Compulsive Hoarding, Housing Stabilization and Fair Housing: A Model for Intervention

Jesse Edsell-VetterCase Management Specialist

Metropolitan Boston Housing PartnershipBoston, Massachusetts

Today’s Objectives Define compulsive hoarding Understand the health and safety risks for

those living in cluttered homes Discuss the role of reasonable accommodation

and fair housing in preventing eviction Explore strategies for addressing compulsive

hoarding Identify the role of community partnerships in

addressing compulsive hoarding

What is Compulsive Hoarding?

DefinitionCompulsive hoarding is: 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)

Hoarding, Squalor and Animal Hoarding Hoarding and squalor are not the same Squalor is defined as filthiness or degradation

from neglect Hoarding is related to the volume of clutter in the

unit, not the cleanliness of the unit Animal hoarding involves the hoarding of

animals. It is best to contact the MSPCA or Tufts University Animal Hording Consortium if you have concerns about animal hoarding

More On Hoarding Hoarding is a mental health disorder Hoarding is not a moral issue; It is not caused by

laziness, lack of standards, lack of responsibility 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)

Demographics & Prevalence

Saving begins in childhood ~ age 13 Average age 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 Emerging Research: ~ 3-5% of US Population (15 million

people)

Course of Compulsive Hoarding

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-threatening

Reasons for Saving

Sentimental - “This represents my life. It’s part of me.”

Instrumental - “I have a need this. I could use this.”

Intrinsic - “This is beautiful.”

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

Clutter / Disorganization

Random piles

Fear of putting things out of sight

Indecisiveness

Churning

Goat Paths

Fear of making wrong decision

Compulsive Hoarding and SafetyCommon health/safety violations, activities of daily living, impact of persons with disabilities

Common Code Violations Blocked egress Fire load

Fire hazards (items in oven, near heat source, etc)

Trip hazards Crush hazards Infestation Plumbing not functioning Sanitation concerns (rotting food, feces, needles, etc) Structural safety (weight of items)

Tenancy PreservationUsing Fair Housing Laws to Address Compulsive Hoarding and Stabilize Tenancies

Fair Housing and HoardingThe Fair Housing Act defines persons with a

disability to mean those individuals with mental or physical impairments that substantially limit one or more major life activities (US Dept. of Justice website)

Compulsive hoarding is a mental impairment that, in most cases, limits a persons ability to conduct one or more major life activities (ex. Showering, cooking, etc)

Fair Housing and Hoarding Compulsive hoarding is a disability Clients with a compulsive hoarding problem have the right to

request a reasonable accommodation from their property owner or housing subsidy provider

A reasonable accommodation would still require that minimum health and safety requirements are met by the client

Reasonable accommodation requests will likely primarily be requests for additional time to come into compliance with housing codes.

Reasonable accommodation plans will also help to hold the client accountable.

To Whom It May Concern:

I am writing to request a reasonable accomodation because of a disability. I would like to propose the following plan to address the issues you have raised in my home:

I will immediately clear an egress path for emergency purposes.

I request an additional time to bring the living room, bedroom and kitchen into compliance. I request an initial 6 weeks to bring the living room into compliance and will work with you and those assisting me to determine appropriate timelines moving forward based on the progress made

I will work with local organizations to reduce clutter in my home and develop a plan to ensure that it will not become re-cluttered moving forward.

Sincerely,

Example: Reasonable Accomodation Letter

Fair Housing and HoardingRefer to Fair Housing and Hoarding FAQ sheet

Addressing Compulsive Hoarding in Subsidized Housing

Annual InspectionsStatement of Family ObligationsTerminationMBHP's Model

Tools in Subsidized Housing Annual Inspections Statement of Family Obligation Termination from the subsidized housing

program Appeal of termination with the opportunity to

be reinstated with conditions

Annual Inspection

Ability to require tenant caused violations to be addressed in order to pass inspection (including clutter/hoarding)

Opportunity to monitor concerns about a potential hoarding problem over time

Statement of Family Obligations

The Section 8 program and other subsidized programs require recipients to sign a Statement of Family Obligations

The Statement of Family Obligations outlines the basic requirements of participation in the subsidy program

The Statement of Family Obligations includes maintaining the unit in a clean and safe manner

Termination and Appeals

Program participants can be terminated for failure to meet their responsibilities under the Section 8 and other subsidized programs

Subsidy recipients receive information about reasonable accomodation and the appeal process

Appealing with a specific, supported plan offers an opportunity for the unit to come into compliance and for the tenancy to be stabilized

Referral is received

Metropolitan Boston Housing Partnership's Model

Property Owner

Housing Inspector

Code Enforcement

Case ManagersHome Visit Conducted

Case Management Plan Developed

Re-inspection with Case Manager Present

Voluntary Compliance

Non-Compliance

A Compulsive Hoarding ModelDeveloped by Steketee and Frost, 2007

Beliefs &Meaning of Possessions Beauty/aesthetics Memory Utility/opportunity Opportunity/

uniqueness Sentimental Comfort Safety

Identity/potential identity

Control Mistakes Responsibility/waste Completeness Validation of worth Socialization

Emotions associated with Objects Positive Emotions

Pleasure Excitement Pride Relief Joy Fondness Satisfaction

Negative Emotions Grief/loss Anxiety Sadness Guilt Anger Frustration Confusion

Quotes from Clients “The idea of being homeless is like death for me.

But after so much loss in my life, I can’t imagine parting with my things – they are all I have left. They are my memories and life.”

“I am a man of knowledge. What would I be if I got rid of my library and other things?”

“What friends? I’ve spent the past 15 years playing with my stuff. I don’t have any human relationships only my stuff.”

Deciding to InterveneWhy address hoarding?

The tenant/client’s perspective

Intervention roles

The power dynamic

Effective Communication Strategies

Primary Intervention Roles

There are two primary roles when intervening in a compulsive hoarding case: The enforcement role: clarifies what is causing

code violations, could lead to eviction, The support role: offers the assistance needed to

meet codes, prevent eviction, address underlying causes, access resources

Power DynamicsBecause of power dynamics a tenant/client may:

Discard items they are not ready to get rid of Say yes to a cleanout when they are not ready Act to please others (including YOU) Act defensively Act out of fear rather than internal motivation

Ineffective Communication Strategies Make decisions (about a plan of action) for a

tenant/client Argue or Persuade Pressure the tenant/client to discard Tell the tenant/client how to feel Give verbal and non-verbal cues that are

judgmental or negative in nature

Effective Communication 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/client “Work with” the tenant instead of “doing for”

them

What Makes Hoarding so Difficult to Treat? Beliefs and Emotions associated with

possessions Core beliefs Vulnerabilities (Time, Family History, Trauma, etc.)

Co-morbid Conditions (Mental and Physical Health)

Problematic Thinking Motivation

Problematic Thinking in Hoarding All-or-nothing thinking

Most, everything, nothing Overgeneralization

Always, never Jumping to conclusions

I’ll need this just as soon as I don’t have it anymore

Problematic Thinking in Hoarding Moral reasoning

Waste not, want not I’m responsible for other people’s well being

Labeling I’m an idiot She’s just greedy

Under- and over-estimating I can read all these eventually I won’t be able to handle getting rid of those

Motivational Challenges Factors Influencing Motivation

How much social support? Are there any home visitors? Can anyone monitor homework? How depressed is the client? Can client tolerate discomfort?

What makes people motivated to change? Confidence Importance

Strategies for Enhancing Motivation Ask open-ended

questions Listen with reflection Summarize Affirm self-efficacy Ask evocative

questions Explore pros & cons

Ask for elaboration Use extreme contrasts Look forward Look back Reframe Provide feedback Encourage change talk

Tools You Can UseExposure: Practicing Sorting & Discarding, Non-Shopping Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts

Exposure: Sorting, Organizing & Discarding Exposure (practice) is the only way to overcome

avoidance and begin to solve the clutter problem Avoidance is fueled by anxiety Anxiety during exposure should be expected at first

What is Being Avoided Distress Decisions Feelings of loss Feelings of

vulnerability

Making mistakes Losing opportunities Losing information Depression Worries about memory

Gradual Exposure for Sorting and Discarding

Work in easier locations first (with highest motivation)

Work on easier objects first; set aside harder objects

into box “to be sorted later”Objects saved for sentimental reasons are often more difficult

For dependent decision-makers, gradually reduce assistance in making decisions

Sorting in 3 Piles Keep- Discard- ‘I Don’t Know’ All items in Keep pile need to have a final location

by end of sorting session Discard can mean: recycle, sell, give away, donate,

garbage, etc. ‘I Don’t Know’ pile is intended as temporary during

sorting process to keep things moving quickly; a decision about all items in this pile must be made before the end of the sorting session

Helpful Hints for Sorting Keep to 3 piles/ do not sub-divide until the end of

sorting Limit amount of time for each sorting session Use a timer to help monitor time- start & stop Sort in an un-cluttered area (sometimes an area will

need cleared for this purpose); this is called a staging area

Strategies for Home Visits Time Limited (1-2 hours) Check-In Set collective agenda Exposure work Use of Pictures

A Case Study: MaureenCollaborative Intervention

What works!

Resources

Maureen Single, Caucasian woman, age 60 Department of Mental Health and SSDI client Total of eleven Axis I and Axis II diagnosis Currently takes 13 mental health medications Lives independently; MBHP holds housing

voucher Substance Abuse and Trauma History

MBHP

Case Study: Team work

Boston University Clinician

Individual Therapy

Group Therapy

Substance Abuse Treatment

Home Visits

Occupational Therapist

Visiting Nurse

Flexible Funds for cleanout

Inspection Dept reasonable accommodation

Organizational Supplies

Monitoring

A Collaborative or Team Based Approach Shared responsibility for case management

Greater opportunity for resource identification

Increases range of knowledge and skills available to the client/tenant

Reduce resources required for any one agency to resolve crisis situation

Increases the networking potential for all organizations that can be used to address future needs

Early identification and intervention Setting specific and realistic timeframes Helping tenant/client learn to set limits and self-monitor

their hoarding Work to understand why the ‘stuff’ is important to the client Post-compliance monitoring Staff and community education Building community and provider partnerships

What Works

What Does Not Work

Avoiding addressing the hoarding problem Removing the clutter Working in isolation- as a person or agency Finger pointing or turf issues Unsupported clean outs without client present Lack of follow-up monitoring