12/1/2017 INTRODUCTION TO EFFECTIVE HOARDING INTERVENTION. Definition. Today s Overview: Is it Hoarding? Mission Statement

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1 INTRODUCTION TO EFFECTIVE HOARDING INTERVENTION Erika Woods Environmental Specialist/ Sanitarian Barnstable County Department of Health & Environment Chair: Cape Cod Hoarding Task Force (CCHTF) Mission Statement The Cape Cod Hoarding Task Force s mission is to raise awareness of compulsive hoarding and to provide education and support for those affected by hoarding through accessible tools, referrals and resources. The Cape Cod Hoarding Task Force (CCHTF) seeks to develop a coordinated response among community agencies to the problem of hoarding in a sensitive and responsible fashion. Erika.woods@barnstablecounty.org Today s Overview: Hoarding Disorder (HD) Definition Attributes Hoarding vs squalor Animal hoarding Examine the challenges in addressing hoarding Explore tools for assessing hoarding Promising programs Strategies to address hoarding Definition Hoarding is a Mental Health Disorder as defined in the DSM V (Diagnostic and Statistical Manual of Mental Disorders) Experts Define Hoarding as: The acquisition of, and inability to discard items regardless of the perceived value put on them by others Living spaces (are) sufficiently cluttered so as to preclude activities for which those spaces were designed Significant distress or impairment in functioning caused by the hoarding (to tenant, others in building, owner, etc). " This definition distinguished hoarding from the collecting of objects generally considered interesting and valuable 2013 American Psychiatric Association In order for a diagnosis of hoarding to be given, these symptoms cannot be from another illness/ injury such as: a traumatic brain injury Is it Hoarding? The hallmark of hoarding behavior is not being able to let go of things. Individuals tend to want to make sure items go to a good home but won t let go. Research shows that brain is signaling that they have made the wrong decision even before they make a decision. Is there a failure to discard a large volume of items? Does the clutter make it hard to use rooms for their intended use? Is there stress or impaired functioning caused by the stress? 1

2 Value of possessions is in the eyes of the individual saving them Intrinsic- (aesthetic) Sentimental Instrumental Other- reasons-safety Not all clutter is hoarding. It could be due to downsizing or other issues Affects 2-5% of the population. Onset- around 13 years old Seek help around age 50 Cleanouts near 100% recidivism rate without any type of behavioral health treatment Study shows individuals more likely to seek help for other mental health problems than HD. Individuals more likely to suffer from chronic medical conditions and obesity. Very often co-occurring mental illness Major depression; anxiety Very often well educated Family history of hoarding is common HOARDING SQUALOR Hoarding vs Squalor? Hoarding and squalor are not the same Squalor is defined as filthiness or degradation from neglect: Two forms domestic and personal Hoarding is related to the volume of clutter in the home, not the cleanliness Squalor is often accompanied by hoarding, however the reverse is seldom the case. HOARDING VS SQUALOR What is Squalor? The severe neglect that they bring on themselves usually results in physical collapse or mental breakdown. Most individuals who suffer from the syndrome do not get identified until they face this stage of collapse, due to their predilection to refuse help from others. [4] Diogenes syndrome, also known as senile squalor syndrome, is a disorder characterized by extreme self-neglect, domestic squalor, social withdrawal, apathy, compulsive hoarding of garbage, and lack of shame. 2

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4 Animal Hoarding The pathological accumulation of animals was first described in 1981 and animal hoarding was formally defined in the public health literature in 1999 using the following criteria: Having more than the typical number of companion animals. Failing to provide even minimal standards of nutrition, sanitation, shelter, and veterinary care, with this neglect often resulting in illness and death from starvation, spread of infectious disease, and untreated injury or medical condition. Denial of the inability to provide this minimum care and the impact of that failure on the animals, the household, and human occupants of the dwelling. Persistence, despite this failure, in accumulating and controlling animals. Hoarding of Animals Research Consortium Animal Hoarding Air Quality Ammonia Bio-aerosols; Fungal spores Dust particles Zoonotic diseases Elder, child abuse/ neglect Squalor Animal cruelty laws Each state in the US has laws prohibiting cruelty to animals and imposing upon caretakers a duty of providing minimal care. Although the laws may differ somewhat in each state, all states require that owners or caretakers of animals do the following: Provide adequate food and clean, potable water daily in sufficient quantities to maintain an animal s normal body weight. Provide shelter from the elements that will allow the animal to stay dry and maintain a normal body temperature. Provide a clean, sanitary environment free of animal feces, urine, and trash. Provide veterinary care necessary to relieve suffering from disease, injury, or illness. In hoarding situations, some or all of these provisions are likely to be violated because animal cruelty statutes prohibit keeping animals in squalid situations. This is despite the fact that a competent adult might often be allowed to live in these conditions unless in violation of a public health or safety code. Therefore, these animal welfare statutes may provide an additional mode of intervention for an adult living in squalor. What to look for: Proper Food & Water Proper Sanitation Proper Comfort Grooming Safety Proper shelter and protection from the weather Proper veterinary care For help, call local animal control, MSPCA or other local animal welfare agency. Challenges to working with individuals Challenges of working with individuals Insight Non-insightful Insightful but not motivated Insightful & motivated but non-compliant Motivation Enhancers support home visitors connection to what s important/ values addressing co-occurring illness 4

5 Personality features Excessively high standards & perfectionism Seeing the narrow categories at the cost of the big picture Indecisiveness and procrastination Difficulty trusting others Difficulty regulating emotions Difficulty taking another perspective Executive functioning Attention Perception Decision making Categorization/ association Prospective memory Special meaning of possessions Beauty/aesthetics Memory association Utility Sentimental Comfort Safety Identity Control Completeness Validation Socialization Assessment Tools Assessment of the Situation HOMES-multi-disciplinary risk assessment Uniform Inspection Checklist Clutter Image Rating Scale-CIR There s an app for that! Readiness to Change Self Assessment Many more H.O.M.E.S. Health Obstacles Mental Health Endangerment Structure & Safety H.O.M.E.S: MULTI-DISCIPLINARY HOARDING RISK ASSESSMENT Structural measure through which level of risk can be conceptualized. Intended as an initial and brief assessment to determine nature and parameters of the problem, and to organize a plan. Can be used differently depending on needs and resources. Other factors are evaluated to gain additional information about capacity to address the problem. 5

6 UNIFORM INSPECTION CHECKLIST Resident: Ensure housing is safe, sanitary, and in good repair. Inspector: Distinction between hazardous vs. housekeeping; Document deficiencies in specifics; Rate each room. CLUTTER IMAGE RATING SCALE Pictorial scale of 9 photos of 3 key rooms Promotes accuracy of assessment of clutter Addresses over and under-reporting Available as an I-phone App 6

7 Treatment: There is no One Size Fits All Promising Programs And Best Practices Medication medication alone does not alleviate hoarding behavior Intervention - cleanout NOT recommended Cognitive Behavior Therapy (CBT) The core principles of CBT are identifying negative or false beliefs and testing or restructuring them. Skills training: Organizing Decision making Problem solving Self Help groups Buried in Treasures Harm Reduction Principles of Harm Reduction for Severe Hoarding First, do no harm Not necessary to stop all hoarding behavior No two hoarding situations are identical, hoarding is a unique interaction between person, condition, and person s environment, and therefore requires a unique plan Person who hoards is an essential member of the harm reduction process Change is slow and failures to honor the harm reduction plan are part of the approach and do not mean the approach is failing People who hoard can make positive changes in their lives even though they continue to hoard Metropolitan Boston Housing Authority: Hoarding Intervention and Tenancy Preservation Project-Started to prevent evictions-loss of vouchers An individualized case management plan based on the client s stated needs, intake/assessment information, and the risk of subsidy loss, eviction, or condemnation. A combination of harm reduction and techniques borrowed from cognitive-behavioral therapy. Weekly or bi-weekly home visits that include sorting/discarding, non-acquiring exercises, and other skills critical to managing the clutter. (mental health counseling not always required) Referrals to appropriate community partners for additional resources. Monitoring for one to two years after passing inspection (when participants allow) Task Forces Models of Task Force Intervention: Education Internal/ professional Community Case Consultation Direct Intervention Initiating the response: Putting it all together Currently 25 Hoarding Task Forces in Massachusetts 7

8 How do we respond once we have a general idea of what s going on? Design appropriate response based on assessment and factors that What legal entities are involved Common code violations What NEEDS to be done to come into compliance Communication key to a good outcome Team approach to response DO S: Imagine yourself in the hoarding client s shoes. Match the person s language. Use encouraging language. Highlight strengths. Focus the intervention initially on safety and organization of possessions and later work on discarding. DON'TS: Use judgmental language Use words that devalue or negatively judge possessions Let your non-verbal expression say what you re thinking Make suggestions about the person s belongings. Try to persuade or argue with the person. Touch the person s belongings without explicit permission ACES: Action words: Show me Tell me about Curious questioning I wonder if Help me understand Empathetic Statements I understand you are worried about I can understand how hard this is. Statements of concern I worry that I m concerned that Preparing to Sort Tiered Approach Three pile system Keep, maybe, discard Short intervals to start (5-10 minutes) Use a timer Keep individual focused Set SMART Goals Specific, Measurable, Achievable, Realistic, Timely Give homework Post goals for individual to see Use visual cues for where items belong (or don t belong) Set sorting guidelines Find out what will help the individual relax-music, tea etc. Imminent Risk Clear egress path 24 Remove items from top of stove Remove items from near heating system Must be corrected to pass inspection Reduce clutter by 25% Egress paths 36 Stacks no higher than 4 Not required but may improve quality of life Clear bed for sleeping Put sheets/ towels in linen closet 8

9 Room Mapping Helpful Tools Let s Practice 9

10 Mary is a 44-year-old, single woman with a history of depression and anxiety. Her home is filled with books, newspapers, and other items collected over the past 28 years. She saves things just in case she will need them later; they may become important. The piles have become so stacked and unstable that she has trouble opening the door to her bedroom. Lately, Mary sleeps on a chair in the living room because her bed has become cluttered with miscellaneous books, newspapers and years worth of mail. She has failed the Section 8 housing inspection due to egress violations and fire hazards in her home. In order to pass inspection, she has been told that she will need to significantly reduce the number of books, papers, and other items in her home. Mary is angry about the need to downsize and does not see any problem with owning books and newspapers since they possess valuable information. However, Mary does fear the potential for homelessness if she continues to fail inspection. CASE ONE Daniel is a 53-year-old man and he lives alone with a physical disability. His family is very concerned because he has fallen while walking with a cane several times in recent months. His last fall resulted in hospitalization for a broken leg. His home has become filled with canned food, computer parts and other items. Daniel plans to use these items when his health improves. Despite these piles getting significantly worse since his divorce 7 years ago. The majority of the food in the refrigerator has spoiled and begun to attract flies. The computer parts are obsolete and rendered useless. The hospital social worker made a recommendation for him to move to a rehabilitation center until his home is cleaned and de-cluttered. Daniel refused the rehabilitation placement and insisted on returning home. Although, he does not think it is necessary, as a compromise, a referral was made for hoarding intervention services. CASE TWO 10

11 Elizabeth is a 79-year-old, frail elder who walks with a cane and has begun to have memory-related issues. The inside of the small home that she owns is filled with clothing, old photographs, knick-knacks, and food. Although, she no longer wears the majority of the clothing, the pieces hold sentimental value, as do the photographs that she has collected throughout her life. Elder Protective Services was called because a neighbor is concerned about her safety due to the appearance of her home from the outside. The roof is missing shingles and presents a potential problem for a leak. Items have begun to pile up on her front porch making it a challenge for any possible repairman or visitor to enter her home. Elder Services have offered to pay for Elizabeth s home to be cleaned-out but she is unwilling to let strangers come in to make decisions about what will be thrown away. Each of these items has significant meaning and if they did not then she would not have held on to them. CASE THREE Cape Cod Hoarding Task Force info@hoardingcapecod MassHousing International OCD Foundation CIR app for iphone, ipad etc Erika A. Woods, BCDHE Erika.woods@barnstablecounty.org RESOURCES 11