improvement agency staff, and other agencies as appropriate. As Home Improvement Agencies are well placed to work with people who do not trust or want to engage with statutory services directly, caseworkers may be appropriate to lead on the engagement, where adequate training and support from specialist agencies is available, particularly where adaptations or essential home repairs are required. Where they are available, handyperson schemes can assist with removal of rubbish, and making small repairs to the home to enable the person to live more comfortably in the property while decluttering is happening, or after the property is cleared...10

11 Reasons for helping people who hoard or live in cluttered environments can, therefore be beneficial to general health as well as mental wellbeing, while continuation of hoarding behaviour can have extremely detrimental effects if left unquestioned: It can be dangerous to health Poor sanitation and cleanliness Poor nutrition: inability to cook safely Inability to use rooms as intended, leading to physical health problems Continuation or exacerbation of mental health conditions Isolation and loneliness Pests and vermin Potential fall hazards and crush injury Smells, mould and noxious fumes It can be detrimental to the property Poor maintenance and repair Damage to fixtures and fittings, and possible structural issues Inability to gain access for gas and electrical safety checks Inability to undertake adaptations Increased risk of fire or flood Increased risk to emergency services entering the property It can be anti-social Isolation or victimisation Increased risk of crime Complaints from neighbours about smells and rubbish Vermin and pests Animal hoarding Risk to visitors to the property, including support staff and services It can be expensive Costs of enforcement Costs of staff time 11..

12 Costs of relocation: eviction; court action; cleaning; repairs Cost to emergency services Costs of lost property value, rental income to landlords and re-letting costs Missed appointments What does the Care Act say? For the reasons given above, quite often people who hoard can be very resistant to change and may not acknowledge that there is a problem, or that they need or want help. They may be fearful of life without their possessions, or anxious about losing the attachment to people or memories that the items give them. Chapter 14 of the Care Act 2014 deals with Safeguarding. Although it is mainly about ensuring that vulnerable people are safe from harm from other people, there is a section that specifically deals with self-neglect, which includes hoarding. Under s.42 of the Act, and under the supervision of an authority s Safeguarding Adult Board, a decision may be made to remove a person from the home if they are deemed to be unable to protect themselves from harm by reason of self-neglect. Such a decision must be predicated by a needs assessment, which includes the impact that removal might have on the person s wellbeing, and must take account of the wishes of the person if they have capacity. Care Act 2014 statutory guidance. Chapter : local authorities [social care] must: Make enquiries, or cause others to do so, if it believes an adult is experiencing, or is at risk of, abuse or neglect. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect, and if so, by whom; 14.17: Self neglect this covers a wide range of behaviour neglecting to care for one s personal hygiene, health or surroundings and includes behaviour such as hoarding. It should be noted that self-neglect may not prompt a section 42 enquiry. An assessment should be made on a case by case basis. A decision on whether a response is required under safeguarding will depend on the adult s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support. If you feel that there is a safeguarding issue, or a question of capacity that the person you are working with does not have the ability to understand the risks or consequences of their actions you should contact your social care department and speak to a social worker or occupational therapist...12

13 Where the home contains children or other vulnerable adults you should always contact your local safeguarding team. What can Environmental Health do? Local Environmental Health teams (district, borough or city councils in two tier areas) have a range of powers that they can use where hoarding behaviour poses a risk to the public or householder. These can range from removing vermin or pests from a property, advising on removal of rubbish and waste, and enforcement, where a statutory power can be used to force the home owner to deal with the issues. They can, in extreme circumstances, declare a property unfit for human habitation, and impose fines if work is not done to a satisfactory condition or within a specified time frame. It is not unusual for members of the public and neighbours to make a complaint to Environmental Services regarding people who live in squalid conditions, or who hoard rubbish or discarded items in and around their home. This could be due to concerns of hazards to themselves or others in the neighbourhood, fire risks, vermin and pests such as rats which can spread disease, or concerns about the householder s safety and health, including where they may have died. Although Environmental Health officers have these powers, however, they are generally only used where all other options have been exhausted and the condition of the property poses a significant danger to the householder or others. Where this is the case though, their powers are mandatory, and they are required to take action. Sometimes, where they householder refuses entry, a warrant may be required to gain entry to determine whether they are required to take action. Section 83 Public Health Act 1936: where the filthy or unwholesome condition of a premises is prejudicial to health or the premises are verminous, Environmental Health departments are required to give notice to the owner or occupier to require them to cleanse the premises. Section 79 [1] Environmental Protection Act 1990: any premises in such a state as to be prejudicial to health or a nuisance and / or any accumulation or deposit which is prejudicial to health or a nuisance is deemed to be a statutory nuisance, and where a statutory nuisance is found to exist, the local authority is required to serve an abatement notice. Prevention of Damage by Pests Act (1949): allows local authorities to require land to be cleared of materials that may provide food or habitat for pests, such as mice or rats. This could be used for garden clearances where hoarded items have spilled out of the home or are stored outside. Where Environmental Health do get involved, they may recover their costs from the householder. This includes works in default : where a householder is not willing or able to undertake the work themselves, the local authority may arrange for the work to be done, and will recover the costs from the person responsible. Although the Housing Health and Safety Rating System (HHSRS) expressly excludes conditions that are attributable to the behaviour of the occupants, and therefore does not cover hoarding or clutter, very often homes where hoarding occurs may well be in disrepair, 13..

14 and it is not unusual for heating, water or electrical systems, for example, to be in a condition that requires attention to avoid a fire hazard or excess cold. DFG and adaptations teams in local authorities are often within environmental health teams, or work closely with them as part of a strategic / private sector housing team. As such, it is in the interest of the HIA and the environmental health officers to develop and maintain good working relationships in relation to people who hoard, so that appropriate action can be taken at the right time whether that is through enforcement or a lighter touch approach to get the best long term outcomes for the individual, the property and the authority...14

15 How can we work with people who hoard? Working with people who have hoarding behaviours or live in cluttered homes can be very challenging, and will require patience and perseverance. It is important that a nonjudgemental attitude is adopted, and sensitivity in touching or moving items is required. Recognise that what you may see as rubbish may have significant emotional resonance for the person you are helping, or by moving something you could be causing anxiety by disturbing their sense of order. Some cases may be shocking, disturbing or distressing but it is important that you remain objective. Do not make assumptions about someone s mental state or triggers, and foster an open dialogue where possible. Sometimes simply having the experience of having someone listen properly without judgement may be the start of a person s change in behaviour. However, also be aware that a person s behaviour may be a symptom of a deeper issue or health condition, such as dementia, anxiety, pain, depression, OCD or other mental health condition. If you have concerns, contact the relevant statutory agency for an assessment. 15..

16 Be sensitive as well as to what you call the items people are accumulating. What do they call the things in their homes? Gather information objectively from neighbours, friends and family where you are able, to try and get a full picture of the person s situation. They may also be willing to help with sorting or clearing, or supporting the person while decluttering work goes on and afterwards to help avoid the situation reoccurring. Be considerate of the person s needs, but also be mindful of risks to yourself. These can be physical risks caused by the items being hoarded, such as crush or trip hazards, pests such as fleas or rats, exit routes being blocked, or and the potential of violence or aggression if the person resists assistance. Be clear about the reasons for helping someone clear their home. Be sure that your goals are shared, ethical and reasonable. Help the person to find their own goals, which meet their needs as well as meeting those of the statutory services that might be involved. This could be, for example, being able to prepare a meal and sit to eat it, to create a space where they feel safe and calm, or even to work to a point where statutory services are able to withdraw and leave them alone. Once work has begun on a shared and achievable goal, other benefits may appear as the relationship grows and issues are uncovered. Work with other agencies both statutory and voluntary to find the right solutions for the person. Hoarding behaviour is very individual, and what works for one person may not work for another, but different agencies will bring different skills and resources to the situation which can help things along. In some areas, self-help groups or support networks may exist which could be helpful. If there is any concern reading safeguarding, other people in the home especially children or other vulnerable adults or animals contact the relevant authority immediately. If there is a threat of violence or aggression, take steps to keep yourself safe, invoke your organisation s lone worker protocols if appropriate, and in the event of actual aggression or violence call

17 Additional Resources The Chartered Institute of Environmental Health - Hoarding and how to approach it - guidance for Environmental Health Officers and others National Housing Federation - Hoarding: Key considerations and examples of best practice NHS Choices - Hoarding Disorder People, Place & Policy Online: Issue 1: Treasures, trash and tenure: hoarding and housing risk Royal College of Psychiatrists - Hoarding Orbit Independent Living - Compulsive Hoarding Project The British Psychological Society - A Psychological Perspective on Hoarding 17..

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