Thoughts on Hoarding
“Negative results can occur when interventions
are not carefully planned with a group of
professionals with hoarding knowledge.”
Source:http://dmh.lacounty. gov/cms1_046522.pdf
Confidentiality
 We will be discussing live and historic case
work as such it is important to feel that we
are working safely. We agree:
 As much as possible to keep the identity
of the client anonymised
 To maintain the confidentiality of other
participants if we are discussing their
case work in our own workplace
 To treat discussions about clients
(professionals, family, etc.) with respect
 Others?
Trainer today
 Megan Karnes (alphabetically!)
 Activist
 Consultant
 Counsellor
 Counselling Supervisor
 Professional Advocate
 Trainer
Collector? Clutterer? Compulsive
Hoarder?
Normal saving
5
Collecting
Cluttering
Hoarding
Social Problem? Yes.







Isolation
Risk
Annoyance
Illegal (due primarily to risk)
Expensive
Recurrent
Stigma
We’ll spend more time on these later.
Psychological Problem? Yes.
 Hoarding disorder is previously recognised clinically
under Obsessive Compulsive Personality Disorder
on Axis II and Obsessive Compulsive Disorder on
Axis I
 Comorbid (found along side) with most recognised
mental disorders
 Hoarding disorder now has its own clinical
recognition in Diagnostic and Statistical Manual of
Mental Disorders V (American) and will be
published the International Classification of
Diseases (ICD) in 2014/15.
Source: Singh, 2012/Mataix-Cols, 2012
Current Diagnostic Criteria
Diagnostic and Statistical Manual of Mental
Disorders criteria:
 Persistent difficulty discarding or parting with
personal possessions, regardless of their actual
value.
 The difficulty is due to a perceived need to
save the items and distress associated with
discarding them.
Source: Mataix-Cols, et. al. 2010
Current Diagnostic Criteria (cont.)
 The symptoms result in the accumulation of a
large number of possessions that congest and
clutter active living areas and substantially
compromise their intended use. If all living
areas are uncluttered it is only because of the
interventions of third parties (e.g. family
members, cleaners, authorities)
Source: Mataix-Cols, et. al. 2010
Current Diagnostic Criteria (cont.)
 The symptoms cause clinically significant
distress or impairment in social, occupations or
other important areas of functioning (including
maintaining a safe environment for self and
others).
 The hoarding symptoms are not due to another
medical condition (e.g. brain injury,
cerebrovascular disease, Prader-Willi
Syndrome)
Source: Mataix-Cols, et. al. 2010
Current Diagnostic Criteria (cont.)
 The hoarding is not better accounted for by the
symptoms of other DSM-5 disorder (e.g.
hoarding due to obsessions in Obsessive
Compulsive Disorder (OCD), decreased energy
in Major Depressive Disorder, delusions in
Schizophrenia or another psychotic disorder,
cognitive deficits in Dementia, restricted
interests in Autism Spectrum Disorder)
Source: Mataix-Cols, et. al. 2010
Prevalence
 Some research finds that it hoarding disorder is
more common in males but more females present
for support (this has also been found to be equal in
terms of how many of each gender hoard)
 No distinction between age, gender, ethnic group,
socio-economic status, educational, occupational
tenure
 92% of compulsive hoarders have at least one other
mental health disorder
Source: Singh, 2012/Sorrentino, 2007
Prevalence (cont.)
 Often family history of OCD and or hoarding (50%
in three studies identified parent, sibling or
offspring)
 Potentially only 5% of hoarders come to the
attention of professionals.
Source: Singh, 2012
Commonly hoarded items
 Old clothes
 Beads
 Magazines
 Fabrics
 CD/Video/DVD
 Pins
 Post
 Rags
 Pens
 Old medication
 Old notes
 Canned food
 Bills
 OCD related: body
 Newspapers
 Receipts
 Cardboard boxes
products (nail, hair,
excrement); rotten
food; animals
Source: Pertusa et al, 2008
Development
 Hoarding often begins in adolescence
 Hoarding becomes significant problem for most
people in their 30′s
 However, the average age of people seeking
treatment is about 50, ranging mainly from
early 40s’ to elderly adults.
Source: Steketee, 2010
Where else?
Other than their own environment, the person
who compulsively hoards:
 May have storage spaces (or several)
 May be using space of other family, friends,
etc.
 May be using external areas of private or
other property including hallways, yards,
vehicles, etc.
Just say no…
Conceptual Model
 Core beliefs and vulnerabilities
 Information processing deficits
 Problems with emotional attachments
 Beliefs about possessions
 Emotional reactions
 Reinforcement properties
Frost/Steketee, 2007
Treatments largely ineffective
 ‘Therapist Guide’ details 43 clients entering a trial,
notes a 14% dropout rate before commencement and a
26% reduction in hoarding symptoms at week 12.
After 26 sessions, with only 17 patients remaining, the
result was a 45% reduction in hoarding behaviours.
(Frost and Steketee 2007)
 Findings have consistently shown that people who
hoard respond poorly to Exposure and Response
Prevention (ERP), CBT and Selective Serotonin
Reuptake Inhibitors (SSRI) medications (Starcevic and
Brakoulias 2008).
What’s Worked
 Introducing other services who are able to help,
including using the family and personal relationships as
a route in
 Consistently working in an open and transparent way
(ways to do that, and to fix it if it goes wrong)
 Working collaboratively (good cop/bad cop)
 Regular contact
 Motivational Interviewing has been found effective in
joining up professional’s goals with user’s autonomy.
Positive Engagement
Our vision of support
Family
Media
Community
Hoarder
Legal
Systems
Mental
Health
Emergency
Services
Social
Support
Their perspective
Social
Support
Mental
Health
Emergency
Services
Legal
Systems
Community
Family
Hoarder
Media
Reflective practice in action
Deliberate
pause
Open
perspective
Thinking
processes
Examination
of beliefs,
goals,
practices
New insights
and
understanding
leading to
action
Brett, 2012/York-Barr, et al, 2001
Hard enough for you…
When we talk about the person who hoards,
what do we mean by outcomes?
 Getting it safe
 Keeping it clear
 Others?
Risk
What are the risks?
 Increased Risk of Fire
 The accumulation of combustible materials, such as
newspapers, clothing and rubbish
 Increased Risk of Structural Damage
 Structural damage threatens the occupants, public
safety personnel and adjacent buildings
 Increased Risk of Disease, Injury and Infestation
 The storage of hoarded items makes cleaning nearly
impossible, which can lead to unsanitary living
conditions and increases the risk of disease
Source: http://www.fairfaxcounty.gov/dpwes/trash/hoarding/public_safety.htm
How do we assess risk?
In terms of our discussion let’s look at:
 Is there a process at all?
Behaviour
al
 What is the process?
 How is it measurable?
 Is it hoarding specific?
Relational
Hoarder
Psycholog
ical
Risk
CIR Ratings
With a show of hands how many people chose
which rating on the CIR?
We’ll have a brief discussion about why looking
at:
 Subjective nature of assessment
o Personal standards
o Personal beliefs about cleanliness
When in doubt, check it out!
 While all tools (not all discussed today) work as a
basic way of beginning the process of assessing
risk, ensure that evaluations are not being made
solely on the basis of ‘how it looks’ or ‘what could
happen if…’
 Fire brigade assess for fire, environment assess
for environmental issues, mental health services,
advocacy, etc.
 Try to engage the client, all evidence points to
this improving outcomes (albeit taking longer-but
also lasting longer!).
Risk is real!
 As much as HoardingUK advocates for engaged
practice that allows time and encourages real
change, this is not always possible
 Risk to others significantly high
 Impact on neighbours significant
 Children
 Animals
 Keep it safe
 Cover your butt
Origins
 Trigger moves person from disorderly or
over tidy to chaotic
 The cycle begins: acquiring behaviours
override ability to discard
 Shifts from manageable to unmanageable
We meet (or they’re discovered)
 Tenancy agreements
 Council/Private processes
 Anti-social behaviour
Motivational Interviewing
MI Core Principles
1. Clarifying contracts (additional principle to
those identified by Miller and Rollnick)
2. Expressing empathy
3. Developing desire to change (develop
discrepancy)
4. Avoiding argument (roll with resistance)
5. Supporting self-belief and self-responsibility
(self-efficacy)
Fuller and Taylor 2005
Open questions
 Questions that cannot be answered with a limited
response, (i.e. “yes‟, “no”, “maybe”, “seven”, “next
week”, etc.)
 Encourages individuals investigate and explore their own
thinking, and moves Facilitators away from giving or
offering “advice”.
 Members to do most the talking, with the goal to elicit
statements that develop discrepancy and reflect selfefficacy.
 People tend to believe what they hear themselves say
http://www.smartrecovery.org/resources/UsingMIinSR.pdf
Affirmations
 Affirming statements help individuals acknowledge
their positive behaviors and strengths
 Builds confidence in their ability to change.
 Allows for both recognition of difficulties and
support of their strengths
 Validates concerns and issues
 Convey respect, understanding and support, and
need to be both genuine and appropriate.
http://www.smartrecovery.org/resources/UsingMIinSR.pdf
Reflective listening
 Mirrors individuals’ comments by repeating back
what was said.
 Confirms understanding of what was said
 Clarifies sure you heard what you think you heard
 Deepens the conversation by allowing the
individual to hear (again) what they said, which will
help them understand their own thoughts better
http://www.smartrecovery.org/resources/UsingMIinSR.pdf
Readiness questions
 What’s different for you now?
 Who else would like to see this change? Do
you feel pressure from that person?
 Is there any risk to change?
 What do you feel might be some obstacles to
that change?
 Is there any other information you need or skill
you need to acquire to make this change?
SMART goals questions
 Tell me 3 reasons why this would be a good
change and 3 reasons why it would be difficult.
 When you bring about this change, how will it
look?
 If you’ve tried this before, what worked for
you? What didn’t work? What do we need to
do to overcome the previous obstacles?
Hoarding Relationship and
the Cycle of Change
Not rigid
 Suggestions, not a road map
 Interchangeable, not an orderly process
 Reusable, bring back in at any stage
 Fluid, flowing, adaptive
Cycle of Change
Prochaska and DiClemente 1982
Cycle of Change
Prochaska and DiClemente 1982
‘Precontemplation’-Gibberish alert!
 Can be thought of as ‘pre-change’
 “What appears to be ‘denial’ is often a normal
stage in the change process which occurs prior
to feeling ready to contemplate change
(precontemplation), rather than a personality
trait.”
 The facilitator can make the position worse by
giving advice, etc.
 Establishing rapport is vital at this stage
Fuller and Taylor 2005
Cycle of Change
Prochaska and DiClemente 1982
Contemplation-Gibberish alert!
 Thinking about changing
 Seeds of doubt have been sown.
 Awareness of some of the advantages of
change and the disadvantages of their present
behaviour is clearer
 However, a clear decision to change has not
been made; they enjoy their current behaviour
and know it will be difficult to change.
Fuller and Taylor 2005
Cycle of Change
Prochaska and DiClemente 1982
Gibberish alert!
 Okay, everyone knows what decision means…
 When there is a clear decision to change you
will hear increased self-motivating language
and reduced resistance talk
 More willingness to make clear contracts for
change and explore with you how to overcome
any barriers.
 The mistake is to rush into action planning too
quickly.
Fuller and Taylor 2005
Cycle of Change
Prochaska and DiClemente 1982
Active changes skills
Most useful:
 Remember ambivalence may still be present
 Monitor small steps
 Appropriate information giving
 Continue to explore and work to remove
barriers
 Active helping
 Celebrate success
Fuller and Taylor 2005
Active change skills (cont.)
Least useful:
 Assume the problem is solved
 Over emphasise the negatives of previous
behaviour
 Provide all the solutions
Fuller and Taylor 2005
Cycle of Change
Prochaska and DiClemente 1982
Maintenance skills
Most useful:
 Be aware when support may still be required
and when to let go
 Build regular support for the new behaviour
 Positive feedback on progress
 Affirm and praise
 Build new skills/behaviours
 Plan for coping and lapse
 Reinforcement of longer term goals
Fuller and Taylor 2005
Maintenance skills (cont.)
Least useful:
 Let go too early
 Over emphasise exploring previous
behaviour
 Hold them in dependency
Fuller and Taylor 2005
Cycle of Change
Prochaska and DiClemente 1982
Relapse skills
Most useful:
 Frame as a part of learning
 Explore how the lapse occurred
 Build strategies for next time
 Empathy/explore ambivalence
 Explore strengths and who can help
 Reflect back self-motivating statements
concerning desire ad confidence to learn from
the experience
 Return to contemplation stage
Fuller and Taylor 2005
Maintenance skills (cont.)
Least useful:
 Label as a failure
 See your own work as a failure
 Lecture, criticise, blame
 Give unwanted advice
 Give up hope
Fuller and Taylor 2005
Techniques
Ready or not!
It may be difficult to begin the process of
moving things out, but a good place to start is
by lessening (ideally stopping) acquisition.
 L earn
 E xplore
 S low Down
 S upport
Reasons for change
Costs to staying the same
Gains of change
Fuller and Taylor 2005
Gains of staying the same
Costs of change
Acquistion
Anything
new?
Negotiate
• Hold for
discussion
• Understand
meaning
• Keep this or not
• If kept remove
something else
Saving Behaviours
How long
• Since worn
• Since used
Set a date
• Two years?
• Seven years?
Discard
• Anything older than
Motivation-Picture this!
 Take a photo
 Make change
 Take a photo
 Make change
 Take a photo
 Make change
Singh
Inability to discard
Create hierarchy:
 What is important
to the person?
 Highest risk
priority?
LEAST
IMPORTANT
LESS
IMPORTANT
MOST
IMPORTANT
Singh
Levels
 Mark a spot on the wall with something bright
 Clear in the area
 Watch the mark become more and more
visible
Singh
Difficulty organising/decision making
B
R
Time
E
A
K
Task
It
D
O
W
N
Process
Attachment-Me space
 Identify an ‘I want’
 Identify the
area
 Clear
 Use the
space
STUFF
SOMETHING
I LIKE TO
DO, USE,
ETC.
STUFF
Singh
Active change-Can/May/Won’t
Three piles:
WON’T GO MIGHT GO
Stays
Put away
appropriately
or used
Singh
Moves to
agreed
space
Used, or
discarded
later
CAN GO
Goes out
immediately
Removed
completely
An ‘Open Relationship’?
 Fire brigade assess for fire, environment assess for
environmental issues, etc.
 Mental Health treats the psychological disorder
 Support groups break down stigma, increase social
engagement, support change
 Advocacy works to ensure that professionals across a
range of services are giving the client what they need
 Role playing e.g. Good Cop/Bad Cop
 Professionals are getting the support they need
It doesn’t happen
 Client will not engage
 Others demand ‘now’
 Time runs out
 Others?
Fuller and Taylor 2005
It’s got to go!
Support in
Identifying
Time for
labelling
Oversight on the
day
Removal
Treatment Group in London
National Hoarding Treatment group
meets once a month- the last Wednesday of
each month from 6.00-8.00 pm at:
The Wordsworth Health Centre
19 Wordsworth Ave
London, E12 6SU
-----------------------------------------------------Islington support group (Islington Residents Only)
Westminster Society for People with Learning
Difficulties.
More details can be obtained from the website:
www.hoardinguk.org
Megan Karnes
megan@hoardinguk.org
www.hoardinguk.org
07908 22 55 11
END