Hoarding Disorder A Brief Overview 1 Definition

Hoarding Disorder: A Brief Overview 1

Definition Compulsive hoarding: • the acquisition of, and failure to discard, a large number of possessions that appear to be useless or of limited value • 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 (Frost & Hartl, 1996) 2

Hoarding, Squalor and Animal Hoarding • • 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 Animal hoarding: involves the failure to provide adequate facilities for animals overcrowded or unsanitary living conditions, inadequate veterinary care, poor nutrition, etc. Contact the MSPCA or Tufts University Hoarding of Animals Research Consortium for information about animal hoarding 3

Demographics & Prevalence • Saving begins in childhood ~ age 13 • Average in treatment = 50 • Marital Status: tend to be single – Low marriage rate, high divorce rate, tend to live alone • Education: ranges widely • Family history of hoarding is common • Squalid conditions uncommon among treatment seekers • Estimates 3 -5% of US Population (15 million Americans) • Occurs cross-culturally: Japan, UK, Australia, Germany • Gender – undetermined/ contradictory findings 4

More on Hoarding is a mental health disorder not a decision Hoarding is not a moral issue; It is not caused by laziness, lack of standards, lack of responsibility Clutter is only a symptom of the problem It is often characterized by low insight: others are often more aware of/bothered by the clutter than the individual 92% of individuals with hoarding have 1 or more other mental health (e. g. , depression, generalized anxiety, obsessive-compulsive disorder, social phobia) 5

Course of Hoarding Disorder Little evidence for history of material deprivation Hoarding may be precipitated by loss Chronic or worsening course Insight fluctuates Severity range from mild to life-taking 6

Hoarding Behaviors • Saving: Sentimental, instrumental, intrinsic • Acquisition: Buying, acquisition of free things • Clutter/Disorganization: Random piles, churning • Difficulty Discarding: Indecision, attachment 7

Understanding the Challenges of Working with People who Hoard • • • Beliefs and Emotions associated with objects Beliefs about self in relation to world Vulnerabilities (Time, Family History, Loss, etc. ) Co-morbid Conditions (Mental and Physical Health) Cognitive Distortions (Problematic Thinking) Motivation 8

Hoarding and Insight • People with hoarding problems have varying levels of insight about the extent of their problem and the ways that it impacts them & those around them – Non-insightful – Insightful but unmotivated – Insightful, motivated, but noncompliant 9

Assessing Hoarding • HOMES Multi-disciplinary Hoarding Risk Assessment Instructions for Use HOMES Multi-disciplinary Hoarding Risk Assessment provides a structural measure through which the level of risk in a hoarded environment can be conceptualized. It is intended as an initial and brief assessment to aid in determining the nature and parameters of the hoarding problem and organizing a plan from which further action may be taken-- including immediate intervention, additional assessment or referral. HOMES can be used in a variety of ways, depending on needs and resources. It is recommended that a visual scan of the environment in combination with a conversation with the person(s) in the home be used to determine the effect of clutter/hoarding on Health, Obstacles, Mental Health, Endangerment and Structure in the setting. The Family Composition, Imminent Risk, Capacity, Notes and Post-Assessment sections are intended for additional information about the hoarded environment, the occupants and their capacity/strength to address the problem. 10

Ineffective Intervention Strategies Make decisions (about a plan of action) for a tenant Argue or Persuade Pressure the tenant to discard Tell the tenant how to feel Give verbal and non-verbal cues that are judgmental or negative in nature 11

Effective Intervention Strategies Be clear about expectations and limitations Ask open-ended questions Reflectively listen Use respectful, non-judgmental language Mirror the language used by the tenant “Work with” the tenant instead of “doing for” 12

Focus on Internal Motivation: The ‘Magic’ Bullet What makes people motivated to change? Confidence Importance Factors Influencing Motivation How much social support? Are there any home visitors? Can anyone monitor homework? How depressed is the tenant? Can tenant tolerate discomfort? 13

Enhancing Motivation Questions to start dialogue: • How has hoarding affected your family? • How does the clutter fit with the things you value in life? • What successes have you had that make you think you address your hoarding problem? • Why would you want to change if it means giving up part of yourself?

HOARDING: THE LEGAL FRAMEWORK 15

LEGAL QUESTIONS WHEN DOES HOUSEKEEPING BECOME A LEGAL PROBLEM? WHEN DOES REASONABLE ACCOMMODATION COME INTO PLAY? 16

PART 1 WHEN DOES HOARDING BECOME A LEGAL PROBLEM? 17

HOARDING IS A LEGAL PROBLEM WHEN… It violates applicable housing health and safety standards, including those for animals It endangers vulnerable people as defined by state law • Children • Elders • Persons with Disabilities 18

HOARDING IS A HOUSING PROBLEM When it violates or progresses toward violating: • The Lease • HUD/DHCD Standards • Local or state health and safety codes • Animal cruelty standards 19

ESSENTIAL HOUSEKEEPING LEASE REQUIREMENTS • DON’T INTERFERE w/ neighbors, staff • MAINTAIN UNIT, Common Areas • NO SERIOUS CODE VIOLATIONS • Follow REASONABLE HOUSE RULES 20

HUD HOUSE RULES (1) May include requirements for: • Garbage disposal, including disposal of – Grease – Smoking materials – Used syringes or other biohazards • Keeping kitchen and bathroom fixtures in operable and sanitary condition, including – no scum or mold build-up – clean drains 21

HUD HOUSE RULES (2) May prohibit • Storage of hazardous materials • Blocking of exits • Blocking of heating vents • Overloading circuits and hazardous use of extension cords • Garbage or clutter that attracts insects or rodents or produces foul odors 22

HUD HOUSE RULES (3) May prescribe repair/maintenance standards • Prompt reporting of repair needs • Clear access to repair area • Prompt reporting of infestation • Cooperation with necessary extermination 23

HUD SANITARY STANDARDS CAT • May require changing of cat litter, but no more than twice/week • May require removing waste from litter, but no more than once/day CATS & DOGS • May prescribe disposal of litter and waste • Require control of noise and odor 24

HUD AND DHCD STANDARDS HUD • Section 8 Housing Quality Standards (HQS) Ch 10 • Pet Policy DHCD • 24 CFR 982 and HQS Ch 8 (Public Housing and Certificates) • State Sanitary Code 105 CMR 410 (all Housing) 25

ANIMAL CRUELTY REQUIREMENTS MGL chapter 272: Sec 77 forbids • unnecessarily fail(ing) to provide (an animal) with proper food, drink… (and) sanitary environment 26

HOARDING IS A SERVICE PROVIDER LEGAL PROBLEM When it endangers: • • Children Elders (over 65) Persons with Disabilities (any age) Animals 27

WHAT KINDS OF DANGER Health and Safety • Physical hazards, especially with disability • Health hazards – Mold – Infestation – Excessive dust • Fire and egress hazards • Structural/systems hazards 28

PART 2 WHEN DOES REASONABLE ACCOMMODATION COME INTO PLAY 29

PERSON W/ A DISABILITY - CIVIL RIGHTS DEFINITION • A PHYSICAL or MENTAL IMPAIRMENT which SIGNIFICANTLY INTEFERES with one or more MAJOR LIFE ACTIVITIES • In this case, the major life activity of housekeeping (and possibly other activities) 30

HOARDING AS A DISABILITY • Civil Rights Definition is FUNCTIONAL, not diagnostic (DSM) • US Supreme Court: the person is “unable” or “very restricted” in the ability to do some “daily life activity” (housekeeping) 31

REASONABLE ACCOMMODATON (1) Applicable when: • Resident has a disability • Disability is cause of housekeeping problem • Resident wants an accommodation 32

REASONABLE ACCOMMODATON (2) Applicable when: • Disability is obvious or there is relevant verification including ability and willingness of resident to cooperate • Accommodation does not – pose undue burden or – require a fundamental change in nature of program 33

UNDUE BURDEN Financial burden • No set formula • Cost of accommodation vs. size & financial condition of owner’s overall housing business Administrative burden (staff time) • How much time? • Effect on ability to carry out other responsibilities 34

FUNDAMENTAL CHANGE IN THE NATURE OF THE PROGRAM FUNDAMENTAL NATURE DETERMINED BY: • Landlord-Tenant Laws • Health, Safety and Animal Protection Codes • Funding source regulations • Lease & House Rules • Industry Practice 35

Accommodation Plan Includes (1) 1. Specific standards in specific areas 2. The timeline for each step and the deadline 3. Who will do the clean up and trash removal 4. Who will check and how often Continued 36

Accommodation Plan Includes (2) 5. Services resident will accept 6. Relevant releases 7. Consequences for failure to follow plan 8. Ongoing monitoring 37

SEEK COURT RA AGREEMENT IF… ¡ There is potential danger to others ¡ Resident is in denial about serious violation ¡ Necessary to involve service providers and/or family (Tenancy Preservation Program) 38