MESS and CLUTTER: SORTING IT OUT
John Snowdon
Old age psychiatrist
jsnowdon@mail.usyd.edu.au
Who should take action?
• Man aged 60 years, sent on schedule which stated: “Grossly
disshevelled, unkempt. Living in profound squalor. Deterioration
in hoarding behaviour in recent months. Poor hygiene. He stated
that he only has one meal a day and has not changed his clothes
for several years. He … slept outside to “protect his privacy”.
Denied self-harm or harm to others (yelling at night as well)”
• Community team notes: “Referred by neighbour who was
concerned about X’s mental state. Has apparently been sleeping
under an umbrella outside his house (on front porch). Collects
rubbish and fills back yard with it. Has no running water or
power. Stays out until 3 a.m., sleeps until midday. According to
neighbour, X shouts to himself in the early mornings. Assessed
outside front door as client refused to let us in Poor insight. Says
he “chooses” to live like that. Does not see a problem”.
• In hospital 13 days. CT brain scan normal. Blood tests OK.
2
Psychological report
• “Significant impairment on tasks of immediate
memory for verbally presented information.
On tests of executive functioning X fell within
the impaired classification overall… Difficulty
focussing his attention, in recalling novel
information and with tasks requiring more
abstract, higher level processing.
He demonstrated poor judgement and
impairment in self-direction and selfregulation. This pattern of results may be
indicative of a frontal lobe condition.”
3
Who should take action?
• 9 years later, referral to community mental health team
from the client’s nephew. The family hadn’t seen X for
30 years, but his uncle wanted to see him before he
(uncle) dies. When they arrived at the property they
found it to be “in squalor” and X was unkempt.
• “The neighbours state they have made numerous
complaints to council about the rats but nothing has
been done. X is sleeping on the front verandah amongst
the squalor and accumulated items”.
• Hasn’t been in the house for 5 months. Dishevelled,
unkempt. Aware he needs to clean up. Orientated. Has
money in the bank. Showered. Given new clothes to take home …
4
Meanings of words
Collecting
Accumulating (eventually amassment)
Hoarding
Pathological animal collecting (“hoarding”)
Environmental neglect (? self-neglect)
Severe domestic squalor
5
Aspects of collectionism, self-neglect and
severe domestic squalor
• Organised and systematic
collecting
• Compulsive acquisition
with little attempt to resist
(items may be of value,
collected systematically but
to excess)
• Hoarding: acquisition of,
and failure to discard
possessions of limited use
or value
• Accumulation of rubbish
• Neglect personal care and
home cleanliness
• Neglect basic health
needs (including
medication)
• Neglect social needs
• Fail to eat/drink enough
• Poor care of finances
• Fail to protect self from
financial or sexual abuse
6
A 2007 review revealed 2 bodies of literature
• Literature on squalor. By 2007 there had been
74 case-reports and 15 reports of case-series in
health sciences journals.
• Literature on hoarding. Various reports, some
mentioning squalor, but no research on the
prevalence of severe uncleanliness in cases of
hoarding.
Snowdon, Shah, Halliday (2007) Internat Psychogeriatrics, 19, 37-51.
Literature review
Macmillan and Shaw (1966). Psychiatric.
Senile breakdown in standards of personal and
environmental cleanliness
Clark et al (1975). Geriatricians.
Diogenes syndrome. 30 inpatients, 66-92
Halliday et al (2000). Special cleaning team.
Squalor. 91 community residents.
70% had mental disorder. None with OCD.
8
Severe domestic squalor
• Squalor: what’s the word mean, and
do we want to use it?
• What is severe domestic squalor?
• Should we be doing something
when we encounter people who live
in squalor?
• Why do some people live in squalor?
Severe domestic squalor
• Cooney and Hamid (1995) referred to
“a reclusive elderly person living alone in a
dilapidated filthy house. The home is
cluttered with rubbish and infested with
vermin. Excrement and decomposing food are
strewn around the floors and the stench
emanating is unbearable to all but the
occupant, who is blissfully unconcerned by the
situation.”
10
Severe domestic squalor
• Some clinicians suggested there was a syndrome:
•
Environmental uncleanliness (and often
associated personal uncleanliness)
and, to a varying extent,
•
•
•
•
Lack of concern about their living conditions
Social withdrawal
Hostile attitudes
Stubborn refusal of help
Severe domestic squalor
• We suggest that ‘severe domestic squalor’
is a description of an environment, not of a
person . Ratings should not be of the
person who lives in that environment, so
the person’s characteristics should be
noted separately and respectfully . It’s not a
syndrome and certainly isn’t a diagnosis!
12
• The term ‘severe domestic squalor’
is
applied when a person’s home is so unclean, messy
and unhygienic that people of similar culture and
background would consider extensive clearing and
cleaning to be essential. Accumulations of dirt, grime
and waste material extend throughout living areas of
the dwelling, along with presence or evidence of
insects and other vermin. Rotting food, excrement
&/or odours are likely to cause feelings of revulsion
among visitors.
• As well as accumulation of waste, there may have been
purposeful collection and/or retention of items to such a
degree that it interferes with occupants’ ability to adequately
clean up the dwelling.
13
Why do some people live in squalor?
• Maybe they have a mental or physical disorder that makes
them incapable of (e.g. weak or had CVA), or unmotivated
(maybe newly so, due to frontal lobe damage) to keep their
domestic environment clean.
• Maybe their vision or sense of smell is impaired.
• Maybe their personality is such that they don’t care about
uncleanliness & don’t notice filth.
(Quntin Crisp ?)
• Maybe they’ve never been organised or learnt to clean.
• Maybe they come from a culture that sees no need for clean
surroundings.
• Maybe there are impediments to cleaning – e.g. it’s out of
reach or cleaning is obstructed by collected, hoarded or
accumulated items.
• They might have Hoarding Disorder: very attached to, and
difficulty discarding, items – maybe even dirty ones.
14
Diagnoses in 2 studies
• Halliday et al (2000): n=81
age range 18-94
Organic mental disorder……22%
Substance abuse……………….10%
Schiz/delusional disorder….21%
Affective disorder……………….5%
Anxiety/phobic disorder ….…6%
Developmental disabiliy…….11%
No diagnosed mental
disorder…………………………25%
• Snowdon & Halliday (2011):
n=120, age 65 years or more
Dementia…………………..35%
Subst abuse/ARBD …….24%
Schiz/paranoid dis……. 15%
Depression…………………..3%
Personality disorder……. 9%
(obsessional 4%)
Physical illness……………..8%
No DSM or
physical disorder ….……5%
15
Severe domestic squalor
Descriptions of cases can be grouped according to
‘severity’ (e.g. rated on the ECCS), or into
(1) those where accumulation of useless items and
articles have obstructed proper care of a person’s
living conditions. ‘Dry squalor’.
(2) those where filth and refuse have accumulated
because of failure to get rid of them. May be filthy
without a lot of clutter. May be ‘wet squalor’.
(3) Both (1) and (2)
16
Pets
• There were pet animals in 42 (25%) of these
metropolitan homes:
Many cats in one house,
11 birds in another
4 or 5 animals in 3 others
3 or fewer in 37
None in 131.
17
• Many “animal hoarders” live in
extremely squalid conditions.
• 78% “heavily littered with trash and
garbage”, and in 45% there was
“profuse urine and feces in the living
room”. (Patronek and Nathanson,
2009)
18
Collecting
(as opposed to hoarding)
is selective object accumulation.
Pleasurable: Psychological benefit
19
Our common understanding is that
hoarding = storing for future use, or
to look at, perhaps
Squirrel away? Bower-bird mentality?
In recent years, excessive item or material
amassment has been widely referred to as
hoarding, even when it’s not done
purposely and the stuff lacks use or value.
20
Do you hoard a lot?
• During your lifetime, have you ever
accumulated so many things that your
home was very cluttered
(to the extent that you could not use some
rooms for their intended purpose) and you
found it very difficult to discard or give
away these items?
Screening question in a 2008-10 London Community Health Study
21
Why do some people hoard?
•
•
•
•
•
•
•
Complex interplay of factors:
Genetic
Personality
Organisational, beliefs, culture, attitudes
Neurobiological disturbance (e.g. brain disorder)
Perceived value of items:
practical, sentimental, intrinsic
Erroneous beliefs
Attachment issues etc. We need psychologists!
22
Compulsive Hoarding
• Some researchers suggested that OCD is the most
common reason for people to excessively hoard
possessions and then to live in unclean conditions
(Saxena et al, 2002; Steketee & Frost, 2003).
• However, recent evidence points to compulsive
hoarding being a genetically and neurobiologically
discrete entity (Saxena, 2007; Pertusa et al, 2008).
• It’s been suggested that compulsive hoarding is really
an impulse-control deficit rather than a compulsion
(Maier, 2004), and anyway, some collect ritualistically
rather than compulsively or on impulse. Others don’t
collect; they just don’t throw away. Ritualistic
collection and unmotivated accumulation of rubbish
should not be referred to as hoarding.
Hoarding
has been defined in the psychological literature as the
acquisition of, and failure to discard, possessions of
limited use or value.
The person
(1) actively acquires stuff ,
(2) purposely keeps it, and (if it’s abnormal/pathological)
(3) living spaces become too cluttered for
activities for which they were designed.
(4) The person’s distressed and there’s
significantly impaired ability to function.
24
DSM-5 Hoarding Disorder
A. Persistent difficulty discarding items, regardless of actual value
B. …due to perceived need to save the items, and distress associated
with discarding them,
C. …resulting in accumulation of possessions that clutter living areas,
thus substantially interfering with function and activities.
D. This causes clinically significant distress or impairment in social,
occupational or other important areas of functioning.
E. Not attributable to a medical condition (brain injury, stroke, etc)
F. Not better explained by the symptoms of another
mental disorder: cognitive deficits (dementia), low energy
(major depression), delusions (schizophrenia), restricted interests
(autism), obsessions (OCD).
Specify if (a) with excessive acquisition, (b) with good/poor/no insight
25
Normative collecting versus Hoarding Disorder
•
•
•
•
•
•
•
Normative collecting
Selective. Cohesive theme.
Narrower range of categories
Planned, organised collecting
Not usually excessive.
Orderly display of collection
Distress rare (e.g. due to cost)
Minimal social impairment;
collecting adds to social life
No significant work
impairment
•
•
•
•
•
•
•
Hoarding Disorder
Non-selective.
Lots of different categories
Lack of planning or focus
Commonly excessive. Free/Bought
Disorganised clutter
Distress is very common
Severe social impairment;
often single, social withdrawal
Occupational impairment
common
26
Prevalence of Hoarding Disorder
• 1.6% of 1698 a South East London population
aged between 16 and 90 years fulfilled criteria
for Hoarding Disorder.
• Studies (mainly in the US) say that 2% to 6%
of adults hoard excessively. But this would
include people whose hoarding would be
attributable to mental disorders such as
dementia, OCD and schizophrenia.
27
Hoarding and squalor
• People who collect or hoard may do so in an
organised way. YES WE CAN !!
• But if they accumulate too much stuff,
or if they don’t keep it in an organised way,
it may be difficult to keep the storage area
(e.g. the whole dwelling)
clean:
• It gets messy!
28
Some people who hoard excessively
don’t keep their dwellings clean
1. If their hoarding is disorganised and very excessive,
they may not be able to reach and clean all areas,
even if motivated to do so.
2. Some people who hoard excessively do so because
they have impaired neuropsychological function
that may result in disorganisation, difficulty in
discarding, lack of awareness that areas or items
are unclean and/or a lack of motivation to clean.
29
Maier (2004) helped us distinguish compulsive
hoarding from non-hoarding accumulation
• OCD or brain change: collecting too much and
then having difficulty discarding. Hoarding.
• Impulse-control deficit (e.g. due to brain
changes) rather than compulsion. Hoarding.
• Ritualistic, grasping behaviour. Collectionism.
Not hoarding.
• Unmotivated to throw away. Accumulate
rubbish. Not hoarding.
Maier T (2004) Acta Psychiat Scand 110, 323-337.
In various neuropsychiatric disorders
(dementia, autism and schizophrenia (OK?)
acquisition isn’t compulsive and isn’t due to
poor impulse control. It’s
“just motor activity without clear intention or
aim, hence stereotypic, ritualistic.”
People collecting in this way may be
indifferent to removal of the items.
Maier liked the term ‘collectionism ’ for this
behaviour.
31
‘Organic’ accumulation
Hoarding disorder
ONSET
Sudden or insidious
Insidious (from adolescence)
ABILITY TO DISCARD
Variable.
Some don’t care
Cannot discard
ACQUIRING
Often indiscriminate
Perceived intrinsic, practical
or emotional value
SQUALOR
Frequent
Uncommon
PERSONALITY
CHANGE
Common
Not
COGNITIVE &
EMOTIONAL
PROCESSES
Disorganised
Indecision, abnormal
categorisation, behavioural
avoidance, attachment to
possessions, etc.
INSIGHT
Poor
Ranges from good to poor
PREVALENCE
< 1%
2–5%
FAMILIAL
Some reported cases
Yes
Collecting, hoarding, accumulating,
disorganisation, mess, squalor: the OVERLAP
• You can collect, hoard &/or accumulate clean
stuff in an organised fashion.
• You might hoard too much, so that even if it’s fairly
well organised, it’s too difficult to keep clean.
• You can accumulate rubbishy stuff (‘cos you haven’t
got round to discarding it yet).
• Disorganised hoarding may result in accumulating
messily and living in SQUALOR.
• You may accumulate rubbish/waste/garbage / filth
by being too laid-back or disabled to throw it out.
It’s not purposeful hoarding. Can lead to SQUALOR.
33
Not all those who self-neglect
and not all those who hoard
live in severe domestic squalor
• Some people neglect (seem not to care
about) cleanliness of themselves, their
dependants or their homes and don’t get
rid of rubbish (e.g. some with dementia,
schizophrenia, alcoholism). Some are
physically or cognitively unable to take
action.
• Excessive or inappropriate collecting (and
especially failure to discard) may lead to
difficulty in cleaning.
Clutter/accumulation in Central Sydney cases of
moderate or severe domestic squalor
• Of 115 cases of moderate/severe squalor, the
degree of clutter/accumulation was deemed to be
minimal or absent in 39 (34%)
moderate
in 37 (32%)
major
in 39 (34%)
Filth but little object clutter may be wet squalor;
item clutter & no faeces etc may = dry squalor!
Accumulation/clutter in cases of
moderate/severe squalor
• There was MINIMAL or no clutter in about half
of the cases where we diagnosed substance
abuse or alcohol related disorder (and 31% of
dementia and 15% of schizophrenia cases).
• There was a MAJOR degree of clutter in most
(76%) of the cases where we diagnosed
personality disorder and no definite DSM-IV
mental disorder.
36
37
• The term ‘severe domestic squalor’
is
applied when a person’s home is so unclean, messy
and unhygienic that people of similar culture and
background would consider extensive clearing and
cleaning to be essential. Accumulations of dirt, grime
and waste material extend throughout living areas of
the dwelling, along with presence or evidence of
insects and other vermin. Rotting food, excrement
&/or odours are likely to cause feelings of revulsion
among visitors.
• As well as accumulation of waste, there may have been
purposeful collection and/or retention of items to such a
degree that it interferes with occupants’ ability to adequately
clean up the dwelling.
38
ENVIRONMENTAL CLEANLINESS AND CLUTTER SCALE (all items 0,1,2,3)
A. ACCESSIBILITY (CLUTTER):
Not / somewhat / moderately / severely impaired
0-29%, 30-59%, 60-89%, 90-100% floor-space inaccessible
B.
ACCUMULATION OF ITEMS of little obvious value (what items?)
C. ACCUMULATION OF REFUSE OR GARBAGE:
None / little / moderate / lots
D. CLEANLINESS OF FLOORS & carpets (excluding toilet / bathroom)
E.
CLEANLINESS OF WALLS, visible furniture SURFACES & window-sills
F.
BATHROOM & TOILET: Not / mildly / moderately / very dirty
G. KITCHEN & FOOD: Clean / hygienic ……to very dirty / unhygienic
H. ODOUR: Nil / pleasant ………………………..to
unbearably malodorous
I
VERMIN: None / Few / Moderate / Infestation
[ Define ]
J.
SLEEPING AREA: Reasonably clean …….to very dirty
SCORE (max 30) …………
BATHROOM & TOILET :
0 = Reasonably clean
1 = MILDLY DIRTY Floor, basin,
toilet, walls, etc. Toilet may
be unflushed.
2 = MODERATELY DIRTY Floor,
basin, shower/bath, etc.
Faeces and/or urine on
outside of toilet bowl.
3 = VERY DIRTY. Rubbish &/or
excrement on floor & in
bath or shower &/or basin.
Uncleaned for months or
years. Toilet may be
blocked and bowl full of
excreta.
40
A. ACCESSIBILITY (clutter):
Score
0
1
2
3
Description
% of floor-space
inaccessible for use
or walking across
Easy to enter and move about
dwelling
SOMEWHAT IMPAIRED access but
can get into all rooms
MODERATELY IMPAIRED access.
Difficult or impossible to get into
one or two rooms or areas
SEVERELY IMPAIRED access –
e.g. obstructed front door. Unable
to reach most or all areas in the
dwelling
0-29%
30 to 59%
60 to 89%
90 to 100%
41
ECCS scores
• A total ECCS score of >12 was found to
indicate, in most cases, that the occupants
were living in moderate or severe squalor. The
median ECCS score in cases of SEVERE squalor
(as judged by JS and GH) was 22
(inter-quartile range 16 to 24).
42
A useful question regarding clutter?
• Tolin et al (2007), in a handbook for those who
compulsively acquire, save and/or hoard, asked
“To what extent does the clutter in your home
prevent you from using parts of your home for
their intended purpose? For example, cooking,
using furniture, washing dishes…....”
Tolin DF, Frost RO, Steketee G (2007). Buried in Treasures. Help for
Compulsive Acquiring, Saving and Hoarding. Oxford: Oxford
University Press.
Interventions
• Reports suggest that agencies worldwide are
generally uncoordinated and consequently
inefficient when trying to intervene and help in
cases of squalor. Insufficient attention,
resources and research have been committed
to improving our understanding and
interventions.
44
NSW Squalor Guidelines
• Expression of interest and meetings between Mercy
Arms & Central Sydney Area Health (similar previous
interactions between South Eastern Sydney Area
Health & Waverley Council)
• Funding provided by Dept. of Ageing, Disability &
Home Care (DADHC)
• Project Officer appointed
• Reference Group convened
45
NSW squalor guidelines (process)
• Reference Group Meetings (Dec 03-Sept 04)
– Brainstorming
– Discussion
– Sample Cases
– 30-item survey of participants/organizations
• Legal review
• Consultation with other relevant/interested persons
• Preparation of Guidelines
– Algorithms (illustration of roles & steps)
– Benefits of a coordinated approach
– Role of the key worker or case manager
– Shortfalls
• Recommendations
46
DIAGRAM 1: ASSESSMENT & MANAGEMENT OF PEOPLE LIVING IN SQUALOR
POSSIBLE
INTERVENTIONS
E. Individual
work & case
Management
(4;8)
C. TAKE IMMEDIATE
ACTION IF REQUIRED
1. For person (eg transfer
to hospital)
2. Dependents (eg refer to
DOCS, RSPCA)
(5.5;7.2-7.4)
A. REFERRAL
Obtain
background
information:
including potential
OH&S issues
(2.2;3;6)
B. HOME VISIT
1. Assessment of
·
Level – squalor
·
Risk
·
Person
·
Dependents
·
Capacity
2. Engage & gain trust of
person
(4; 5.1-5.2;2.2;10.3)
F. Cleaning
(7.8)
D. JOINT AGENCY CASE
CONFERENCE
Convene meeting with delegates from
relevant services to determine action
plan, within context of;
1. Persons physical/mental health
2. Capacity
Does the person have impaired
decision making re accommodation,
services,
health and or Financial management.
3. Acceptance of assistance. (4;8;10.3)
RESISTS HELP
or LACKS CAPACITY
REFUSES
ASSESSMENT
PEOPLE WHO RESIST
ASSESSMENT OR
HELP
SEE DIAGRAM 2
G. Medical &
psychiatric
services (2.62.7;7.2-7.4)
H. Home
services (7.5)
L. CONTINUING FOLLOW
UP & SUPERVISION
TO PREVENT
RECURRENCE.
(Case management; NGO
services; Community
Treatment Order & Mental
Health; GP) (5.6;7.47.7;10.6)
I. Council
services
(5.2;7.1)
J. DOH (7.6)
K. Residential
care (7.4)
FURTHER DETAILS
A-L: See explanatory notes
2.2-10.6 Relevant sections of Guidelines
Page 1
47
Assessment and management of people
living in squalor
•
•
•
•
•
•
Referral
Home visit
Take immediate action if required
Joint agency case conference
Possible interventions (e,f,g,h,i,j,k)
People who resist assessment or help:
consider Mental Health Act, Local Government Act,
Residential Tenancy Act, guardianship, etc.
• Continuing follow-up and supervision to prevent recurrence
48
Possible interventions
• Individual work and case management
(flexible
and supportive). Care re OH&S issues
•
•
•
•
•
•
Cleaning
Medical and psychiatric services
Home services
Council services
Department of Housing
Residential care
49
Occupational health and safety
•
•
•
•
•
•
•
•
•
Is the structure of the building safe and secure?
Are there damaged electric wires trailing …. ?
Are there sick or aggressive animals in the dwelling?
Are there fire hazards?
Has there been spillage: urine, faeces, grease, liquids?
Is there a health risk? (mould, ammonia, pathogens)
Is personal protective equipment required?
Are exits from the home blocked?
Etc.
50
Should we intervene?
• “There is good reason to agree with Sutherland and
Macfarlane’s (2014) view that health workers have a
responsibility to be proactive. From experience, it is
clear that not only health practitioners but local
council officers and community service personnel
commonly shy away from enforcing interventions in
squalor and hoarding cases in spite of observed
effects of their behaviour on neighbours, cohabitants and pets. Sometimes the necessary
applications to courts and Tribunals prove too
difficult or too expensive.”
•
Snowdon J (2014). ANZ Journal of Psychiatry. Commentary
51
DIAGRAM 2: PEOPLE LIVING IN SQUALOR RESISTING ASSESSMENT OR HELP
PERSON WHO
RESISTS ASSESSMENT
OR HELP
MEDICAL &
PSYCHIATRIC
ASSESSMENT
(See G;7.2;7.4)
NO, lacks
capacity
M. DO THEY
HAVE
CAPACITY?
(2.2;10.1;10.3)
YES, has
capacity
DON’T
KNOW
O. KEY
WORKER/CASE
MANAGER TO
CONTINUE TO
LIAISE &
persuade person
to accept help (4)
N. CANNOT EVEN ASSESS CAPACITY BECAUSE
PERSON REFUSES TO OPEN DOOR OR SPEAK TO
PEOPLE
Consider;
1. Mental Health Act, Section 27 Assessment (if evidence
of likely mental illness, apply to Magistrate for order to
conduct assessment of patient in presence of Police)
2. Council can order inspection (with Police) under Local
Government Act
3. DOH or Landlord can apply to conduct inspection under
Residential Tenancy Act (5.1-5.2;10.4;10.6)
Q. Apply for a
GUARDIAN to be
appointed to make
decisions about health
& accommodation (in
consultation with case
manager etc.)
and/or
R. Use Mental Health
Act to COMPEL
TREATMENT
(10.7;11.2;7.2;10.6)
Guardian can
make decisions
about
INTERVENTIONS
including
CLEANING &
MEDICAL
TREATMENT
(SEE DIAGRAM 1)
S. Apply for
FINANCIAL
MANAGER to be
appointed
(10.7-10.8;11.2)
Financial Manager
can make decisions
about
ACCESS TO
PROPERTY,
CLEANING &
PAYMENT FOR
CLEANING
(SEE DIAGRAM 1)
REFER TO
COUNCIL
P.
ENVIRONMENTAL
HEALTH OFFICER
(± FIRE BRIGADE,
RSPCA, POLICE)
ASSESSMENT of
risk to neighbours &
community
(5.2-5.5;7.1)
If
unsuccessful
CONTINUING FOLLOW
UP & SUPERVISION
To prevent recurrence.
(SEE DIAGRAM 1)
SUBSTANTIAL
PROBLEM
eg fire risk,
rodents,
infestation
USE APPROPRIATE
LEGISLATION
(DETERMINED BY
PROPERTY
OWNERSHIP) to
compel owner/
occupant to remove
risk & permit cleaning
(See P;10.410.5;10.10-10.11)
FURTHER DETAILS
M-S: See explanatory notes
2.2-11.2 Relevant section of Guidelines
Page 1
52
NSW Squalor Guidelines:
Recommendations 1
• Publication and distribution of guidelines
• Education to health, welfare and housing workers
re assessment of risk, engaging clients, means by
which to gain access
• Need to develop risk management strategies,
home assessment tools, hazard identification
• Appointment of an experienced community
worker to act as a coordinator who could provide
information, collect data, provide support
53
Recommendations (cont)
• Service agreements between organizations including
development of lines of communication and
information management strategies /protection of
confidentiality
• Development and maintenance of local lists of
cleaning services
• Need for additional and recurrent funding for
management
• Further research including aetiology, interventions,
time taken to intervene, costs, early identification of
cases, nature of problem in rural settings
• Reconstitution of the Reference Group as an Advisory
Committee
54
• Psychiatric services have given insufficient
attention to how best to intervene in cases of
HOARDING (and particularly Hoarding
Disorder). What about CBT or motivational
interviewing? What’s the evidence?
• Equally, psychologists and associated
research teams haven’t been rating and
thinking about squalor associated with
hoarding.
55
Treatment for compulsive hoarding
• Strategies to overcome compulsive hoarding have been
demonstrably effective (Steketee & Frost, 2006), and could well
be helpful in some cases of squalor where hoarding is regarded
as a major contributory factor. Steketee G, Frost RO (2006)
Compulsive Hoarding and Acquiring: Workbook. Oxford: Oxford
University Press.
• Hoarding Task Forces in the US have run conferences, and
convene groups to work on decluttering. CBT is useful.
Organisers are available in the US and here. In Buried in
Treasures, Tolin et al provide a series of photographs of cluttered
rooms so that people can rate the amount of clutter .
• The Cumberland Anxiety Disorders Unit provided decluttering
workshops in 2005-6. Melbourne experts Kyrios and Mogan.
• CCHS holds a list of NSW psychologists willing to treat hoarding.
Jessica Grisham (UNSW) has written widely.
56
Accommodation of Central Sydney subjects
living in unclean conditions
MILD (or data
incomplete)
MODERATE
or SEVERE
TOTAL
Department of
Housing
20
49
69
Owner-occupied
20
(or owned by close
relative)
(43%)
49
69
(43%)
Private rental
1
8
9
Boarding-house or
NGO-run
Unknown
4
7
11
2
0
2
47
113
160
TOTAL
Co-habitation of people living in
unclean conditions in Central
Sydney
• 125 subjects (78%) lived alone
• In 8 households there were two persons aged 65+
living together (6 married couples, a son with
mother, 2 male friends), all 16 being included in our
data-base
• 19 subjects lived with others aged <65
• None of those subjects rated as living in severe
squalor were living with someone,
but 22 (10 being both 65+) of those in moderate
squalor were living with others.
One-year outcome
• Sydney subjects referred in 2000-2006 were followed
up after 1 year:
• 59 (56%) were still living at home, of whom 38 were
living in moderate/severe squalor, and 21 mild. Few of
the homes were judged to be much cleaner at 1 year.
• 28 (27%) had moved to residential care, of whom 25
had been living in mod/severe squalor.
• 8 (8%) had died, 5 being in mod/severe squalor.
• 10 (9%) (7 being in mod/severe squalor) had moved,
mostly to live with relatives.
59
Prevalence/incidence
• The population of persons aged 65+ living outside aged
care facilities in Central Sydney (Eastern sector) is about
18,000.
• The incidence of cases of people 65+ living in
moderate/severe squalor = 0.7 per 1000
• These are cases referred to an old age psychiatry
service; the number of non-referred cases can only be
guessed. Some were referred but refused to see us.
• Because over half of those referred are found to be still
at home after one year, the prevalence of people aged
65+ living in moderate or severe domestic squalor at
about 1.5 per 1000.
60
Comparison with Halliday et al’s data
• Subjects in the London study had been referred (mainly
by social services) to a special duty cleaning service,
provided only for people of limited means. Most (94%)
were renting from the local council or housing
association. In Sydney, 41% of the subjects were in public
housing.
• London subjects were aged 18–94 (mean 63) years,
whereas ours were all aged 65 +.
• LCRS mean (range): 17 (6 to 34) in London, 17.7 in Sydney.
• Male: 72% in London, 65% in Sydney.
• Single: 54% in London, 39% in Sydney.
• Living alone: 84% in London, 78% in Sydney
61
Points to consider
The prevalence of cases of severe domestic squalor
among older people is about 1 per 1000.
Younger people, too, may live in squalor.
In a majority of cases there is clutter (either rubbish or
accumulated articles), but some live in uncluttered
‘wet’ squalor.
Interventions are often uncoordinated. Guidelines and a
new rating scale (the ECCS) may help services to
provide appropriate care.
People have the right to live in the way they choose,
providing it is legal and not harmful to themselves or
others.
Most people who purposely HOARD (acquire and then
purposely retain items) do not live in squalor. Some do.
NSW legislation & severe domestic squalor
– Mental Health Act, 2007
• Section 19, mentally ill or mentally disordered
• Section 23, Magistrates order for medical examination or observation where physically
inaccessible
– Guardianship Act, 1987
• disabilities (e.g. dementia, mental retardation) which limit decision making capacity and
may result in neglect
– Local Government Act, 1993
• ‘to do work on land or premises not in a safe or healthy condition’
• Amended in 2006 to include a new order 22A (Waste Removal Orders) allowing council
to issue an order to remove or dispose of waste on a residential premises that is likely to
cause a threat to public health or the health of the individual. This can be issued to an
owner or occupier of the premises.
– Residential Tenancy Act, 1987
• DOH or Landlord can apply under act to inspect property and carry out repairs
– Public Health Regulation, Public Health Act, 1991
• prosecution where excessive vermin infest premises
– Nuisance Action, Common Law
• neighbours property significantly impinges upon own e.g. squalor, water, smell
– Inebriates Act, 1912