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Professional Perspectives on Animal Hoarding
Francesca Alix Burniston
Submitted for the Degree of
Doctor of Psychology
(Clinical Psychology)
School of Psychology
Faculty of Health and Medical Sciences
University of Surrey
Guildford, Surrey
United Kingdom
September 2016
1
Abstract
Objectives
Although theoretical conceptualisations of animal hoarding have been published, few
empirical studies have been conducted. The current study investigated animal hoarding from
the perspectives of professionals who come into contact with people who hoard animals
through their employment in various capacities, primarily in animal welfare.
Design
A qualitative research design was employed using inductive thematic analysis.
Methods
Twelve professionals who had experience working in animal hoarding were interviewed.
Participants’ professions included: mental health nurse, vet, animal behaviour consultant,
animal inspector, animal warden and animal welfare officer. Participants reported working in
a diverse range of locations across the UK. Semi-structured interviews were conducted either
in person or over the telephone. Interviews were audio recorded and transcribed verbatim
before analysis.
Results
Animal hoarding was conceptualised primarily by the presence of multiple animal neglect or
suffering. The term ‘animal hoarding’ was used by participants to reflect those who are
neglecting animals unintentionally, living in squalor, self-neglecting, experiencing distress or
mental health problems, and using animals as a replacement for people. Animal hoarding
2
appears to be maintained or repeated despite interventions from animal professionals,
possibly because the human aspects of this issue are currently overlooked.
Conclusions
Better understanding and education, particularly on the human aspects of animal hoarding,
are needed for both professionals and the public. Joint working and greater communication is
needed in both directions between animal professionals and those working in mental health
and social services.
Practitioner Points
The findings suggest that animal hoarding should be given much greater attention,
both clinically and in research, within the field of psychology.
There are social and mental health aspects of animal hoarding which are inadequately
addressed by professionals in the UK currently. Animal professionals should be aware
of psychological and social issues such as the mental capacity of individuals to make
decisions about their animals. Social and psychological interventions should be
offered to engage people who are hoarding animals, safeguard people living in animal
hoarding situations, address social isolation or support network issues, relieve
psychological distress from comorbid mental health problems, increase insight, and
instigate behaviour change.
The current study is limited by the representation of only professional perspectives on
animal hoarding. The perspectives of animal hoarders and their families are not
represented.
There was a majority of animal professionals compared with mental health
professionals interviewed in the current study which may have caused a paucity of
3
information on the social and mental health aspects of animal hoarding and
professional responses to this.
4
Acknowledgements
I would like to thank my friends and family for supporting me throughout the last three years.
In particular my fiancé Matt has given me so much encouragement and reassurance, and been
the best proof-reader I could have asked for. I need to also thank my fellow trainee and best
friend Lucy for all the peer supervision, support and wine she has provided.
I have enjoyed all of my clinical placements immensely and am very grateful to all of my
placement supervisors and the teams that I have worked in over the last three years.
I am also very grateful to Dr Laura Simonds for the excellent supervision she has given over
the course of my major research project.
5
Contents
Abstract..........................................................................................................................2
Objectives...................................................................................................................2
Design........................................................................................................................2
Methods......................................................................................................................2
Results........................................................................................................................2
Conclusions................................................................................................................3
Practitioner Points......................................................................................................3
Acknowledgements........................................................................................................5
MRP Empirical Paper..................................................................................................13
Abstract.......................................................................................................................13
Objectives................................................................................................................13
Design......................................................................................................................13
Methods...................................................................................................................13
Results.....................................................................................................................13
Conclusions.............................................................................................................14
Practitioner Points.................................................................................................14
6
Introduction................................................................................................................16
Background and Classification.............................................................................16
Aetiology..................................................................................................................18
Characteristics........................................................................................................20
Consequences..........................................................................................................22
Research Question..................................................................................................24
Method........................................................................................................................24
Design......................................................................................................................24
Ontology and Epistemology..................................................................................25
Participants.............................................................................................................25
Data Collection.......................................................................................................26
Analysis...................................................................................................................27
Credibility...............................................................................................................27
Results.........................................................................................................................28
Unintentional Animal Neglect...............................................................................30
Self-Neglect and Owners’ Suffering.....................................................................34
Animals as Replacements for People....................................................................36
7
Repetition or Maintenance of Animal Hoarding.................................................37
A Human as well as an Animal Issue...................................................................39
Discussion....................................................................................................................42
Limitations..............................................................................................................47
References...................................................................................................................49
Appendix A: Advertisement Used to Recruit Participants....................................54
Appendix B: Evidence of Ethical Approval.............................................................55
Appendix C: Information Sheet................................................................................57
Appendix D: Consent Form......................................................................................60
Appendix E: Demographic Questionnaire...............................................................61
Appendix F: Interview Schedule...............................................................................64
Appendix G: Professional Transcriber Confidentiality Agreement (Anonymised)
..................................................................................................................................................66
Appendix H: Coded Extracts from More than One Interview..............................68
Extract Exemplifying Definitions and Categories of Animal Hoarding
(Interview B).......................................................................................................................68
Extract Exemplifying Commercial Animal Hoarding (Interview E)................69
Extract Exemplifying Unintentional Animal Neglect (Interview B).................70
8
Extract Exemplifying Self-Neglect and Owners’ Suffering (Interview I).........71
Extract Exemplifying Animals as Replacements for People (Interview H)......72
Extract Exemplifying Repetition or Maintenance of Animal Hoarding
(Interview B).......................................................................................................................73
Extract Exemplifying a Human as well as an Animal Issue (Interview L).......74
Appendix I: Coding Memos......................................................................................76
Appendix J: Initial Thematic Map...........................................................................78
Appendix K: Final Thematic Map............................................................................79
Appendix L: Reflective Statement............................................................................80
A Grounded Theory Analysis of Animal Hoarding.....................................................82
Introduction................................................................................................................82
Background and Theoretical Rationale...............................................................82
Research Question..................................................................................................86
Method........................................................................................................................86
Design......................................................................................................................86
Participants.............................................................................................................87
Interviews................................................................................................................89
9
Ethical Considerations...............................................................................................89
R&D Considerations..................................................................................................91
Project Costing...........................................................................................................91
Proposed Data Analysis.............................................................................................91
Involving/Consulting Interested Parties..................................................................92
Contingency Plan.......................................................................................................92
Dissemination Strategy..............................................................................................93
References...................................................................................................................94
The Impact of Compulsive Hoarding on Families and Carers: A Systematic Review97
Abstract.......................................................................................................................97
Objectives................................................................................................................97
Methods...................................................................................................................97
Results.....................................................................................................................97
Conclusions.............................................................................................................98
Practitioner Points.................................................................................................98
Statement of Journal Choice.....................................................................................98
Introduction..............................................................................................................100
10
Aims of Review.....................................................................................................104
Methods.....................................................................................................................104
Search Strategy.....................................................................................................104
Data Extraction and Evaluative Method...........................................................106
Results.......................................................................................................................106
Qualitative Findings.............................................................................................106
Quantitative Findings..........................................................................................115
Quality Assessment of Papers.............................................................................122
Discussion..................................................................................................................124
Limitations............................................................................................................128
Future Research Recommendations...................................................................129
References.................................................................................................................133
Clinical Experience....................................................................................................139
Mole Valley Community Mental Health Recovery Service..................................139
North West Surrey Child and Adolescent Mental Health Service.........................139
Sutton Community Mental Health Team for Older People...................................139
East Surrey Community Team for People with Learning Disabilities...................140
11
Traumatic Stress Service........................................................................................140
PSYCHD CLINICAL PROGAMME........................................................................141
TABLE OF ASSESSMENTS COMPLETED DURING TRAINING......................141
Year I Assessments................................................................................................141
Year II Assessments...............................................................................................142
Year III Assessments..............................................................................................143
12
MRP Empirical Paper
Abstract
Objectives
Although theoretical conceptualisations of animal hoarding have been published, few
empirical studies have been conducted. The current study investigated animal hoarding from
the perspectives of professionals who come into contact with people who hoard animals
through their employment in various capacities, primarily in animal welfare.
Design
A qualitative research design was employed using inductive thematic analysis.
Methods
Twelve professionals who had experience working in animal hoarding were
interviewed. Participants’ professions included: mental health nurse, vet, animal behaviour
consultant, animal inspector, animal warden and animal welfare officer. Participants reported
working in a diverse range of locations across the UK. Semi-structured interviews were
conducted either in person or over the telephone. Interviews were audio recorded and
transcribed verbatim before analysis.
Results
Animal hoarding was conceptualised primarily by the presence of multiple animal
neglect or suffering. The term ‘animal hoarding’ was used by participants to reflect those
who are neglecting animals unintentionally, living in squalor, self-neglecting, experiencing
13
distress or mental health problems, and using animals as a replacement for people. Animal
hoarding appears to be maintained or repeated despite interventions from animal
professionals, possibly because the human aspects of this issue are currently overlooked.
Conclusions
Better understanding and education, particularly on the human aspects of animal
hoarding, are needed for both professionals and the public. Joint working and greater
communication is needed in both directions between animal professionals and those working
in mental health and social services.
Practitioner Points
The findings suggest that animal hoarding should be given much greater attention,
both clinically and in research, within the field of psychology.
There are social and mental health aspects of animal hoarding which are inadequately
addressed by professionals in the UK currently. Animal professionals should be aware
of psychological and social issues such as the mental capacity of individuals to make
decisions about their animals. Social and psychological interventions should be
offered to engage people who are hoarding animals, safeguard people living in animal
hoarding situations, address social isolation or support network issues, relieve
psychological distress from comorbid mental health problems, increase insight, and
instigate behaviour change.
The current study is limited by the representation of only professional perspectives on
animal hoarding. The perspectives of animal hoarders and their families are not
represented.
14
There was a majority of animal professionals compared with mental health
professionals interviewed in the current study which may have caused a paucity of
information on the social and mental health aspects of animal hoarding and
professional responses to this.
15
Introduction
Background and Classification
Compulsive object hoarding was defined by Frost and Gross (1993) as the excessive
accumulation of, and difficulty discarding, possessions. In the fourth edition of the
Diagnostic and Statistical Manual (American Psychiatric Association [APA], 2000),
compulsive hoarding was categorised as a symptom of Obsessive-Compulsive Disorder
(OCD). However, since DSM-V, ‘Hoarding Disorder’ has been defined as a diagnostic
category in its own right (APA, 2013) and evidence has supported this creation of a distinct
disorder (Mataix-Cols & Pertusa, 2012). The factors thought to set those with Hoarding
Disorder apart from those with non-pathological collecting behaviours include a larger
quantity of collected items and resultant distress or impairment in everyday functioning
(APA, 2013).
Patronek (1999) was the first to describe the pathological collecting of animals as a
variant of compulsive object hoarding, and an under-recognised public health problem in the
United States of America (US). Animal hoarding was defined by Patronek (1999) as
collecting a large number of animals without the ability to provide acceptable care in terms of
nutrition, sanitation and veterinary care. This neglect to animals may be the main aspect that
differentiates animal hoarding from the non-pathological collecting of animals (multiple
animal ownership).
Debates about the value of psychiatric classifications are on-going (Dalal &
Sivakumar, 2009; Kecmanovic, 2012), however, an overview of the current classification
queries surrounding animal hoarding behaviours will be detailed here in order to demonstrate
the background and context to this issue. A conceptual overview and comparison of object
16
and animal hoarding (Frost et al., 2011) has suggested some symptom similarities between
the two. Animal hoarding may be similar to object hoarding in that active and passive
excessive acquisition can both occur, along with great difficulty relinquishing animals, which
is akin to the inability to discard objects. In both, these issues can often lead to homes
becoming dysfunctional (Frost et al., 2011). Animal hoarding could therefore be considered a
subtype of ‘Hoarding Disorder’, as it may meet the current diagnostic criteria (Kress,
Stargell, Zoldan, & Paylo, 2016). However, this supposition could be debated as only one
empirical study has attempted to compare and contrast object hoarding and animal hoarding
(Slyne, Tolin, Steketee, & Frost, 2013). Additionally, this single empirical study by Slyne et
al. (2013) was limited to the investigation of animal hoarding which occurred within the
context of concurrent object hoarding.
It has been proposed that those who hoard animals may often also hoard objects.
Indeed households were described as heavily cluttered in sixty-nine percent of animal
hoarding cases from across North America (Patronek, 1999). The extensive accumulation of
newspapers, rubbish, and pet and human food items were also described in some US animal
control agency case records—implying the hoarding of objects along with animals (Patronek,
1999). McGuire, Kaercher, Park and Storch (2013) surveyed social services staff members in
the US and found that only two percent of reported cases involved the hoarding of animals
alone, whereas forty-seven percent involved the hoarding of inanimate objects but no
animals, and fifty-one percent involved both hoarded animals and inanimate objects.
Compulsive hoarding of objects has also been discussed as a component of Diogenes
Syndrome (also known as senile squalor syndrome). This is a disorder which is not currently
recognised in DSM-V but described as a cluster of symptoms including self-neglect, extreme
squalor and reclusiveness (Clark, Mankikar, & Gray, 1975). Frontal executive dysfunction
17
has been implicated in people living in squalor, regardless of other medical or psychiatric
comorbidities (Lee et al., 2014). Nathanson (2009) suggested that animal hoarding could also
be aligned with conditions associated with squalor as animal hoarding can occur co-morbidly
with self-neglect. Saldarriaga-Cantillo and Rivas Nieto (2015) have even suggested the term
‘Noah Syndrome’ to describe a subtype of Diogenes Syndrome in which animal hoarding
occurs.
Despite the apparent commonalities between object and animal hoarding, Patronek
and Nathanson (2009) draw out several conceptual issues, such as the inappropriateness of
using terms such as ‘failure to discard’, in relation to animals. Whereas object hoarders
might construe seemingly useless items as having value, there is no evidence that animal
hoarders see the clutter and rubbish they cannot discard as having value. The attachment
between a person and even their most valued inanimate objects is likely to be profoundly
different to that between a person and their animals. Additionally, unlike inanimate objects,
animals can suffer. Frost et al. (2011) suggest that although animal hoarding may not be as
prevalent as object hoarding, it is an extremely destructive behaviour with serious personal
and public health consequences, which may be more significant than those which accompany
the hoarding of objects.
Aetiology
Three conceptual papers have suggested a wide variety of models to explain animal
hoarding, based solely on the authors’ clinical work (Frost et al., 2011; Nathanson, 2009;
Patronek & Nathanson, 2009). Several of these models have an interpersonal or attachment
component. Patronek and Nathanson (2009) proposed a developmental trajectory in which a
persistent struggle to form functional attachments with others could result in animal hoarding
behaviours. This model proposes that childhood adversity, which has led to strong urges for
18
intimacy with simultaneous fears of abandonment, may predispose individuals to both
hoarding and personality disorders. In childhood, it is suggested that animals provide
protection and comfort for those who have not been able to form positive attachments with
humans, whereas in adulthood the ownership of multiple animals can become a primary
component of an individual’s sense of self. Patronek and Nathanson (2009) observed that loss
of an adult relationship or serious illness were often precipitants of animal hoarding, and
therefore proposed that animal hoarding may also be a complicated grief reaction resulting
from attachment disturbance. It has been suggested that co-morbid animal and self-neglect
could be common among the animal hoarding population because the individuals may have
become completely reliant on dysfunctional human-animal relationships (Nathanson, 2009).
Steketee et al. (2011) interviewed sixteen animal hoarders and eleven multiple pet owners
who did not meet the criteria for animal hoarding. The differences between animal hoarding
and multiple pet ownership were analysed in the form of frequency counts of qualitative
themes. Thematic content which was unique to animal hoarders included: “problems with
early attachment, chaotic childhood environments … and the presence of more dysfunctional
current relationships” (Steketee et al., 2011, p. 114). Further exploratory investigation of
these themes is therefore needed to increase understanding of the aetiology and
phenomenology of animal hoarding.
Other theories have suggested links between animal hoarding and certain features of
personality disorders or frontal lobe dysfunction. Dissociation and a lack of mentalisation
(understanding the mental states of others) may explain the lack of insight that people who
hoard animals demonstrate. In particular, Patronek and Nathanson (2009) suggest that these
states might result in a worldview in which, despite suffering, animals are seen as being cared
for. Frost et al. (2011), on the other hand, suggest that a form of delusional disorder might
explain the lack of insight that animal hoarders may demonstrate. The current study will
19
attempt to acquire perspectives on the aetiology of animal hoarding from people who have
worked professionally with those who hoard animals, in order to better understand the critical
life experiences which may trigger the onset of animal hoarding.
Characteristics
By summarizing case reports from animal control agencies across the US, Patronek
(1999) suggested that animal hoarders were mostly female, and almost half were over sixty
years of age. Calvo, Duarte, Bowen, Bulbena and Fatjó (2014) reviewed twenty-four case
reports of animal hoarding in Spain, finding that hoarders could be characterised as “elderly,
socially isolated men and women” (p. 199) who presented with chronic animal hoarding
issues over the course of more than five years. Joffe, O’Shannessy, Dhand, Westmana and
Fawcett (2014) reviewed finalised prosecutions for offences relating to animal hoarding in
Australia, also finding that most were female but reporting that most were forty to sixty-four
years of age at the time of their first offence.
Dogs, cats, farm animals and birds were found to be the most commonly hoarded
animals (Patronek, 1999), although it may be most common for an individual to hoard only
one species of animal, usually dogs or cats (Calvo et al., 2014). Patronek (1999) found that
the median number of animals hoarded per case was thirty-nine, whereas the mean number of
animals per case found by Calvo et al. (2014) was fifty. In eighty percent of cases animals
were found to be living in inadequate conditions, which had caused some animals to perish
(Patronek, 1999). Calvo et al. (2014) reported that in seventy-five percent of Spanish cases,
poor welfare had resulted in the animals showing aggression and fear as well as contracting
parasitic and infectious illnesses. Animals requiring veterinary care were identified in all the
offence cases reviewed by Joffe et al. (2014), with animals having died in forty-one percent
of cases.
20
Williams (2014b) defined animal hoarding using the hypothesised characteristic that
animal hoarders cannot recognise their own inability to care for their animals. Patronek
(2006) described this as poor insight and significant denial regarding the animal care being
provided. Patronek (1999) found that in fifty-eight percent of cases, animal hoarders would
not acknowledge that a problem existed, according to the investigating animal control officer.
The suffering of animals in hoarding cases might therefore go unrecognised by the owner,
which could explain why most cases of animal hoarding are only brought to the attention of
the authorities by neighbours who complain of unsanitary conditions (Patronek, 1999).
Slyne et al. (2013) reported that erroneous beliefs may be apparent in the context of
animal hoarding behaviours. For example, despite the squalid conditions in their homes,
object hoarders who were also housing over ten animals were more likely than those housing
less than ten animals to state that they were the only ones who could care for their animals
adequately. Vaca-Guzman and Arluke (2005) have found that hoarders use a variety of
justifications for their treatment of animals including “denying wrongdoing, being a Good
Samaritan, and professing to be victims of the system … attributing their poor performance to
external events, appealing to defeasibility, scapegoating, and self-handicapping” (p. 338).
Steketee et al. (2011) found that significant mental health concerns were present for
those classed as animal hoarders, but absent for multiple pet owners who did not meet criteria
for animal hoarding. As previously mentioned, Nathanson (2009) proposed that self-neglect
was a characteristic of the animal hoarding population due to lack of sanitation in the home;
however, it has been noted that not all animal hoarders live in the hoarding environment with
their animals (Berry et al., 2005). Following consultation with an expert panel including
representation from mental health, social services, and law enforcement professionals,
Patronek (2006) suggested three possible categories of animal hoarders. It was proposed that
21
‘overwhelmed caregiving’ animal hoarders tended to have more Axis I psychological
disorders than ‘rescuing, mission-driven’ and ‘exploitative’ animal hoarders. These
categories were also differentiated by their engagement with authorities (fewer reported
issues with ‘overwhelmed caregivers’ compared to ‘rescuers’ and ‘exploiters’) and their
method of acquisition (passive for ‘overwhelmed caregivers’, but active for ‘rescuers’ and
‘exploiters’). Mental health workers therefore need to be aware of animal hoarding
behaviours and how they might collaborate with other services to tackle it (Williams, 2014a).
The use of psychological interventions for animal hoarding must also be investigated
(Williams, 2014a). The three different categories of animal hoarding proposed by Patronek
(2006) imply that different types of intervention may be needed for different categories of
animal hoarder. It will be important to further understand variability in animal hoarding
profiles so that the most effective interventions are provided. Calvo et al. (2014) stated that:
“further studies are needed to fully elucidate the epidemiology, cross-cultural differences and
aetiology of this under-recognised public health and welfare problem. More research might
help to find efficient protocols to assist in the resolution and prevention of this kind of
problem” (p. 199).
Consequences
Slyne et al. (2013) demonstrated the ways in which the consequences of animal
hoarding may be more significant than those associated with object hoarding by investigating
high versus low animal ownership within the context of concurrent object hoarding. Their
sample consisted of self-identified individuals who hoarded objects and also owned animals,
as well as family and friends of object hoarders who owned animals. Their results suggested
that, despite no differences in the overall condition of the home, hoarding objects and owning
more than ten animals was associated with a decrease in quality of life compared with
22
hoarding objects and owning fewer than ten animals. Quality of life was affected via
sacrifices in multiple areas of life such as finances, employment, social life, and sanitation of
the home. Arluke et al. (2002) explored how the press reported on animal hoarding in one-
hundred articles, suggesting that “drama, revulsion, sympathy, indignation, and humour” (p.
113) were all conveyed. It was proposed that these representations of animal hoarding painted
an inconsistent picture that may confuse the public and may not adequately represent the
significance of animal hoarding.
The Hoarding of Animals Research Consortium (HARC, 2010) has estimated that
dependent or vulnerable adults or children live in around ten to fifteen percent of homes
where animal hoarding is taking place. Approximately half of the animal hoarders described
in animal control agency case reports lived alone with their pets (Patronek, 1999); therefore,
many may have been residing with others. HARC (2002) suggested that extreme squalor
within the homes of animal hoarders may impair the functionality of households to the extent
that they may not be fit for human occupancy and may ultimately be condemned. Animal
hoarding was theorised to have been the origin of “a range of medical, social, and economic
problems” (HARC, 2002, p. 125). The health and wellbeing consequences of animal hoarding
are therefore significant for the animals, their owners, and those living with animal hoarders.
Frost, Steketee and Williams (2000) have reported that hoarding is a community
health problem which affects the health and safety of not only the individual, but also those
around them. It was found that animal hoarding was more serious and difficult for American
health departments to manage than object hoarding which did not involve animals. Multiple
community agencies were needed to work with individuals who were hoarding, which often
resulted in significant costs. “A full response is likely to be prolonged and require a cross-
jurisdictional multiagency effort” (Castrodale et al., 2010).
23
To conclude, although conceptual proposals have been made about the aetiology and
phenomenology of animal hoarding, there is little extant empirical work to either support or
extend current theorising. Currently, it is unclear whether animal hoarding is best understood
as a variant of Hoarding Disorder (compulsive hoarding of objects), or a possible
characteristic of those living in squalor (such as those described by Diogenes Syndrome), or
whether it sits outside of these classifications. “Animal hoarding continues to receive
negligible attention by the psychological community, either in theoretical or applied work”
(Patronek & Nathanson, 2009, p. 275). Further research is therefore needed to investigate the
potential antecedents, characteristics and consequences of animal hoarding using empirical
evidence derived from primary studies. There is no current published work offering a
conceptualisation of animal hoarding from a UK perspective as current research has
predominantly originated from the US. In a step towards this, the current study explores
animal hoarding from the perspective of professionals in the UK who have worked with
individuals they believe to have been hoarding animals in various capacities, primarily in
animal welfare.
Research Question
How is animal hoarding understood from the perspectives of professionals who have
worked with this in animal welfare and mental health roles?
Method
Design
A qualitative research design using inductive thematic analysis (Braun & Clarke,
2006) was employed. This form of inductive analysis allowed the development of themes
from the data without a priori assumptions, therefore lending itself to the exploratory nature
24
of the study. The semantic level at which the themes were analysed allowed for interpretation
whilst retaining focus on the explicit interview data.
Ontology and Epistemology
The epistemological framework of ‘contextualism’ and the ontological position of
‘critical realism’ were taken. This acknowledges that people’s meaning-making and
experiences are described within a specific historical and socio-cultural context.
Participants
The only inclusion criteria for participation was experience of having worked
professionally with people whom the participant considered to be hoarding animals. The
sample consisted of twelve individuals who were all recruited via email advertisements and a
snowballing sampling strategy. Email advertisements were sent out directly to those who
were identified through internet searches as being potentially appropriate participants, as well
as through local authority councils and animal charities (see Appendix B). No incentives for
participation were offered. The current professional occupations of the participants included:
one animal behaviour consultant, one forensic vet, one animal inspector, one canine welfare
officer, one animal welfare manager, one animal rehoming manager, one dog warden, one
animal warden, two animal chief inspectors, one veterinary surgeon in small practice, and one
mental health nurse and team manager. All but one of the participants were therefore
employed in roles which primarily involved the promotion of animal welfare. Participants
reported working in a diverse range of locations across Britain and Northern Ireland, and one
participant reported working nation-wide. The sample consisted of six females and six males.
The mean age of interviewees was 48 years old with a range of 36-72. Most participants (ten)
described their ethnic origins as White including White British, White European and White
25
American; one participant described their ethnic origins as being that of a Pacific Islander,
and another one participant described themselves as Asian Indian.
Data Collection
Ethical approval for this study was gained from the University of Surrey Ethics
Committee (see Appendix C). Those who expressed an interest in taking part in this study
were initially sent an information sheet outlining the nature and purpose of the study, their
rights as a participant, and how data would be used and stored (see Appendix D). If the
individual wished to continue with participation they signed a consent form (see Appendix E)
and then filled in a short demographic questionnaire (see Appendix F) before engaging in
discussions guided by a semi-structured interview schedule designed to elicit information
regarding the potential antecedents, characteristics and consequences of animal hoarding (see
Appendix G). This semi-structured interview schedule ensured consistency across interviews
whilst allowing flexibility for the interviewees to describe their own ideas and experiences.
Care was taken to ensure that no leading questions were included in the interview schedule.
Prompts within the interview schedule were designed in order to give elaboration on the
questions or to encourage greater depth of description by the interviewees. Interviews took
place either in person or over the telephone. Telephone interviews were offered because
resource for the project was limited and this allowed participation by people from across the
UK. Interviews were audio recorded with consent from participants, then transcribed
verbatim either by the author or by a professional transcriber who had signed a confidentiality
agreement (see Appendix H). The interviews ranged in length from 36 minutes to 105
minutes with a mean length of 60 minutes. Signposting information was supplied at the end
of the interviews. This indicated where participants might find support if any of the issues
raised in the interview caused them distress.
26
Analysis
Data analysis followed Braun and Clarke’s (2006) step-by-step guide for conducting
thematic analysis. The processes of transcription and repeated readings of the data occurred
alongside initial line-by-line coding (see Appendix I). Engagement and familiarisation
occurred both with the interviews transcribed by the researcher, and with those professionally
transcribed. The interviews which had been professionally transcribed were also checked for
accuracy against the original recordings. Codes were then sorted into candidate themes which
were collated, synthesised, revised and reviewed in order to better define them. This included
the re-coding of each transcript using these developing themes and ascertaining whether
themes reflected apparent meanings within the whole data set. Throughout this process a log
of developing ideas and patterns was written and frequently referred back to in order to aid
the development of the analysis (see Appendix J), along with thematic maps of the data (see
Appendix K & L). The final themes were agreed upon, defined and named in discussion with
the research supervisor, thereby interactively testing and developing the interpretations of the
data (Hayes, 2000).
Credibility
The researcher and research supervisor met regularly throughout data collection and
analysis to reduce single-researcher influences on the study and to therefore increase
credibility of the research. The credibility of the study was also judged according to
Yardley’s (2000) four principles: “sensitivity to context; commitment and rigour;
transparency and coherence; impact and importance” (p. 215). Citation of the relevant
literature in the field and acknowledgement of ethical issues and the social context of the data
show sensitivity to context. Commitment and rigour were demonstrated through in-depth
engagement with the data. Transparency and coherence were strived for through the above
27
description of the methodology of this study as well as the use of reflexivity throughout the
process. The impact and importance of this research are reflected upon within this report,
particularly with regards to the practical and clinical implications of the results.
Results
An overall definition of animal hoarding was identified which conceptualised it as
multiple animal households in which there is neglect or suffering to the animals. “The
definition I would use is anyone who keeps a number of animals that exceeds their ability to
look after them.” Hoarding was not necessarily defined by an absolute number of animals;
instead, the critical factor seemed to be the owners’ ability to care for their animals.
Two participants explicitly named three categories of ‘animal hoarding’: “There’s
profit-making, there’s … the disease of hoarding, and then there is ‘because I … can’t get rid
of things, so I just keep them’”. However, the most commonly made distinction within the
rest of the data was between only two categories that could be described as commercial
animal hoarding and overwhelmed ‘rescuing’ animal hoarding.
Although both commercial and overwhelmed ‘rescuing’ animal hoarding do seem to
fit under the overall definition of animal hoarding—multiple animal households in which
there is neglect of the animals—one participant was unsure whether breeding for profit in
poor conditions could be classed as animal hoarding. The generic category ‘animal hoarding’
may be used specifically to describe overwhelmed ‘rescuing’ animal hoarding, not
commercial animal hoarding. This was evidenced in the data by participants describing the
core features of animal hoarding but stating that commercial animal hoarders did not
evidence these features. For example, most people who hoard animals were described as
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completely unable to relinquish animals to others; however, commercial animal hoarding
requires the relinquishing of animals, as they are sold to other people for profit.
She is able to give some of them away … I’m not sure I would class her as an animal
hoarder in that she … did keep an awful lot … there was probably 30 or 40 cats in
the house at any one time … that’s a really tricky one because they are hoarding, but
… a true animal hoarder doesn’t pass the animals on, they keep them … They’re like
collections, … they don’t … knowingly breed them, they don’t pass them on, sell
them, I think it’s more people that cannot bear to be separated from these animals.
Participants talked about overwhelmed ‘rescuing’ animal hoarding more frequently
than commercial animal hoarding, possibly because it was considered to be ‘true’ animal
hoarding, and professionals could sympathise with it more. Overwhelmed ‘rescuing’ animal
hoarding was also thought to be related to mental health problems, may have been less well
understood, and may be more difficult for professionals to work with.
Interviewer: do you see that [puppy farming] as different from animal hoarding?
Participant: I do in as much as it’s deliberate … there’s deliberate … intent to make
money out of animals. Whereas hoarding, people I’ve dealt with personally have also
got some sort of mental health issue very often as well.
Commercial animal hoarding was also called unofficial breeding or puppy farming.
The conditions in which the animals are kept and bred are not ideal and the litters are sold on
to pet shops or individuals for profit. “In my experience you can have commercial premises
for hoarders. The general definition of a hoarder, the number of animals exceeds the
capacity to look after them, but they chose to have that number because they are puppy
farms.” Banned, unusual or popular breeds may be hoarded, depending on what is profitable,
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and the animals may be housed in commercial premises outside of the owners’ homes. People
who are making a profit from their animal hoarding behaviour were described as “lazy”,
“selfish” and “greedy”, and their greed was thought to outweigh the needs of the animals.
They were also described as “callous”, “hard-hearted”, “persistent offenders” who may not
see their actions as problematic due to a belief that unofficial breeding is similar to farming:
“the commercial hoarders … they feel that it’s like farming cattle or farming sheep … that
they perceive some sort of commercial enterprise. Like all these hoarders they don’t see the
problem.” One of the interviewees thought that those profit-making from hoarding animals
would stop if they were no longer making money from it, which would seem to concur with
the perceived traits described above. Commercial animal hoarding is often prosecuted as
unlicensed breeding or as an animal welfare offence and animal professionals in this study
endorsed this approach as appropriate for this population.
Having presented the distinction drawn between commercial and overwhelmed
‘rescuing’ animal hoarding, professional conceptualisations of overwhelmed ‘rescuing’
animal hoarding are presented below in five main themes: ‘unintentional animal neglect’,
‘self-neglect and owners’ suffering’, ‘animals as replacements for people’, ‘repetition or
maintenance of animal hoarding’, and ‘a human as well as an animal issue’.
Unintentional Animal Neglect
This theme encapsulates what was seen to be a defining characteristic of
overwhelmed ‘rescuing’ animal hoarding: the unintentional nature of the suffering
experienced by the animals in these situations and how such unintentional neglect arises.
Suffering was often seen as a result of neglect rather than abuse, and was
predominantly described as “unintentional” and “not wilful” on the owners’ part. Instead,
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neglect occurs due to poor living conditions for both the animals and the owner, ignorance
about animal needs, and a number of animals that is overwhelming to care for.
It’s always well-meaning people … they’re not trying to harm the animals, but they
are harming the animals, they just have no knowledge of what they’re doing … it’s
out of their control almost … I don’t think I’ve ever come across anyone that’s
intentionally … caused abuse to the animals in that way … Just appalling … housing
conditions … lack of exercise, it’s just … the basic five freedoms [of the animals] …
aren’t being met.
The living conditions were often referred to as “squalid”, “overcrowded”, “untidy”
and “unclean”, with extreme squalor described in some cases:
Complete squalor, … lack of sanitation … and these are … houses that people are
living in, there’s not a clean work surface, there’s not even vaguely clean work
surfaces … everywhere is just covered in faeces and urine and … the smell is
incredible in a lot of these places … and the people are living in these conditions
without realising that there’s any problem at all.
Animals were thought to be suffering due to a lack of human interaction, a lack of
exercise and little mental stimulation, and not receiving veterinary care. They may also be fed
old food or inadequate amounts of food, not given enough litter trays, or shut into the house.
Someone hoarding would be to the point where … the animals in question aren’t …
given … their daily needs. … The five needs under the animal welfare act … I think as
soon as that starts to become an issue … I would look at it as a hoarding issue.
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Animal suffering included injuries from in-fighting, constant pregnancy, urine scalds,
respiratory problems, disease, difficulties due to inter-breeding, stress and mental suffering,
starvation, and death. “From the animal point of view, you see animals with fleas, lice, …
hair loss, scabies, … urine scald, … underweight or dead, … in very very poor conditions.”
Growing up in households in which cleaning was not the norm may lead people to
these behaviours in adult life. This may be exacerbated by poor education about hygiene and
how to care properly for animals. One interviewee wondered whether animal hoarding could
be a learnt behaviour:
I think if … they accept it as the norm, they go on to do it themselves. … We do see
families and … the same name crops up and they live a few miles apart and you
discover they’re actually related. … I’ve come across that more than once and they
are all adults but … they presumably lived in the same house at some point so maybe
it’s something that you learn.
Mental health issues might also prevent animal hoarders from identifying and
preventing animal suffering:
There’s something about having very clear boundaries, about … what number will
you stop … and that’s very difficult for some people, especially if they become
perhaps … more infirm, or they’ve got some mental health problems, that is difficult
for … them to put those boundaries in cognitively.
Animals are acquired and retained in overwhelmed ‘rescuing’ animal hoarding
situations primarily through unintentional breeding and an inability to give any animals away.
“They hadn’t … got any of the cats neutered … and they were all inbreeding amongst each
other.” Some people who are hoarding animals may hold incorrect beliefs about neutering
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being cruel. Not only does this maintain the acquisition of animals, it also demonstrates a
lack of understanding about how to adequately care for animals. Acquiring can also happen
through the owners being given animals from the local community to ‘rescue’, taking in or
feeding strays, or purchasing animals. “One particular lady, she couldn’t say no so she
became a de-facto drop off point for … abandoned, stray, injured, sick, dead or dying cats
and people just came to her, she couldn’t say no and she became overwhelmed.”
An escalation of the unintentional neglect of animals seems to occur over time.
Acquiring animals can be very quick due to inadvertent breeding; however, the situation
becoming overwhelming or out of control and the development of extreme squalor may
accumulate slowly over the course of several years. “It’s months not weeks and it’s years not
months, you know it takes time to accumulate that amount of dirt, smell, debris, noise, and
not notice it … it’s not a lifestyle change overnight in my experience.” One interviewee
described three stages of animal hoarding and two interviewees talked about multiple animal
owners who they thought were “on the verge” of becoming animal hoarders. These accounts
support a view that unintentional neglect to animals develops or escalates over time.
Some thought that people who are hoarding animals may be delusional about the
condition of their animals and their ability to care for them, further demonstrating how
neglect may be unintentional. Owners may believe that they are rescuing animals, that the
animals need them, and that they are the saviour of their animals and the only person able to
provide adequate care for them. “She goes: … these cats need me because I’m their saviour,
I’m their mother … I am looking after them.”
Many of the professionals interviewed described people who hoard animals as being
in “denial”. “I would say out of … ten cases you would get six or seven that would deny
there’s a problem, even though from an outsider’s perspective looking in … there’s obviously
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a problem.” Some interviewees said that some people who hoard animals have admitted to
not coping and were relieved when professionals intervened. However, a larger proportion of
those described could not admit to there being a problem and pleaded not guilty when
prosecuted. Their situation may become the norm over time, and therefore they become
accustomed to the squalid environment and unable to see the problem. Being in denial about
the situation is likely to prevent help-seeking behaviours. In this way, animal hoarders could
be seen as “vulnerable adults” who may lack mental capacity to make decisions about
animal care. “It is about mental capacity, does somebody have the capacity to understand the
decisions that they’re making … around their animals … the numbers and the treatment, the
care?”
Self-Neglect and Owners’ Suffering
This theme captures the ideas that as well as unintentionally neglecting animals, those
who hoard animals may be neglecting themselves, and suffering both physically and
mentally.
Due to living in squalid home environments with their animals, health difficulties may
arise for the owner. “Maybe not directly from the animals, although … I’ve seen owners who
are covered in flea bites and … scratches and things like that … there’s bound to be health
issues." An extreme example of this is given below:
He had a house and bedroom covered in dog faeces … one day he fell over … he got
stuck in the faeces … he couldn’t move. The dogs were starting to get hungry, he had
developed gangrene in his foot and the worst of it was the dogs had started eating his
toes. That’s when we were called in. He had his leg amputated and we took the dogs
off him.
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Self-neglect was described in many cases. Some individuals may go without food
themselves in order to feed their animals and may be giving space over to animals, which
limits the functionality of rooms in their houses. “These people are somewhere on the
Diogenes spectrum” (a disorder involving extreme self-neglect). As well as Diogenes
syndrome, depression and anxiety, agoraphobia, bipolar disorder, neuroticism, psychosis,
dementia, self-harm, and addiction were all mentioned in connection with animal hoarding.
I think maybe they’re susceptible to depression, I think that’s probably a big part of it
… and they … don’t cope with life in general and I think they just surround
themselves by things … to be in their comfort zone.
Some, but not all, of the people who were described as animal hoarding were also
object hoarding. This involved hoarding either animal-related paraphernalia such as statuettes
and pictures of animals, or hoarding rubbish and not cleaning out excrement or even dead
animals from their houses. The phrase ‘mental health problem’ was used in general terms by
participants and evidenced by descriptions of distress and a lack of understanding of societal
norms. Suffering and self-neglect could therefore be increased by the presence of concurrent
object hoarding or other forms of psychological distress.
Participants were unsure whether mental health problems cause animal hoarding or
vice versa. “They might’ve been absolutely fine and then something changes, so ... if they
lose a partner … what starts first … the mental health problems associated with those losses,
or the animal hoarding?” Animal hoarding was considered to be a mental health problem
itself by one interviewee and another defined animal hoarding as “pathological”.
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Animals as Replacements for People
Animal hoarding may arise and be maintained by problematic relationships with other
people or experiences of loss. Some interviewees described childhood experiences which
may have lead people to distrust or dislike humans and prefer animals, therefore making them
vulnerable to animal hoarding as an adult.
A few have mentioned about being abused, … being left alone and the only thing they
could relate to … was animals, … and then the animal was taken away from them,
and they … were put into care, the animal was ripped out of their arms and they’ve
never forgiven anybody, and they’re never ever gonna allow that to happen to them
again.
Various changes in circumstances and significant relationships were also thought to
precipitate animal hoarding problems, and in particular the unintentional neglect discussed
earlier. Examples given included: family break up, divorce, adult children leaving the home
and loss. Loss in particular was mentioned frequently:
Sometimes someone’s lost someone and then they get a cat … you know for the
company … which can then escalate out of control … and then you know other times
people have had the cat or cats already … at the very beginning and obviously that
cat is going to be a big part of that person that … they’ve lost … because they’ve got
memories to … those particular animals that they had with that person … Obviously
the struggles that people face when they lose someone … a lot of important things get
left on the backburner so, … neutering … and protecting your animal isn’t … the
most important … it’s just that … they’re dealing with other issues in their life so it’s
something that goes amiss.
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The animals may be a relief from these changes in circumstances that have occurred
in their lives by providing a replacement for people they have lost or by giving the owners a
sense of safety. “All sorts of disasters in their life, whether the animals gave them a bit of
relief … in their own sort of way, it’s quite possible.”
People who are hoarding animals were commonly described as having no visitors,
wishing to be alone, withdrawing and becoming reclusive due to a preference for animals and
a dislike of leaving their animals. They may be isolated from their community and may have
strained family relationships. Some were hypothesised as having no children and using
animals as a substitute for children or friends. “A lot of people in that situation, do end up
becoming … a recluse and hiding away … and then a cat becomes company for them.”
Reclusiveness may sustain and complicate animal hoarding behaviours due to the resulting
lack of practical and emotional support, and the fact that their living conditions become the
norm if they do not socialise and see how others live.
It is easy to see how, given the potential childhood experiences described above and
the social isolation they may experience, people may gain comfort from owning many
animals, despite not being able to adequately care for them.
It’s something that gives you a comfort and, I don’t know much about the psychology
of hoarding but … they say that it’s one of those things that gives you … a certain
control … and I guess some people get that control, that feeling, from having a house
full of things that they can care for, or they think they care for.
Repetition or Maintenance of Animal Hoarding
This theme represents the idea that animal hoarding is considered an intractable
problem and is complicated by a resistance to seek help or engage with professionals.
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Recidivism seems to be a characteristic of overwhelmed ‘rescuing’ animal hoarding as this
could be as high as “one hundred percent”. No singular current professional response to
animal hoarding was thought to be particularly helpful in preventing recidivism. One
interviewee thought that taking all the animals away upsets the owners, and leads to the
owner acquiring more animals. Others thought that negotiations between animal
professionals and the animal owner about the rehoming of some animals also resulted in
quick recidivism. Some thought that disqualifications from owning animals resulted in a
greater chance of recidivism. Owners were reported to have found loopholes in prosecution
cases which allowed them to own animals again after disqualification orders, such as owning
animals under a partner’s name or moving county. “Yes we get successful prosecutions but
that person will go on and do the same again as soon as they get the opportunity.”
Recidivism may be high due to the reluctance of people who hoard animals to engage
with professionals. “The sort of things where people don’t answer the door when you know
they’re in.” Embarrassment and worry about animal removal may prevent owners from
visiting vets and seeking help when their animals are unwell. “It gets to the point where
they’ve lost control, and it’s now too embarrassing … it’s gone too far to ask for help.” Some
people do eventually ask for help and may be relieved for professional input having admitted
to not coping, but this may occur at a stage in animal hoarding which is too late for the
animals. “The animal is really suffering and … at the point where it’s dying and that’s when
we get called by the actual owners them-self.” The majority, however, were described as
extremely reluctant to give up their animals, experiencing distress at the removal of their
animals or any change in their environment.
They get very distressed when you start removing animals … from that environment
which could be the worst environment in the world for anyone to live in but they get
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distressed when it’s changed … they don’t like it to be cleaned or the animals to be
removed.
The nature of professionals’ interactions with people who are animal hoarding, and
the necessity, in some situations, of animal removal, may explain why professionals
described people who were animal hoarding as difficult to communicate with, and initially
“aloof”. Professionals may even be seen by animal hoarders as the “enemy”.
A Human as well as an Animal Issue
This theme represents the idea that the management of animal hoarding is primarily
undertaken by animal professionals but that effective support and intervention is only likely
to occur when the human dimensions are focussed upon.
Whilst animal charities may rehome animals or put them down, negotiation and
compromise with owners is sometimes sought, and some animal charities may refrain from
intervening even in situations that are not ideal. Where intervention is deemed necessary, a
range of methods is used such as neutering, giving advice to the owner, addressing the health
issues of the animals, and conducting follow up visits to the property. In practice, animal
welfare officers engage in response and prevention:
Our job is split into two, reactive and proactive … we respond to welfare concerns in
calls from the public and then … from … the proactive side of our job we run a
number of community outreach projects, to help prevent welfare issues from arising
in the first place.
Animal professionals indicated that they need to use a range of styles, both
authoritative and approachable, when working with animal hoarding issues.
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If someone is really digging in their heels then we will start spouting the animal
welfare act at them … become a bit more authoritative … one moment … you have to
…. take the nicey, nicey approach and the other times we do have to be more of the
policeman-y type.
Animal professionals therefore recognised that there are both human and animal
needs that have to be balanced in these cases. One vet even described working as a “de-facto
social worker” and “de-facto psychologist”, needing to take a gentle approach with people
who are hoarding animals, but also needing to seize animals in imminent danger.
Animal charities may have contact with mental health services, social services and
housing associations but this inter-agency working might not be sustained or joined up: “you
will have a point of contact but it’s only on a one-off basis.” For example, one participant
described an animal owner who was known to have been on medication for mental health
issues but stated that the mental health services working with the individual may not have
been aware of the animal issues occurring in their home. Participants also described mental
health workers not having sufficient relevant experience: “she just … could not believe …
what was going on … I suspect most of her clientele she had seen at her clinic or her office,
very, very seldom had she been into the house of a hoarder.” Additionally, mental health
services may not be able to pass on all potentially helpful information to animal welfare
agencies:
Very little is ever known … in some cases, where they have got social workers or
community mental health team workers … they will understand more … but … that
information is privy to them, and doesn’t get passed on, aside from any really
relevant parts.
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Participants emphasised the importance of joined up working between animal
professionals and those working in social and mental health services:
You want to work together, because … as an enforcing officer, perhaps the worst
thing you can do for that person could be the best thing for the dogs, but you’ve the
two to consider. You could blunder in there and seize all the animals, and that’s it.
But then what’s that person going to do? So, it’s very important that we have a tied
up response, so that there are people there to help the person.
Court cases against the animal owner are pursued in severe cases when no other
interventions have helped. Animal behaviour specialists give evidence in court in order to
show the mental suffering of animals, but mental health workers were not mentioned as
having been involved in any court cases.
The RSPCA tends to use very … blunt animal welfare legislation to prosecute these
people and I think rather than prosecute them they often need help … people fail to
see that this is a mental health issue in my view, or a social issue, rather than an
animal welfare or neglect issue.
Participants suggested that better understanding and education on animal hoarding as
a human or mental health issue is needed for both the public and professionals. This includes
magistrates, GPs, and mental health practitioners, who may see animal hoarding as a
“lifestyle choice” or a purely animal issue, and may therefore not provide the assistance that
is needed by the animal owner.
Social services, psychology, veterinary sciences and judicial systems … I personally
would like to make a bridge between all of them and the separated … siloes of
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knowledge within those four sort of headings but … these cases ... transect all of that
and … the animal part of it is a small part of it.
Participants considered that the animals’ quality of life often cannot be improved until
the owner’s life improves: “we’re dealing with … the animals and the problem is not with
the animals or with the environment or with us, it’s with the person.” As such participants
suggested there is a need for greater mental health service input in addition to improved
mental health and social services interventions for animal hoarding. People need to be
safeguarded if living in animal hoarding situations. Mental health workers and social workers
need to address the social isolation and support network issues of people who are hoarding
animals and provide some form of therapeutic intervention.
Call the psychologist … save two hundred thousand pounds by giving … some
therapy for this person, getting some … assistance for this person and maybe … the
recidivism will be lower you’ll certainly save money, you’ll make the person’s life
better and you’ll certainly make the animal’s lives better.
The one participant who worked in mental health noted that the provision of therapy
may also help people who are hoarding animals “to recognise that there’s a problem.”
However, they also pointed out that: “there are no identified interventions for working with
people with animal hoarding.”
Discussion
The perspective of professionals in this study is that animal hoarding can be defined
primarily by the presence of multiple animal neglect or suffering. Despite this overarching
definition, which conceivably includes those who hoard animals for commercial and profit-
making purposes, the term ‘animal hoarding’ was generally used by participants to reflect
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those who are neglecting animals unintentionally, are unable to relinquish animals, may be
experiencing distress or mental health problems, and could therefore more accurately be
described as overwhelmed or ‘rescuing’ animal hoarders.
Commercial animal hoarding is often prosecuted as an animal welfare offence, and
the professionals interviewed seemed to endorse this approach. It appeared to have been
sympathised with less than other categories of animal hoarding, perhaps because
professionals did not link it with human suffering and psychological distress. In contrast with
overwhelmed ‘rescuing’, professionals did not suggest that commercial hoarding might
require any additional multi-disciplinary responses. This comparative lack of professional
challenges posed by commercial animal hoarding perhaps explains the relative dearth of data
on this category of animal hoarding within this study.
Whilst it is acknowledged that there could conceivably be some differences between
‘overwhelmed’ animal hoarding and ‘rescuing’ animal hoarding, as suggested by Patronek
(2006), the current study suggests a distinction between the two may be unnecessary.
Patronek (2006) suggested that ‘overwhelmed caregivers’ may exhibit better engagement
with authorities compared with ‘rescuers’; however the professionals who participated in this
study did not make this distinction, and instead proposed that all animal hoarding is difficult
to work with professionally given denial and delusional beliefs, resistance to change or
intervention and, therefore, high levels of recidivism. This aligns with Frost et al.’s (2011)
conclusions about the chronic course of animal hoarding. The participants in the current study
did, however, suggest that those in the earlier stages of animal hoarding, and those who are in
less denial about their situation, may be more accepting of input from professionals. Patronek
(2006) also suggested that ‘overwhelmed caregivers’ could be differentiated from ‘rescuers’
by their method of acquisition of animals (passive versus active); however, the information
43
about animal acquisition in the current study was generalised to all animal hoarders.
Additionally, the distinction between passive and active acquisition may not be clear in that
people may initially actively obtain animals but subsequently passively acquire more by not
neutering their animals.
In terms of the aetiology of animal hoarding, the current study might support the
theory of a developmental trajectory which includes childhood adversity and the loss of an
adult relationship (Patronek & Nathanson, 2009; Steketee et al., 2011). Animals were
described as replacements for people following childhood experiences which may have led to
a distrust or dislike of humans. A change in circumstances, including the loss of a loved one,
was also cited by the professionals in the current study, along with the idea that animal
hoarders may have become reclusive over time and found comfort from these adverse
attachment disturbances through their animals. These precipitants may lead to self-neglect
and the unintentional neglect of animals through self and animal care becoming
overwhelming to cope with alone. The descriptions of animal hoarders self-neglecting and
living in extreme squalor support the suggestion that animal hoarding could be a symptom of
squalor-related conditions, such as Diogenes Syndrome (Nathanson, 2009; Saldarriaga-
Cantillo & Rivas Nieto, 2015).
It was postulated that unintentional animal neglect may occur due to squalid
conditions, an overwhelming number of animals to care for, poor education and knowledge
about hygiene and animal care, as well as delusional beliefs and denial of the situation. These
findings lend support to the assertions that animal hoarders have poor insight into their
difficulties, may hold erroneous beliefs about their ability to care for animals and may deny
the problem (Frost et al., 2011; Patronek, 1999; Patronek, 2006; Patronek and Nathanson,
2009; Slyne et al., 2013; Vaca-Guzman & Arluke, 2005). The practical implications of this
44
potentially poor insight are that animal hoarders may not seek help and may even reject
assistance when it is offered.
Similarly to Patronek (1999), Calvo et al. (2014) and Joffe et al. (2014), the current
study reports that animal hoarding can have extremely harmful effects on the animals,
including death in some cases. In addition, this study describes some of the consequences of
animal hoarding on the owner and those living with them. Slyne et al. (2013) has similarly
reported on such consequences, stating that quality of life may be significantly reduced by
owning more than ten animals whilst object hoarding concurrently. These effects are clearly
significant; however, it was suggested by professionals in this study that animal hoarding
may be thought of by the general public as a “lifestyle choice”, which may mean that general
concern for people who are animal hoarding is low. These attitudes may inadvertently sustain
animal hoarding if they result in perceptions of animal hoarders as community rescue centres
where unwanted animals can be deposited. Such attitudes may be perpetuated by the media,
as evidenced by Arluke et al.’s (2002) study of press reports which concluded that the
significance of animal hoarding may be inadequately represented in the media. Future
research could investigate public attitudes toward animal hoarding in order to test whether
media reporting has had any effect.
The current study has built upon, and extended understandings of animal hoarding
outlined in previous conceptual work and the limited empirical research originating from
other parts of the world. The novel research findings of this study include the discussion of
current professional responses to animal hoarding in the UK and the many potential
improvements for future professional practice that were suggested. Overwhelmed ‘rescuing’
animal hoarding raised a dilemma from a professional perspective as it was described as both
a human and an animal issue, perhaps without being approached as such currently. Instead, it
45
was the animal professionals’ view that they bear the brunt of intervention, despite extremely
high recidivism rates and the human side of animal hoarding, which they may not necessarily
be trained to deal with. These human aspects include the reluctance of people who hoard
animals to engage with professionals, their potential denial of the problem, and the possibility
of other comorbid mental health problems. Animal welfare professionals working with
animal hoarding issues could be given training by other agencies on therapeutic engagement
skills and any other relevant mental health topics. Training on the Mental Capacity Act
(Department of Health, 2005), for example, would provide animal professionals with relevant
knowledge about the mental capacity of individuals in relation to making decisions about
animal care and welfare.
Better awareness, reporting and communication between animal agencies,
veterinarians, mental health services, social services, and those in the judicial system may
also be needed in all directions in order to increase professional understanding of both the
animal and human aspects of this issue. It was even suggested that animal hoarding
behaviours will continue, despite involvement from animal professionals, until the owners’
issues are resolved. These findings concur with Castrodale et al. (2010) who argued that
multiagency efforts are needed in response to animal hoarding. A more multi-disciplinary
approach to intervention might include mental health and social services being utilised in
order to engage people who are hoarding animals, safeguard people living in animal hoarding
situations, and address any social isolation or support network issues. The participant who
worked in mental health rather than animal welfare was able to add extra recommendations
such as the provision of psychological intervention aimed at increasing insight and changing
behaviour. Psychological interventions may be necessary for animal hoarders who have
become overwhelmed as Patronek (2006) suggested that they may experience more Axis I
psychological disorders than ‘exploitative’ (commercial) animal hoarders. Significant mental
46
health concerns have been noted in conjunction with animal hoarding both in the current
study, and by Steketee et al. (2011). Animal hoarding may therefore be associated with
serious suffering and psychological distress for the individuals in these circumstances.
Further investigation of this is required as a large variety of comorbidities were suggested by
the professionals in the current study. Future research should explore this further by noting
what conditions are most commonly presented alongside animal hoarding behaviours. The
use of psychological interventions for animal hoarding could also be researched within the
mental health field, taking the various possible comorbidities into account.
Future research on compulsive hoarding should demonstrate awareness that animals
could be a primary hoarding which results in the criteria for object hoarding being met.
Erroneous conclusions may be made if aspects of the behaviour being researched have not
been properly defined. Future research should also attempt not to pathologise all collecting
behaviour, for example, by labelling individuals as object hoarding because they own a lot of
animal-related paraphernalia such as litter trays, cages or animal food, which may be
necessary for the care of multiple animals. The results of this study also suggest that labelling
someone as animal hoarding because they are primarily object hoarding and also own
multiple animals, may be inappropriate if the animals are adequately cared for.
Limitations
The current study only represents professionals’ perspectives on animal hoarding.
Future research would benefit from verifying the findings of this study, and extending
understanding from the perspective of the animal hoarders themselves, and their families.
This is likely to require extreme sensitivity on the part of researchers, given that the current
findings suggest animal hoarders may be extremely resistant to professional involvement.
47
The majority of the professionals sampled in the current study worked in animal
welfare and this may have resulted in a paucity of information on the human and mental
health aspects of animal hoarding, and the current professional responses to these aspects of
animal hoarding. The sample was lacking in representation from mental health and social
service professionals because only one professional from a mental health background
answered the advertisements for participation. Although it is difficult to be certain because no
statistics are currently available, it is speculated that the sample may reflect the reality of a
comparatively small amount of mental health and social service professional involvement in
animal hoarding in the UK.
48
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MRP Empirical Paper Appendices
Appendix A: Advertisement Used to Recruit Participants
Characteristics and Perceptions of Multiple Animal Ownership
We are a group of researchers from the School of Psychology at the
University of Surrey. We are conducting a study about views of multiple animal ownership in which there is neglect of and suffering to animals. There is very little research on this topic internationally and none in the UK. To do this, we are recruiting a range of professionals who work in animal welfare, social services and psychology to take part in an interview in order that we may understand this issue in more detail.
If you are interested in finding out more about this study, and what
participation would involve, please contact ______________ With thanks for your consideration.
54
Appendix B: Evidence of Ethical Approval
55
56
Appendix C: Information Sheet
Participant Information Sheet –
Study TitleCharacteristics and Perceptions of Multiple Animal Ownership
Introduction
We would like to invite you to take part in a research study. Before you decide you need to understand why the research is being done and what it will involve for you. Please take the time to read the following information carefully. Talk to others about the study if you wish.
What is the purpose of the study?
We are conducting a study to understand more about situations in which people acquire multiple pets/animals and then get into difficulty looking after them. Sometimes the difficulties result in neglect of or suffering to animals and severely compromised living conditions for the animals, their owners and other family members. There is very little research on this topic internationally and none in the UK. To understand more about these situations, we are recruiting a range of professionals involved in animal welfare, social services and psychological services to take part in an interview.
Why have I been invited to take part in the study?
You are being invited to take part based on your experience of working professionally with people who have acquired multiple pet/animals and subsequently have experienced difficulty looking after them. You have received this information sheet because you have seen one of our advertisements about this study and have contacted us to know more about our study.
Do I have to take part?
No, participation is voluntary. Even if you agree to take part you can change your mind before or during the interview. We will give you the option of whether you permit us to use any information you have supplied up to that point. If you take part in the interview but subsequently change
57
your mind about your data being used, you can request it be withdrawn within one week of the interview by contacting the Principal Investigator or the Co-Investigator.
What will my involvement require?
We would ask you to take part in an interview. This would take place in a convenient location, such as at your place of work, the University, or over the telephone. The interview should take around 60 minutes, although it may be quicker than this. With your permission, the interview would be recorded. We are unable to pay participants to take part in this study or to reimburse any travel expenses.
What are the possible disadvantages or risks of taking part?
The interview will require you to think about your experience of dealing with cases of animal neglect or suffering. This may be upsetting.
What are the possible benefits of taking part?
There may be no direct benefit to you of taking part in this study. However, we will send a summary of the findings to participants and present our work at professional conferences. We anticipate that this information will be of benefit to professionals who work with people who have difficulties looking after multiple pet/animals.
What happens when the research study stops?
The study should be completed in September 2016. If you would like a summary of our findings, please contact the Principal Investigator.
What if there is a problem?
Any complaint or concern about any aspect of the way you have been dealt with during the course of the study will be addressed. Please contact _______, Principal Investigator on ___________. You may also contact the Head of School, _____________, on __________.
Will my taking part in the study be kept confidential?
Yes. All interview data is treated in confidence. All of the information you give will be anonymised so that those reading reports from the research will not know who has contributed to it. The interview will be recorded with your permission. The recording will be typed up and anonymised. A professional transcriber may be employed to type up the interview and they will sign a confidentiality agreement.
Anonymised interview transcripts will be stored securely in accordance with the Data Protection Act 1998 for a period of 10 years after which they
58
will be securely destroyed. Interview recordings will be securely destroyed at the end of the study.
Contact details of researchers
To register your interest in taking part, to ask any questions before or after taking part in the study, or to withdraw your data, please contact the Principal Investigator, _________, on ______________ or the Co-Investigator, ____________.
Who is organising and funding the research?
The research is being organised by the University of Surrey.
Who has reviewed the project?
The study has been reviewed and received a Favourable Ethical Opinion (FEO) from the University of Surrey Ethics Committee.
Thank you for taking the time to read this Information Sheet.
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Appendix D: Consent Form
Study Title: Characteristics and Perceptions of Multiple Animal Ownership
I have read and understand the Participant Information Sheet. I understand the nature, purpose and likely duration of the study. I have been given the opportunity to ask questions and have understood any information given as a result.
[ ]
I consent to the anonymised interview data I supply being used by the researchers for this and other studies. I understand that I will not be identifiable in any publications or presentations arising from this research.
[ ]
I understand that the personal data I supply is held and processed in the strictest confidence, and in accordance with the Data Protection Act (1998). I understand that my personal data (e.g. name, contact details) are only accessible to the Principal Investigator and the Co-Investigator.
[ ]
I understand that I am free to withdraw from the study during participation without needing to justify my decision. I understand that I can withdraw my data up to one week after the interview.
[ ]
I understand that the interview will be recorded and may be typed up by a professional transcriber. The transcriber will sign a confidentiality agreement.
[ ]
I confirm that I have read and understood the above and freely consent to participate. I have been given adequate time to consider my participation and agree to comply with the instructions and restrictions of the study.
[ ]
Participant Signature: Date:
Name of Participant:
Signature of Person Taking Consent: Date:
Name and Role of Person Taking Consent:
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Appendix E: Demographic Questionnaire
Demographic questions for Professionals
To begin, I’d like to get some basic information about you (such as your age, education and occupation). The reason that I’d like this information is so that I can describe the context of this research in the write up. The information that you give will never be used to identify you in any way because this research is entirely confidential. However, if you don’t want to answer some of these questions, please don’t feel that you have to.
Are you:
(Tick the appropriate answer)
Male __ Female __
How old are you?
[ ] years
How would you describe your ethnic origins?1
Choose one section from (a) to (e) and then tick the appropriate category to indicate your ethnic background.
White
English/Welsh/Scottish/Northern Irish/British __
Irish __
Gypsy or Irish Traveller __
Any other White background, please write in below
_________________________________________
Mixed/multiple ethnic groups
White and Black Caribbean __
White and Black African __
1 The format of this question is taken from the 2011 UK census.61
White and Asian __
Any other mixed background, please write in below
__________________________________________
(c) Asian or Asian British
Indian __
Pakistani __
Bangladeshi __
Chinese __
Any other Asian background, please write in below
_________________________________________
Black/African/Caribbean/Black British
African __
Caribbean __
Any other Black/African/Caribbean background, please write in below
_________________________________________
Other ethnic group
Arab __
Any other ethnic group, please write in below
_________________________________________
What is your highest educational qualification?
(Tick the appropriate answer)
None __
GCSE(s)/O-level(s)/CSE(s) __
A-level(s)/AS-level(s) __
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Diploma (HND, SRN, etc.) __
Degree __
Postgraduate degree/diploma __
What is your current occupation?
Animal welfare inspector __
Animal welfare officer __
Animal collection officer __
Veterinary professional in a companion animal practice __
Veterinary professional in an equine practice __
Veterinary professional in a production animal practice __
Veterinary professional in an exotic practice __
Veterinary professional in a mixed practice __
Other (please specify) __________________________________________
How many years have you held your current role/occupation?
[ ] years
We would like to profile the location of respondents. If you are happy to do so, please tell us, in the space below, which county you work in:
__________________________________________
End of questionnaire. Thank you.
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Appendix F: Interview Schedule
Topic guide for interview with professionals
Remind them that they are being audio recorded and that whilst they have given me a signed consent form they are also giving their verbal consent.
Demographic questions
Indicate that participant should not name any specific individuals they have worked with or any details that might convey a person’s identity.
Initially, I’d like to get an idea of your experience of working with people who have lots of animals/pets but find it difficult to look after them.
How many times have you encountered this?
Now, I’d like to get some idea of what some of these cases have been like for both the animals/pets and the owners and their family.
How many animals/pets were owned and what sorts of animals/pets were they?
How did the person get lots of animals? What were the living conditions like for the animals and their
owner(s)? Did any of these cases occur in cluttered homes/did it seem that
they have difficulties with acquiring and not discarding objects? Were the animals being neglected? How? What was the owner
doing/not doing that meant the animals were being neglected? Were the owner and/or their family members experiencing any
effects of having many animals/pets (e.g. home environment, job, money, health, social relationships, family relationships, leisure)?
Was anyone in the neighbourhood/local community affected? In your experience of these cases, did the owners tend to have any
particular characteristics (e.g. age, gender, relationship status, employment status)?
Did the owner have awareness of the difficulties they were having caring for lots of animals?
How did you get involved in these cases? What was your role? How do these cases tend to end up (for the animals/owners/family
members)? Has this work had any impact on you? Or on your colleagues?
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Have you received any support/resources after dealing with these cases? Prompt: support, supervision, resources?
Thinking more now about your own views from working with these sorts of cases rather than the specific cases themselves:
How do you think some people get into having lots of animals/pets that they cannot care for?
Why do you think some people end up acquiring lots of animals/pets?
Do you know of/have you experienced any cases where multiple pet owners have had their pets removed and then subsequently gained more animals and neglected them, repeating this pattern?
If so, why do you think this repeating pattern might happen? What do you think can or should be done to help people avoid
acquiring more animals/pets than they can’t care for?
How do you personally define animal hoarding and in what ways, if any, do you think animal hoarding is different from multiple pet ownership?
Is there anything else you think it is important to mention about this topic?
Thank you very much for taking part. We really appreciate your time.
Sources of Support:
Should this interview have caused you any discomfort or distress, or if you are concerned about animal welfare issues please consider gaining support from the following sources:
Your organizational/occupational support services (for professionals) Your General Practitioner (GP) The RSPCA - www.rspca.org.uk Sane - www.sane.org.uk Mind - www.mind.org.uk the Samaritans - www.samaritans.org
We are also interested in speaking to people who have experience of acquiring many pets but who have subsequently found it difficult to care for them all, and their family members. Would you be able to pass
our advert onto anyone who might be interested?
65
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Appendix G: Professional Transcriber Confidentiality Agreement (Anonymised)
Study Title: Characteristics and Perceptions of Multiple Animal Ownership
This research is being undertaken by Francesca Burniston (Trainee Clinical Psychologist). The purpose of the research is to explore the potential antecedents, characteristics and consequences of animal hoarding.
As a transcriber of this research, I understand that I will be hearing recordings of confidential interviews. The information on these recordings has been revealed by interviewees who agreed to participate in this research on the condition that their interviews would remain strictly confidential. I understand that I have a responsibility to honour this confidentiality agreement.
I agree not to share any information on these recordings, about any party, with anyone except the researcher of this project. Any violation of this and the terms detailed below would constitute a serious breach of ethical standards and I confirm that I will adhere to the agreement in full.
I ________ agree to:
Keep all the research information shared with me confidential by not discussing or sharing the content of the interviews in any form or format (e.g. audio files, CDs, transcripts) with anyone other than the researcher.
Keep all research information in any form or format (e.g. audio files, CDs, transcripts) secure while it is in my possession.
Return all research information in any form or format (e.g. audio files, CDs, transcripts) to the researcher when I have completed the transcription tasks.
After consulting with the researcher, erase or destroy all research information in any form or format regarding this research project that is not returnable to the researcher (e.g. CDs, information stored on my computer hard drive).
Transcriber:
__________________
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(print name)
(signature)
4th August 2015
(date)
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Appendix H: Coded Extracts from More than One Interview
Extract Exemplifying Definitions and Categories of Animal Hoarding (Interview B)
Initial Line-By-Line Coding
Interview Extract Further coding/subordinate themes
Definition of AH – unable to care for animals
Commercial, neglectful and collecting hoarding different categoriesCommonality between categories – AH definition
Commercial AH dog breeders, domestic AH more modest numbers of animals
Multi-species AH common, Multi-species households with single species hoarded
P: yes, again that definition that you sort of forced out of me at the start: what is a hoarder? And in my opinion the ability to care for the animals are normally exceeds their ability to care for it.
I: yeah. So it sounds like…
P: commercial hoarding and then sort of neglectful hoarding, collecting hoarding I think are different categories of hoarding, umm umm, and the common thing that runs through them all is that definition, they cannot care for the animals that they have. And that’s the difference between multi-pet household.
I: hmm, yeah. And have you seen a difference in terms of the number of animals according to whether they are sort of a household property or more of a commercial hoarding?
P: umm, urr, I think the differentiation is the species so yeah the biggest commercial dog breeder or puppy farmers and then the more sort of domestic sort of things that I dealt with tends to be more modest numbers so into the twenties and thirties, sixty, umm larger number of cats plus fifty cats, fifty dogs and then birds into the hundreds.
I: hmm, and you talked very briefly about multi-species hoarding, how common do you think that is?
P: umm, that is umm, you can have multi-species households and multi-species hoarding household and that is common but what is more common is multi-species household with single species hoarding so you’ll have a cat lady who’ll have just two dogs, you know, sixty cats, two birds, you know, and a pig or a goat or something.
I: yeah.
Definition of AH
Categories of AH Definition of AH
Commercial AH
Categories of AH
Single species hoarded
Single species hoarded
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Multi-species households with single species hoarded
P: they have, so single species hoarding is more common than multi-species hoarding but multi species household with single species hoarding is more common if I haven’t confused you.
Extract Exemplifying Commercial Animal Hoarding (Interview E)
Initial Line-By-Line Coding
Interview Extract Further coding/subordinate themes
Over 100 dogsOwner purporting to be a respectable breederPoor conditions
Breeding
Selling puppies to finance other dogs, money spent on dogs not ownersVicious cycle of breeding to sell
Commercial breeder – no gains
Commercial breeder – sell some puppiesReporting by
P: Yes, definitely. A very large case, umm, where somebody had German Shepherds and they had over a hundred of them. But I became involved, and they were always, always assuring us that they were trying to be a respectable breeder, although they had never applied for a license under the breeding of dogs act. And they certainly wouldn’t get one, because the conditions of the premises, umm, but for one or two people, as there were on the scene at the time, to control 118 large German Shepherds, it proved that they couldn’t, because one would escape and mate with another, and, you know, up to nine pups would be born. So another advert would go out to finance just the German Shepherds. And to be fair, looking at it from a financial point of view, I’m sure every single penny did go back into the dogs, by looking at the housing, and the clothing, and how that person live. Umm, so yes I’m sure that it was a vicious cycle that the more dogs they got, produced more money, but it would only pay for the dogs that there were. So, umm.
I: Yeah.
P: There was no real gain out of it.
I: Yeah. I was just going to say that. That’s sort of paradoxical isn’t it, because umm, it’s sort of saying that they’re breeding them as a business to make money, but it sounds like they weren’t rehoming many of them.
P: They, no, well, the difficulty was they put them all up for sale, and they’d advertise them all, and they would sell quite a few. Umm, and that’s how obviously we got to find out about it, because
Delusional beliefs
Acquiring – breeding
Commercial animal hoarding
Commercial animal hoarding
Commercial animal hoarding
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people who have bought puppies from AH
Commercial breeder – prosecuted for unlicensed breeding and animal welfare offences.
people then complained that they’d bought this puppy that’s not vaccinated, it smells, it’s not very well at all. And, the pedigree papers they were given were, umm, works of fiction shall we say as well. So investigations were carried out by various agencies, and, you know, the welfare was indeed found to be poor, and as well as being prosecuted for running an unlicensed breeding establishment on numerous occasions, they were also prosecuted for animal welfare, umm, convictions as well.
Commercial animal hoarding – animal welfare offence
Extract Exemplifying Unintentional Animal Neglect (Interview B)
Initial Line-By-Line Coding
Interview Extract Further coding/subordinate themes
Treatment of animals not bad but environment bad
Cruelty through neglect rather than abuse
I: can you tell me a little bit about the ways in which these animals were being treated?
P: umm so umm there was there was a, well umm, it varies, in general the treatment, the treatment towards the animals is actually not bad and this is an important distinction that I’ve observed, the treatment towards the animals is not bad. The environment these animals are in is very bad and there is a difference because I have to differentiate when I’m taking these people to court or trying to take these people to court. What is suffering and what is likely to cause suffering and so the legal question I have to ask myself and be asked of me in the court and I find that the animals can tend to be umm, umm, they don’t tend to be abused or injured or treated cruelly by the owners but they do tend to be what I call neglected so it’s more like a passive abuse so they have injuries on them that are through neglect or bad diet or poor diet or through not being taken to the vet or through fighting with other animals and they have injuries on them so they almost, it’s almost a passive thing. These aren’t people who are deliberately going out, in my experience, to be cruel to animals. The cruelty comes from a neglect.
I: yeah, yeah. And you named several ways in which they might have been neglected then but umm in general what’s the most common ways in
Unintentional animal neglect
Unintentional animal neglect
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Animals not fed enough
which they have been neglected?
P: okay, umm, losing weight and not being fed enough.
Animal neglect
Extract Exemplifying Self-Neglect and Owners’ Suffering (Interview I)
Initial Line-By-Line Coding
Interview Extract Further coding/subordinate themes
Low health risk from ammonia and disease
Not eating well, No access to shower,
Dishevelled and smelly
Self-neglect
Energy and money spent on animals, Self-neglect
P: Um, uh, ok, so, well, I’d um, there’s going to be, it, it’s a low risk, but it increases with um, animals kept in closed, transfer of disease from, from animal to humans, um, I haven’t come across it but I know ammonia levels can be very much increased in some properties which are really significant health risk, to anybody in the building uh, and some people seem to build a tolerance to that um, they often don’t eat well, they can’t access their uh, perhaps um, their amenities so they might not wash and shower as much, um, it’s all traffic so when people sort of you know take the mick out of the mad cat lady, that sort of dishevelled and slightly um, smelly presentation would be something that isn’t uncommon
I: Mmm
P: And often some of the people I’ve worked with, and especially horsey people, they put a lot of effort in trying to keep their animals going, and neglect themselves
I: Mmm
P: All, all their energy is taken in looking after their animals, and all their money, in as much as they’ve got, so they can end up, yeah, they’ve got too many animals, they’re not doing them quite right and they’re also neglecting themselves
I: Mmm, and I’m presuming that will have a knock-on effect on their social relationships, or
Self-neglect
Self-neglect
Self-neglect
Self-neglect
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Reduced social circles Reduced family support
their relationships within
P: Abso
I: Their family
P: Absolutely, yeah, yeah, absolutely, that, they, um, the friends that they might have they’ll have reduced socially, social circles um, family members may not be as supportive as they might be or they may be yeah, I, I have um, a, a mother-in-law who was a um, possession hoarder, and you know, I just know how difficult that is to do, to be, trying to support somebody who’s becoming old and infirm
Reduced social support
Extract Exemplifying Animals as Replacements for People (Interview H)
Initial Line-By-Line Coding
Interview Extract Further coding/subordinate themes
Repeating pattern – like to see new lifeAnimals as reason to liveElderly people need dependents
Animals as replacement for friends and family
Animals reason for living Need dependents
P: (Pause) I don’t know, I don’t know, everybody’s different aren’t they? It’s um (pause) I really don’t know, maybe they like to see new life, new kittens. Perhaps they you know, obviously they want a reason to get up in the mornings. Um, you know they want, you know, or I think a lot of elderly people definitely want or need something that’s dependent on them to give them a reason to, you know, like I say, to get up and live.
I: Um hm
P: If you take that away from someone, you know it’s, it’s been proven you know if there’s an elderly person that’s lost all its friends and family around them because everybody’s died around them and all they’ve got left is their pets and then their pet goes, they die very quickly afterwards.
I: Hm
P: Um, they’ve you know almost lost, um, reason, for, for living. Um, but yeah I think you know, um, the lady I’m thinking of in particular, I think she wants, she wants them to be dependent on her.
Repeating pattern
Animals as dependents
Animals as replacements for people
Animals reason for living Animals as dependents
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Owners enjoy animal dependency
I: Um
P: You know, she, she, she sets up all these little beds and things in her back garden. Puts the food out for them every single day – you know she likes them coming to her. You know the cats love her, she looks like the pied piper sometimes, she walks down the road and the cats are you know and all the cats are jumping up other people’s gardens and off they go following her, she kind of prides herself on it you know, um, so you know, they like that dependency
Animals as dependents
Extract Exemplifying Repetition or Maintenance of Animal Hoarding (Interview B)
Initial Line-By-Line Coding
Interview Extract Further coding/subordinate themes
Negotiating animal numbers with owner
100% recidivism
Cost of housing 100% recidivism
Recidivism high when negotiations have happenedOwners don’t understand, Bans – recidivismCourts not best but only option
P: and the owner goes “okay I’ll do that, I’ll do that” umm and they say “right, you know, you can’t have any more than ten animals” so you have this voluntary agreement if you (inaudible) we’re going to give you two back, pick your favourite two, we’ll euthanize a few and we’ll give a few away or put them down and you can have two and you can tell us you’ll be a good boy and, but recidivism is always one hundred percent. They never stick to that and I always tell the councils “don’t do that because in a month’s time they are going to have another three hundred animals” and they go “well we’ll deal with that when we have to but for now we can’t afford to to house twenty or thirty dogs for eighteen months”. Recidivism is always one hundred percent. It is always, sorry it’s very high. Very high.
I: even when umm the owners have been given a complete ban?
P: so, not with a complete ban, when this horse trading thing goes on. “Here’s two dogs, we’ll take twenty from you yeah, promise not to do it again”. They go “yeah yeah yeah, I promise” but again it goes back to the communication thing, they don’t know what’s going on. With regard to the ban, oh that’s a good one, yeah there is recidivism, it’s not as high but they can ignore the ban too, you’re right actually yeah, I tell these ones, they tend to ignore the ban. The courts aren’t the best place to
RecidivismNegotiations result in recidivism
Recidivism
Negotiations result in recidivism
Prosecutions result in recidivism
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currently deal with these things but the court seem to be the only place available currently to deal with these things and it’s a very blunt tool.
Extract Exemplifying a Human as well as an Animal Issue (Interview L)
Initial Line-By-Line Coding
Interview Extract Further coding/subordinate themes
Difficult to bring hoarding to others attention
Hoarding mentality
Psychology not their expertise
Need to consult GPGP may not understand
No psychology provision
GP needs more knowledge
Psychological
P: it’s really difficult coz they know there’s a clear link with hoarding, but I’ve found it difficult to bring it to the attention of people without being accused of stepping over my boundary of, of knowledge, so if you’ve got a solicitor and you’re trying to interview someone, and you’re trying to say ‘don’t you recognise that you’ve got a kind of hoarding mentality,’ the defence solicitor will immediately attack you for saying ‘who do you think you are, are you some sort of qualified psychologist, how dare you say this about my client’
I: Right
P: Um, you could say to somebody ‘I genuinely believe that you’ve got,’ coz they, they may often agree it, and you may well say ‘well can I suggest you go and speak to your GP,’ uh, I, I can remember one woman who I suggest she go and speak to her GP so she could go and get some advice from her GP, and she, she came back to me, when I saw her again and said ‘the GP didn’t know where to look, did you have any, any,’ she kind of knew she had a problem, but I couldn’t give her anything to say, here is a clinical study, here is a psychologist who’s looked into this
I: Mmm
P: He will be able to give your GP some advice
I: Mmm
P: And that would’ve been brilliant, because I think I could’ve broken that cycle, but I had nothing
I: Gosh
Animal professional overstepping role
Mental health issuePsychology not animal professionals’ expertise
Owners need to see GP
No psychology provision
Psychological
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support might break the cycle
Never worked with a psychologist or mental health worker
Animal professional overstepping role
Animal professional overstepping role by talking to owners
Need for animalsTypical animal hoarder
P: All I knew was my own common sense
I: Yes, yeah, so you haven’t ever worked with um, a psychologist or
P: No
I: What about any mental health workers?
P: No, well you can’t, as soon as you try it people get very defensive
I: Mmm
P: You can’t work, my job is enforcement, and I’ve either overstepped my role by doing that, and I should put myself back in my box, um, or you’re being rude and abusive and you’re, do you know what I mean?
I: Mmm
P: You can’t, and I talk to them, honestly I do, but you’re constantly waiting for that complaint to come it to say, who the hell do you think you are to, to make the assumption that person
I: Mmm
P: Um, uh (giggles) and let everyone kind of know it’s the elephant in the room
I: Yeah
P: But how do you, how do you approach it coz it’s a, a, it’s an issue that they have with just being surrounded by animals, and it’s almost a typical person, you can almost see, and I’m not saying it’s exclusive, but there’s almost typical person you can spot
support might break the cycle
Animal professional overstepping role
Animal professional overstepping role
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Appendix I: Coding Memos
‘Multiple animal household’ results in less suffering to the animals than ‘animal hoarding household’?
‘Multiple animal household’ more likely than ‘animal hoarding household’ to contain multiple species?
RSPCA not seeing distinction between ‘multiple animal ownership’ and ‘animal hoarding’?
Theme ‘appearing normal’ might indicate invisibility of difficulties/hidden difficulties leading to cases not being identified early?
Theme of RSPCA assistance with subthemes of e.g. neutering? Spectrum of severity of animal hoarding with risk factors such as fewer adults in a
household or mental health problem. Connections could be made between cleanliness and having visitors and then not
having any support and then things escalate because no support and lack of cleanliness becomes the norm. This is linked to code of loneliness, desire to be alone, and acquiring animals because of loneliness, not having visitors due to animals and unsure of how loneliness cycle starts.
Need to have a focus on relational and social aspects of AH? And link to need for SS and mental health services to pay attention to these issues.
Mental health and social services not always involved because of owners not asking for help?
The cases referred to in transcript B are quite severe. It might need to be considered that ‘more mental health issues than animal issues’ type themes might only relate to the more severe cases.
Three categories of multiple animal ownership in which there is suffering to the animals – profit-making, hoarding (not admitting problem, denial, filthy conditions), difficulty giving up animals/overwhelmed (admits problem, relieved when animals removed).
Denial, astonished to be found guilty, pleading not guilty – all linked. Part of denial of problem is not understanding needs of animals and making excuses
and telling RSPCA officers anything they want to hear to keep their animals. Link between AH and object hoarding might be due to difficulty discarding
rubbish/squalor rather than collecting. There may be some themes including the words ‘multiple animal ownership’ which in
interview C refers to multiple animal ownership with suffering to animals ie overwhelmed caregiver category.
This particular transcript (E) talks a lot about puppy farms, commercial breeders and that category of owners.
Suggestion of tightening up dog breeding laws would be helpful specifically for breeding category of animal hoarders.
Realization with hindsight might lead to a break in the repeating pattern such that people don’t get that bad again, whereas people who never come to realise the suffering of their animals will be prosecuted and repeat the pattern.
‘Happy to stay at home – don’t see how others live’ related to reclusive themes?
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Having money may mean things get more severe before seen by professionals e.g. example in transcript H of brother and sister who were hoarding objects and animals and had enough money to buy the house next door so that no one would complain.
People living together are worse cases and encourage each other. E.g. brother influencing sister example.
‘Reclusive’ theme could be merged with themes about not being able to get out of the house because of needing to look after animals.
Animal Hoarder not noticing medical problems until the animal is dying could be related to lack of awareness/denial of problems. Seeing the animals everyday reduces likelihood of noticing issues/lack of education/knowledge of taking care of animals. This might be how it starts?? Then denial is used as a defense against realizing this?
Mental health professionals could help at earlier stages with people who have mental health problems and some animals, supporting to get the animals neutered etc. – as evidenced by description of ‘Care planning needed for animals when owners become mentally unwell’.
‘Resisting professionals’ code could be a main theme including all issues of owners not allowing professionals in and being difficult to work with.
‘Tolerance from family and professionals’ = not enough concern from MH professionals about animals welfare?
Squalor and not cleaning up excrement, litter trays etc could be construed as object hoarding when it gets very severe.
Reclusive/private/ashamed due to theme of not wanting people to see into house/not engaging with help.
Seems to be a timeline of hoarding, over which things like number of animals and dirt in house snowballs. Help can be given early on but later on more pejorative action will be taken and prosecutions may be pursued.
First buying animals THEN breeding in some cases. ‘Difficulty recognizing problem’ theme could be both description of animal hoarders
and also suggestion for how to help/focus for interventions.
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Appendix J: Initial Thematic Map
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Ameliorating Factors
Current professional responses.
Increased multi-agency working and reporting needed.
Better education needed.
Improved mental health and social services interventions needed.
Characteristics
Mental health issues.
Unintentional animal neglect and animal suffering.
Squalid conditions. Overwhelmed/out
of control. Escalation over
time. Recidivism.
Sustaining Factors
Reclusiveness. Comfort gained from
animals. Delusional beliefs. Denial. Owner embarrassment
and worry. Reluctance to engage
with professionals.
Precipitants
Childhood experiences – distrust of humans.
Compensating for loss.
Overwhelmed ‘rescuing’ Animal
Hoarding
Commercial Animal Hoarding
Profit-making. Traits. Prosecutions.
Definition of Animal Hoarding
Figure 1. Initial thematicmap.
Appendix K: Final Thematic Map
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Figure 2. Final thematic map.
A Human as well as an Animal Issue
Current professional responses.
Increased multi-agency working and reporting needed.
Better education needed.
Improved mental health and social services interventions needed.
Repetition or Maintenance of Animal Hoarding
Recidivism. Reluctance to
engage with professionals.
Owner embarrassment and worry.
Self-Neglect and Owners’ Suffering
Self-neglect and negative consequences for the owners.
Mental health issues.
Animals as Replacements for People
Childhood experiences – distrust of humans.
Compensating for loss. Reclusiveness. Comfort gained from
animals.
Unintentional Animal Neglect
Unintentional animal neglect and animal suffering.
Squalid conditions. Overwhelmed/out of
control. Lack of
awareness/education. Escalation over time. Delusional beliefs. Denial.
Overwhelmed ‘rescuing’ Animal
Hoarding
Commercial Animal Hoarding
Profit-making. Traits. Prosecutions.
Definition of Animal Hoarding
Appendix L: Reflective Statement
Coming to this project I had no prior personal or professional experience of animal
hoarding. This may have supported an inductive thematic analysis that was data-driven as I
had few prior assumptions about what the data might look like before conducting the
interviews. However, a literature review was completed before data collection and the semi-
structured interview schedule was designed to capture certain aspects of professionals’
experiences of animal hoarding, which had been brought to my attention by the current
theoretical and empirical literature. In this sense, the analysis was driven by the data itself
and, in some ways, by particular analytic questions, as I cannot deny the influence that I may
have had on the data in this study. I will also have influenced the type of data collected in this
study by being the individual who conducted the interviews. I hope that my naivety on the
subject enabled participants to describe their own experiences of, and ideas about, animal
hoarding, with minimal influence from myself. I also deliberately chose to use phrases such
as ‘people who have lots of animals but find it difficult to look after them’
or ‘multiple animal ownership in which there is neglect of and suffering to
animals’, rather than using the term ‘animal hoarding’ when describing
the study, or within the initial stages of an interview. It is hoped that this
decision allowed participants the flexibility to describe the aspects of this
phenomenon that they felt were relevant or important. It also allowed me
to ask participants to give their personal definitions of animal hoarding
without constraining their answers too much, as no suggestion was made
that these initial interviewer phrases necessarily represented animal
hoarding, unless the participant indicated as such.
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I think that my clinical skills as a trainee clinical psychologist and therapist will
hopefully have helped put the participants at ease, as the style in which I tried to conduct the
interviews was curious, understanding and engaging, even when done over the telephone.
However, I did note that conducting interviews over the telephone was more difficult than
conducting interviews in person in terms of understanding or inferring what participants
might have been trying to convey. This might reflect a difference in the perceptibility of my
engagement skills and interviewing style when in person versus over the telephone. This was
something that I tried to bear in mind and I endeavoured to adapt my interviewing style in
subsequent telephone interviews after making this observation. I tried to be particularly
encouraging, and attempted to clarify answers more regularly, in future telephone interviews.
My role as a trainee clinical psychologist will also have influenced the themes that I
identified, and may have caused a focus on the data extracts which mentioned the human and
mental health aspects of animal hoarding. This will also have been affected by my beliefs
about diagnostic classifications and the social constructionist ideas about diagnostic
categories that are taught on the doctorate in clinical psychology. This may have influenced
the results away from answering classification questions and towards a broader understanding
of animal hoarding as a behaviour which could be indicative of psychological distress.
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MRP Proposal
A Grounded Theory Analysis of Animal Hoarding
Introduction
Background and Theoretical Rationale
Compulsive hoarding was defined by Frost and Gross (1993) as the excessive
accumulation of, and difficulty discarding, possessions. Frost and Hartl (1996)
conceptualised hoarding within a Cognitive-Behavioural Model as including: “(1)
information processing deficits; (2) problems in forming emotional attachments; (3)
behavioural avoidance; and (4) erroneous beliefs about the nature of possessions” (p. 341). In
the fourth edition of the Diagnostic and Statistical Manual (DSM-IV), compulsive hoarding
was categorised as a symptom of Obsessive-Compulsive Disorder (OCD). However, since
DSM-V, ‘Hoarding Disorder’ has been defined as a diagnostic category in its own right
(American Psychiatric Association, 2013) and evidence has supported this creation of a
distinct disorder (Mataix-Cols & Pertusa, 2012).
Patronek (1999) was the first to describe the pathological collecting of animals as a
variant of compulsive object hoarding, and an under-recognised public health problem.
Animal hoarding was defined as collecting a large number of animals without the ability to
provide acceptable care in terms of nutrition, sanitation and veterinary care. This neglect to
animals is what differentiates animal hoarding from multiple animal ownership. By
summarizing case reports from animal control agencies across the United States, Patronek
(1999) estimated that there were between seven-hundred and two-thousand cases of animal
hoarding annually. In eighty percent of cases, animals were found to be living in inadequate
conditions, which had caused some animals to perish. Hoarding animals clearly, therefore,
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has very different implications to hoarding inanimate objects. Animal hoarders were mostly
female, and almost half were over sixty years of age. Dogs, cats, farm animals and birds were
the most commonly hoarded animals and the median number of animals hoarded per case
was thirty-nine. Approximately half of the hoarders described in these case reports lived
alone with their pets; therefore, many were residing with others. The Hoarding Animal
Research Consortium (HARC; 2010) has estimated that dependent or vulnerable adults or
children live in around ten to fifteen percent of homes where animal hoarding is taking place.
The health consequences of animal hoarding, therefore, are significant for the animals, their
owners and the family of animal hoarders.
Two studies have attempted to compare and contrast object hoarding and animal
hoarding (Frost, Patronek, & Rosenfeld, 2011; Slyne, Tolin, Steketee, & Frost, 2013). Frost
et al. (2011) argue that animal hoarders would appear to meet the basic diagnostic criteria for
Hoarding Disorder because their homes are usually cluttered and dysfunctional. They appear
to have difficulty discarding (relinquishing animals) and have impulses to acquire animals
which result in significant impairment. Animal hoarding could therefore be considered a
subtype of Hoarding Disorder. However, animal hoarders may differ from object hoarders in
certain areas. Frost et al. (2011) suggest that although animal hoarding may not be as
prevalent as object hoarding, it is an extremely destructive behaviour with serious personal
and public health consequences, which may be more significant than those which accompany
the hoarding of objects.
Slyne et al. (2013) demonstrated the ways in which the consequences of animal
hoarding may be more significant than those associated with object hoarding by investigating
multiple animal ownership within the context of concurrent object hoarding. Their sample
consisted of self-identified individuals who hoarded objects and also owned animals, as well
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as family and friends of object hoarders who owned animals. Their results suggested that
hoarding objects and owning more than ten animals was associated with a decrease in quality
of life. Quality of life was affected via sacrifices in multiple areas of life such as finances,
employment, social life, and sanitation of the home. It was suggested that in order to obtain a
true assessment of the impact of animal hoarding on individuals and families, it is necessary
for studies to gain the perspectives of both the animal hoarders and their family (Slyne et al.,
2013).
Slyne et al. (2013) reported that erroneous beliefs may be apparent in the context of
animal hoarding behaviours. For example, object hoarders who were also housing over ten
animals were more likely than those housing less than ten animals to state that they were the
only ones who could care for their animals adequately, despite the squalid conditions in their
homes. Similarly, Patronek (1999) found that in fifty-eight percent of cases, animal hoarders
would not acknowledge that a problem existed, according to the investigating animal control
officer. Ego-syntonicity is a critical factor which distinguishes hoarding disorder from OCD.
Individuals who hoard may lack insight (Tolin, Fitch, Frost, & Steketee, 2010)—they do not
view hoarding as pathological and may fail to recognise the negative effects of their
behaviour, for example, the suffering of their animals. The suffering of animals in hoarding
cases might therefore be unintentional and go unrecognised by the owner, which might
explain why most cases of animal hoarding are brought to the attention of authorities by
neighbours who complain of unsanitary conditions (Patronek, 1999).
To-date only one peer-reviewed publication, written by Steketee, Gibson, Frost,
Alabiso and Arluke (2011), has gathered primary data directly from animal hoarders.
Steketee et al. (2011) interviewed sixteen animal hoarders and eleven multiple pet owners
who did not meet criteria for animal hoarding. Thematic content which was unique to animal
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hoarders included: “problems with early attachment, chaotic childhood environments,
significant mental health concerns, attribution of human characteristics to animals, and the
presence of more dysfunctional current relationships” (Steketee et al., 2011, p. 114).
However, atypical qualitative and quantitative methods were used to describe the differences
between animal hoarding and multiple pet ownership, and the consequences of animal
hoarding were not explored. Further investigation of these themes, and other aspects such as
the consequences of animal hoarding behaviour, will therefore greatly benefit our
understanding.
Three conceptual papers have suggested a wide variety of models to explain animal
hoarding, based solely on the authors’ clinical work (Frost et al., 2011; Nathanson, 2009;
Patronek & Nathanson, 2009). Patronek and Nathanson (2009) have proposed a
developmental trajectory in which a persistent struggle to form functional attachments with
others could result in animal hoarding behaviours. In childhood, it is suggested that animals
provide protection and comfort for those who have not been able to form positive attachments
with humans, whereas in adulthood the ownership of multiple animals can become a primary
component of an individual’s sense of self. A model of animal hoarding as a complicated
grief reaction is also proposed (Patronek & Nathanson, 2009). Other theoretical models of
animal hoarding which have been suggested based on the authors’ clinical work, but have not
been generated by primary research, include: a delusional model, a dementia model, an
addictions model, and an attachment model (Nathanson, 2009). It has also been suggested
that co-morbid animal and self-neglect could be common among this population because
individuals may become completely reliant on dysfunctional human-animal relationships
(Nathanson, 2009). However, many of these models overlap, and an overarching conceptual
framework of animal hoarding, based on primary data, is needed. No investigations currently
exist into the phenomenon of animal hoarding in the United Kingdom (UK) as each of the
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afore-mentioned publications originated from the United States. Research is needed in order
to explore the longitudinal factors which contribute to animal hoarding as well as the life
experiences which may have triggered the onset of animal hoarding. Patronek and Nathanson
(2009) suggest that this could be acquired through interviews with adult children or siblings
of animal hoarders. The current study will therefore attempt to acquire data from family
members of people who hoard animals, as well as animal hoarders themselves, in order to
better understand these critical life experiences.
To conclude, much remains unknown about animal hoarding and basic studies of
animal hoarding are still very much needed. Previous research has indicated that an
overarching conceptual framework of animal hoarding, based on primary data from the UK,
is required. This should aim to include further investigation of the possible connections
between object and animal hoarding as well as the potential antecedents, characteristics and
consequences of animal hoarding, as experienced from multiple perspectives (including the
family of animal hoarders).
Research Question
How is animal hoarding understood from the perspectives of professionals, animal
hoarders and their family members in terms of its potential antecedents, characteristics and
consequences?
Method
Design
A qualitative research design using grounded theory will be employed. Semi-
structured interviews will be conducted with purposively sampled participants including:
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veterinary professionals, RSPCA inspectors and officers, local authority environmental and
housing officers, multiple pet owners who have experienced difficulties owning animals, and
their family members. Document analysis will be conducted on RSPCA and clinical case
studies and court reports of animal hoarding prosecutions in order to further inform our
understanding of animal hoarding. Data collection and analysis will proceed in parallel as is
prescribed by the grounded theory approach and theoretical sampling—that which is guided
by the emerging conceptual framework—will follow on after purposive sampling.
Participants
Veterinary professionals, RSPCA inspectors and officers who expressed an
interest in participating in future research on animal hoarding will be approached via the
contact details they freely supplied when they took part in a previous survey study.
Other veterinary professionals and RSPCA inspectors and officers will be recruited via
email advertisement which will be sent through co-investigators in the School of
Veterinary Clinical Sciences at the University of Surrey and contacts at the RSPCA.
This includes the RSPCA’s Chief Veterinary Officer, who has provided feedback on the
current study design. Statistics from the RSPCA (2014) indicate that there are currently
three hundred and thirteen RSPCA inspectors, fifty eight animal welfare officers and
eighty three animal collection officers who could potentially all be contacted.
Local authority environmental health and housing officers will be recruited via
email advertisement, which will be distributed by relevant section managers at local
councils.
Multiple pet owners and their family members will be recruited through contacts
at the RSPCA. These RSPCA contacts—who are in touch with people who have had
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difficulties with owning multiple animals—will be given participant information sheets
to distribute to anyone whom they think would be appropriate. If potential participants
are interested in taking part they can then contact the researcher directly.
Law databases such as Westlaw UK, clinical psychology databases such as PsychInfo,
and websites such as HARC, RSPCA, and the British and Irish Legal Information Institute,
will be searched for any case studies and court reports which report on animal hoarding as it
is defined in this proposal. The following search terms will be used: hoard* AND animal*,
multiple AND pet*, multiple AND animal*, hoard* AND pet*.
There is no recommended sample size for use with grounded theory as the goal
in this analysis is to reach theoretical sufficiency (Dey, 1999) or data saturation (the
point at which no new or previously unidentified themes are emerging). Both theoretical
sufficiency and saturation are dependent on the amount and richness of the descriptive
data, rather than the number of participants. Guest, Bunce and Johnson (2006) found that
basic codes in qualitative research become present at around six interviews and
saturation can be reached by twelve interviews. However, saturation depends on the
diversity of knowledge within the sample and whether the objectives of the research are
narrow or broad. The sample recruited in the current study may be quite diverse and the
objectives are quite broad, therefore it may require a relatively large sample size. Fifteen
interviews, lasting up to sixty minutes each, are expected to be sufficient for the
development of an initial conceptual framework of animal hoarding, along with the
analysis of case studies and court reports.
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Interviews
Three separate semi-structured interview topic guides have been created, one for
participants who are professionals, one for participants who are multiple pet owners who
have experienced difficulties owning animals and one for their family members (see
Appendices A-C). These topic guides were designed to elicit information regarding the
potential antecedents, characteristics and consequences of animal hoarding. Information
sheets and consent forms have been created which are specific to the participant group being
interviewed so that they are appropriately accessible and sensitive to the participants
undertaking the study.
Interviews will be held in person where possible but telephone interviews will
also be offered so that participation is not limited by geographical location. Interviews
will be recorded and transcribed shortly after they have been individually conducted.
Ethical Considerations
A joint application to the University of Surrey Ethics Committee will be
submitted between co-investigators at the School of Psychology and the School of
Veterinary Medicine (myself, Dr Laura Simonds, Professor Mark Cropley, Professor
Gail Anderson and Dr Alasdair Cook) shortly after this proposal has been marked and
approved.
Informed consent will be gained from all respondents via participant information
sheets and consent form. These will be given out prior to conducting the interviews and
will include: a description and rationale for the study; consent for audio recording,
transcription, analysis and write-up of the data; information on the secure and
anonymous storage of data; details about when the data will be destroyed (see
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Appendices D-F). Participants will be informed that they can withdraw at any time
during the interview and that in this event, they will be able to choose whether or not the
data they have already supplied can be used by the researchers. All participants will be
able to request withdrawal of their data within one week of taking part in the interview.
Ethical considerations have been made including the risk that the participants
may experience some discomfort or distress when asked to recall animal neglect and
suffering. This will be mitigated by the information sheets and consent forms.
Information will also be supplied at the end of the interviews, which will signpost
participants to where they might find support if any issues raised in the interview cause
them distress. However, most participants will be professionals who are accustomed to
working with animal neglect and who have their own professional support networks.
Some risk to the researcher may be involved in travelling to unknown locations
in order to conduct interviews. University guidance will be followed in relation to field-
work and researchers will use their professional judgment about whether or not field-
work will be undertaken. Interviews will be arranged at convenient neutral locations, at
the University of Surrey, or over the telephone if any risk to the researcher were
anticipated, for example, being exposed to an environment where animals are currently
being hoarded. Listening to potentially emotive or distressing accounts of animal
suffering is an additional risk to the researcher. However, the researcher conducting the
interviews will be a trainee clinical psychologist who is trained in interviewing and
accustomed to hearing emotive accounts from others. The trainee will also receive
appropriate supervision for these interviews.
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R&D Considerations
Not applicable as no NHS Trust employees or service users are expected to be
involved in this project.
Project Costing
The cost of researcher travel to interviews will be covered under PsychD Clinical
Psychology programme trainee expenses. Consumables such as printing of information
sheets and consent forms, as well as digital recorders, will carry no cost as they will be
supplied by Mark Cole in the department of psychology, or met by the researcher.
£200 will be spent on a professional transcription service in order to transcribe
some of the interviews. The remaining interviews will be transcribed by the researcher.
Participants will not be reimbursed for their time or incentivised to take part.
Proposed Data Analysis
Grounded theory will be used to analyse initial data in parallel with further data
collection through theoretical sampling. Inductive line-by-line open coding will be
conducted on each transcript or document, before focused coding produces higher order
analytical categories (Willig, 2008). Connections will then be made between categories
and categories will be elaborated using an axial coding paradigm (Corbin & Strauss,
2008). Through this process of analysis, an overall conceptual framework describing the
phenomenon of animal hoarding will be developed and refined. The use of full grounded
theory is the first choice of analysis but abbreviated grounded theory could be used if
there are time or resource constraints (Willig, 2008).
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Involving/Consulting Interested Parties
The RSPCA’s Chief Veterinary Officer has been consulted on participant
information and consent, as well as email advertisements, recruitment and interview
topic guides in order to involve interested parties (the majority of participants will be
professionals). It will be difficult to consult animal hoarders on the design of questions
as they will be recruited through the RSPCA, however, consultation with the RSPCA
has provided a non-researcher perspective on the questions.
Co-investigators on this study include: Dr Laura Simonds (Psychology Lecturer,
University of Surrey), Professor Mark Cropley (Professor of Health Psychology,
University of Surrey), Professor Gail Anderson (Head of Veterinary Education and
Veterinary Clinical Sciences, University of Surrey), and Dr Alasdair Cook (Research
Fellow in Veterinary Epidemiology and Head of Department of Veterinary
Epidemiology and Public Health, University of Surrey). Collaboration has therefore
already been established between the School of Veterinary Medicine and the School of
Psychology.
Contingency Plan
If the initial design should encounter any problems, it is anticipated that this
would be in the successful recruitment of participants who hoard animals, and their
family members. If this problem occurs the contingency plan would be to recruit people
who have worked clinically with animal hoarders including experts in the field. Even if
animal hoarders could not be recruited, a sufficient model, which would add to the
current literature base, could be derived from the professionals’ data.
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Dissemination Strategy
A summary report will be fed-back to animal welfare organisations, professional
bodies and charities (e.g. the British Veterinary Association, RSPCA, PDSA, Blue Cross
for Pets, International Fund for Animal Welfare, Dogs Trust, Cats Protection, and
Companion Animal Welfare Council).
A manuscript will also be submitted to a high-impact peer-reviewed journal (e.g.
Journal of Abnormal Psychology, Journal of Psychiatric Research, The Veterinary
Journal, or British Journal of Clinical Psychology).
The resulting conceptual framework will be presented at national meetings and
conferences (e.g. the Animal Welfare Foundation Annual Discussion Forum, British
Psychological Society Division of Clinical Psychology Annual Conference, and the
UFAW Animal Welfare Conference).
Articles will also be written for non-specialist publications and websites in order
to communicate findings to the general public (e.g. Dogs Monthly, Your Cat Magazine,
and Psychologies).
94
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Arluke, A., Frost, R., Steketee, G., Patronek, G., Luke, C., Messner, E., Nathanson, J., &
Papazian, M. (2002). Press reports of animals hoarding. Society and Animals,
10, 113-135.
Corbin, J., & Strauss, A. (Eds.). (2008). Basics of qualitative research: Techniques and
procedures for developing grounded theory. London: Sage.
Dey, I. (1999). Grounding grounded theory: Guidelines for qualitative inquiry. San
Diego: Academic Press.
Frost, R. O., & Gross, R. C. (1993). The hoarding of possessions. Behaviour Research
and Therapy, 31, 367 381.
Frost, R. O., & Hartl, T. L. (1996). A cognitive-behavioral model of compulsive
hoarding. Behaviour Research and Therapy, 34(4), 341-350. doi:10.1016/0005-
7967(95)00071-2
Frost, R.O., Patronek, G., & Rosenfeld, E. (2011). Comparison of object and animal
hoarding. Depression and Anxiety, 28, 885-891.
Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An
experiment with data saturation and variability. Field methods, 18(1), 59-82.
Hoarding Animals Research Consortium (HARC). (2010). Animal hoarding and public
95
health. Retrieved from http://vet.tufts.edu/hoarding/pubhlth.htm#A4
Mataix‐Cols, D., & Pertusa, A. (2012). Annual research review: Hoarding disorder:
Potential benefits and pitfalls of a new mental disorder. Journal of Child
Psychology and Psychiatry, 53(5), 608-618.
Nathanson, J. (2009). Animal hoarding: Slipping into the darkness of comorbid animal
and self-neglect. Journal of Elder Abuse and Neglect, 21, 307-324.
Patronek, G. (1999). Hoarding of animals: An under-recognized public health problem in
a difficult-to-study population. Public Health Reports, 114, 81-87.
Patronek, G., & Nathanson, J.N. (2009). A theoretical perspective to inform assessment
and treatment strategies for animal hoarders. Clinical Psychology Review, 29,
274-281.
RSPCA (2014). Facts and figures. Retrieved from http://media.rspca.org.uk/media/facts
Slyne, K.E., Tolin, D.F., Steketee, G., & Frost, R.O. (2013). Characteristics of animal
owners among individuals with object hoarding. Journal of Obsessive-
Compulsive and Related Disorders, 2, 466-471.
Steketee, G., Gibson, A., Frost, R.O, Alabiso, J., Arluke, A., & Patronek, G. (2011).
Characteristics and antecedents of people who hoard animals: an exploratory
comparative interview study. Review of General Psychology, 15, 114-124.
Tolin, D. F., Fitch, K. E., Frost, R. O., & Steketee, G. (2010). Family informants’
perceptions of insight in compulsive hoarding. Cognitive Therapy and
Research, 34(1), 69-81. doi:10.1007/s10608-008-9217-7
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Willig, C. (2008). Introducing qualitative research in psychology. Maidenhead: Open
University Press McGraw-Hill.
97
MRP Literature Review (with appendices if appropriate)
The Impact of Compulsive Hoarding on Families and Carers: A Systematic Review
Abstract
Objectives
Compulsive hoarding is the excessive accumulation of, and difficulty discarding,
possessions. Hoarding behaviours pose unique environmental challenges which may threaten
the health of people living with a person who hoards. This review aims to critically appraise
the current conceptual and empirical literature on the phenomenology of hoarding as it
pertains to family members and carers of hoarders.
Methods
The databases Pubmed, The Cochrane Collaboration, ISI Web of Science (accessed
through Web of Knowledge), PsychInfo, PsychArticles and Medline were searched using the
following search terms: hoard*, hoard* AND care*, hoard* AND relati*, hoard* AND chil*,
hoard* AND famil*, hoard* AND "loved one" or hoard* AND (loved one), hoard* AND
insight, hoard* AND accommodation, hoard* AND severity, hoard* AND impact and hoard*
AND burden. Seventeen studies matching inclusion criteria were evaluated and synthesised.
Results
Family members of compulsive hoarders experience a substantial amount of burden
and this may negatively impact relationships between hoarders and their families. Support for
families is needed, along with psychoeducation to enable greater understanding of
compulsive hoarding.
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Conclusions
Recommendations for future research included further investigation of the
experiences of family members of people who hoard generally, with particular interest being
made to the development and evaluation of psychological interventions for these relatives. It
will also be important for future research to investigate families and carers of people who
exhibit hoarding behaviours in the absence of Obsessive-Compulsive Disorder and to
determine whether associations exist between carer distress, carer burden and the lack of
insight demonstrated by hoarders in the studies reviewed here.
Practitioner Points
There is a lack of relevant theory and research on families and carers of people who
compulsively hoard.
The experiences of family members of people who hoard must be investigated further
and particular interest must be made to the development and evaluation of
psychological interventions for the relatives and carers of people who hoard (which
should include support and psychoeducation), or which include them in the provision
of psychological interventions for people who hoard.
This review included an assortment of papers of variable quality. Common limitations
of the studies presented here include self-selected purposive sampling and the use of
ungeneralisable samples.
Statement of Journal Choice
The British Journal of Clinical Psychology was chosen as a potential publication for
this review. The journal accepts review papers which make contributions in clinical
psychology on a range of psychological problems. The discipline of the contributors and
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audience is therefore also clinical psychology, which is appropriate for this review. The
impact factor of the British Journal of Clinical Psychology is 2.333, which is higher than
some other journals considered for the publication of this review. One of the central articles
cited in this review, Wilbram, Kellett and Beail (2008), was published in this journal,
indicating that papers on similar topics would be considered for publication in the British
Journal of Clinical Psychology.
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Introduction
Compulsive hoarding can be defined as the excessive accumulation of, and difficulty
discarding, possessions, resulting in substantial distress and clutter which impairs or prevents
the intended use or function of living spaces (Frost & Gross, 1993; Frost & Hartl, 1996). It is
generally a chronic condition which is significantly affected by life stressors and traumatic
events (Tolin, Meunier, Frost, & Steketee, 2010b). Compulsive hoarding behaviours have
been conceptualised within a Cognitive-Behavioural Model by Frost and Hartl (1996), and
are described as complex phenomena related to: “(1) information processing deficits; (2)
problems in forming emotional attachments; (3) behavioural avoidance; and (4) erroneous
beliefs about the nature of possessions” (p. 341).
Before DSM-V, hoarding behaviours were viewed as a symptom of Obsessive-
Compulsive Disorder (OCD); however, ‘hoarding disorder’ is now a diagnostic category in
its own right (American Psychiatric Association, 2013). A review of the literature by Mataix-
Cols and Pertusa (2012), suggested that the benefits of creating a diagnostic category for
hoarding disorder which is independent of OCD, outweighed the probable risks. The potential
to help those who would previously have gone unnoticed by services (due to displaying
hoarding behaviours without any OCD symptoms) offset the potential for pathologising
collecting and saving behaviours in some individuals which do not cause significant distress.
The recent creation of an independent diagnostic category may explain the dearth of research
on hoarding in the absence of OCD.
The prevalence rates of hoarding problems has differed across studies. Samuels et al.
(2008) found that the prevalence of hoarding was 5.3% in an American sample. In contrast,
Mueller, Mitchell, Crosby, Glaesmer and de Zwaan (2009) found that, in Germany,
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compulsive hoarding was reported as prevalent in 4.6% of the sample. A United Kingdom
(UK) sample of twins showed that compulsive hoarding behaviours were both prevalent and
heritable with 2.3% of twins found to meet criteria for hoarding (Iervolino et al., 2009).
Nordsletten et al. (2013), on the other hand, have estimated that hoarding disorder itself has a
prevalence of 1.5% in the UK. The variability in UK prevalence estimates may have resulted
from the different procedures employed by Iervolino et al. (2009) and Nordsletten et al.
(2013), and the fact that one was an estimate of hoarding behaviours whereas the other was
an estimate of hoarding disorder. Nordsletten et al. (2013) also reported that many people
with hoarding disorder may have a physical health problem or a co-morbid mental health
problem. People with hoarding disorder are therefore likely to experience considerable
adversity in their daily lives which, along with the paucity of research specific to hoarding
disorder, suggests it is very important that more research be undertaken to aid our
understanding of hoarding disorder.
The economic and social burdens of hoarding provide yet more reasons why hoarding
must be better understood. Tolin, Frost, Steketee, Gray and Fitch (2008b) found that self-
identified hoarders reported a greater amount of mental health service utilisation and a greater
number of work impairment days than those with other mood, anxiety and substance misuse
problems. Many hoarders also reported having been evicted or threatened with eviction due
to their problems with hoarding. Hoarding is a serious community health problem which can
incur significant costs to communities and pose serious health risks for both the individual
and those around them (Frost, Steketee, & Williams, 2000a). Despite the findings that people
with compulsive hoarding can pose both a burden and a risk to those around them, research
has focused mostly on the treatment of hoarding with little specific consideration of its social
consequences.
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Several studies have reported on the relative stability of hoarding symptoms over time
(Besiroglu et al., 2007; Mataix-Cols, Marks, Greist, Kobak, & Baer, 2002; Rufer, Grothusen,
Mass, Peter & Hand, 2005). This stability suggests that hoarding may be difficult to treat.
Mataix-Cols et al. (2002) found that behaviour therapy was unsuccessful in treating hoarding
symptoms in participants with OCD. Hoarding symptoms of OCD were also found to have
remained unchanged over a period of two to four years and after six years (Besiroglu et al.,
2007; Rufer et al., 2005). Whilst Selective Serotonin Reuptake Inhibitors may be effective
overall in the treatment of OCD, hoarding symptoms seem to respond poorly to them
(Mataix-Cols, Rauch, Manzo, Jenike, & Baer, 1999). Frost (2010) reviewed various studies
on the effectiveness of medication as treatment for hoarding behaviours and concluded that
whilst the majority of studies indicate that medication is not a successful treatment for
hoarding, there were problems with the methodologies of these studies and therefore the
conclusions which can be drawn from them are limited. These findings indicate that more
research needs to be done to investigate what works in the reduction of hoarding behaviours.
With specific importance to this review, the findings suggest that those caring for, or living
with, people who hoard, are doing so over long periods of time, with the possibility that
treatment will be unsuccessful. In spite of this, few studies investigating psychological
interventions for hoarding have included family members or carers of people who hoard.
Carers and family members of hoarders face unique environmental challenges (Frost
et al., 2000a) and much more research is needed to understand the effects of these unique
challenges. A small-scale review of four qualitative papers by Büscher, Dyson and Cowdell
(2013) assessed evidence of the effects of hoarding disorder on families. Thematic analysis
was used in order to synthesise the data and three themes emerged: ‘quality of life’, ‘shattered
families’ and ‘rallying around’. The theme ‘quality of life’ included issues of well-being
among family members of people with compulsive hoarding. ‘Shattered families’ referred to
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the conflicts which impacted family relationships and the feelings of loss experienced by the
families of people who hoard. The theme ‘rallying around’ included both positive and
negative responses that the families experienced. Families felt a duty to help but also reported
colluding with the person who hoards as a potential response strategy. Evidence of the
families maintaining hope was the main positive element identified by Buscher et al. (2013).
The current review takes a wider scope in order to incorporate more potentially relevant
evidence than that reviewed by Buscher et al. (2013). Due to the scarcity of research in this
area, a review is needed which will include all papers that have investigated the effects of
hoarding behaviours on families. It is hoped that this strategy will provide more relevant data
than that reviewed by Buscher et al. (2013) and will therefore be better able to make
comprehensive suggestions for future research.
Many compulsive hoarders have very little social support due to the nature of their
problems. For example, some hoarders become socially isolated due the embarrassment they
may experience when inviting others to their house (Saxena & Maidment, 2004). Greater
difficulty in social and family life has also been reported among OCD patients with
compulsive hoarding compared to non-hoarding OCD patients (Frost, Steketee, Williams, &
Warren, 2000b). Research into the effects of hoarding on the families of those who
compulsively hoard is needed because social support is known to have an effect on mental
health and good social support may act as a protective factor against psychopathology.
Students with lower social support for example, were found to be more likely to experience
mental health problems (Hefner & Eisenberg, 2009). A study by Steketee (1993) found that
empathy from significant others, and positive interactions with them, were associated with
maintaining positive gains following behavioural treatment for OCD. Criticism and anger
from significant others, and a belief by them that clients could control their OCD symptoms,
were associated with relapse at 6-14 month follow-up. These results support the argument
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that families of those with problems such as hoarding, must be included in the treatment
process and may even require therapeutic support of their own. They also suggest that
families may require psychoeducation in order to better understand the symptoms of mental
health problems.
Aims of Review
Despite research stating that hoarding behaviours can pose a serious threat to the
health of communities, in particular, people living with or near the person who hoards (Frost
et al., 2000a), treatment research has focused almost exclusively on the individual with
hoarding disorder and very little research has reported on family interventions. The impact of
hoarding on people living with or near a person who compulsively hoards has also been
largely neglected in the current literature, despite compulsive hoarders reporting problematic
family lives compared to non-hoarders (Frost et al., 2000b). Therefore, there is a strong
rationale for a review of the current compulsive hoarding literature as it pertains to carers or
family members of hoarders. The aim of this review was to evaluate and synthesise existing
literature on the impact of hoarding on family members or carers in order to make
recommendations for future research.
Methods
Search Strategy
A systematic search of the databases Pubmed, The Cochrane Collaboration, ISI Web
of Science (accessed through Web of Knowledge), PsychInfo, PsychArticles and Medline,
was conducted with no limiting parameters other than that the search term be in the title of
the article. Additionally, hand searches through the references of key articles allowed for
further confidence in the inclusion of all relevant literature. The search terms used were as
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follows: hoard*, hoard* AND care*, hoard* AND relati*, hoard* AND chil*, hoard* AND
famil*, hoard* AND "loved one" or hoard* AND (loved one), hoard* AND insight, hoard*
AND accommodation, hoard* AND severity, hoard* AND impact and hoard* AND burden.
Figure 1 shows the number of articles included and excluded at each point in the
search process. A total of 146 papers were found through this method of searching. Any
duplicate articles were first removed using RefWorks Software (ProQuest, 2014), leaving a
total of 74 articles which were fully screened for eligibility. Hand searching revealed an
additional 5 papers which were also screened.
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Potentially eligible records identified through database searches (N= 146):
Pubmed N = 7 (title only),
The Cochrane Collaboration N = 16 (title only),
ISI Web of Science (accessed through Web of Knowledge) N = 58 (title
only),
Psychinfo N = 35 (title only),
PsychArticles N = 2 (title only),
Medline N = 28 (title only)
Potentially eligible records (N = 74)
Exclusion of duplicate records and any non-peer
reviewed empirical studies (N = 72)
Exclusion of articles after screening (N =
62):
1. No mention of hoarding behaviours/not human hoarding (N = 26)2. No mention of family/carers of hoarders (N = 32)3. Outcomes or implications not about impact or
Full text articles assessed for eligibility
(N = 79)
Additional potentially relevant
articles found through hand
searching (N = 5)
Nordsletten et al. (2014)
Kellett et al. (2010)
Frost et al. (2011)
Drury et al. (2014)
Frost et al. (2000b)
72 articles were excluded due to meeting one of the three exclusion criteria. Articles were
excluded if they contained no explicit mention of hoarding behaviours or if the hoarding
behaviour mentioned was not human hoarding. Articles were also excluded if they contained
no mention of family members or carers. Additionally, articles were required to have
outcomes or implications which could be related to the impact on, or management of,
hoarding by family members or carers.
Data Extraction and Evaluative Method
Data from all seventeen papers in the final sample were initially extracted and
tabulated. Critical Appraisal Skills Programme (CASP) checklists and the ‘standard quality
assessment criteria for evaluating primary research papers from a variety of fields’ were used
as a basis from which to evaluate the final seventeen articles (CASP UK, 2013; Kmet, Lee, &
Cook, 2004). Data from each paper was synthesised and relationships between papers were
analysed.
Results
Table 1 shows a summary of all seventeen papers included in this
review.
Qualitative Findings
The themes found by all qualitative papers included in this review
can be seen in Table 2. These individual themes were synthesised into the
following overarching themes.
107
Exclusion of articles after screening (N =
62):
1. No mention of hoarding behaviours/not human hoarding (N = 26)2. No mention of family/carers of hoarders (N = 32)3. Outcomes or implications not about impact or
Additional potentially relevant
articles found through hand
searching (N = 5)
Nordsletten et al. (2014)
Kellett et al. (2010)
Frost et al. (2011)
Drury et al. (2014)
Frost et al. (2000b)
Loss. Wilbram, Kellett and Beail (2008) described the way in which family
members often began their interviews by detailing not only the level of
clutter in the
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109
Table 1
Summary of included papers
Reference Quantitative or qualitative Location Design Sample
size Participants
Drury et al. (2014)
Quantitative London, UK Survey 68 Individuals meeting DSM-5 criteria for HD (37), relatives of individuals meeting criteria for HD (55), and comparison groups of self-identified collectors (51) and relatives of collectors (25)
Frost et al. (2000b)
Quantitative Massachusetts, USA
Survey 04 OCD hoarders (37), OCD non-hoarders (20), other anxiety disorder subjects (13) and community controls (34)
Frost et al. (2011) Quantitative Massachusetts, USA
Survey 1302 Adults who self-identified as having significant hoarding problems (887), adult children of such individuals (295), and spouses of such individuals (120)
Gomes et al. (2014)
Quantitative Brazil Survey 228 Patients with OCD (114) and family members (114)
Kellett et al. (2010)
Qualitative Sheffield, UK Interviews 11 People who compulsively hoard.
Nordsletten et al. (2014)
Quantitative London, UK Survey 134 Relatives of someone with problematic hoarding (102) and relatives of someone with normative collecting behaviour (32)
Plimpton et al. (2009)
Qualitative Massachusetts, USA
Interviews 6 Parents of children who showed signs of compulsive hoarding
Sampson (2013) Qualitative Minnesota, USA
Interviews 12 Family members of persons who hoard
Sampson et al. (2012)
Qualitative Minnesota, USA
Interviews 8 Adult family members of people who hoard
Storch et al. (2007)
Quantitative Florida, USA Survey 80 Children or adolescents with OCD (80) and their parents
Storch et al. (2011)
Quantitative Florida and Massachusetts, USA
Survey 123 Children and adolescents diagnosed with primary OCD (123) and their parents
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111
Tolin et al. (2008a)
Quantitative Connecticut, USA
Internet Survey
665 Family informants
Tolin et al. (2008b)
Quantitative Connecticut, USA
Internet Survey
1519 Self-identified hoarding participants (864) and family informants (655)
Tolin et al. (2010a)
Quantitative Connecticut, USA
Internet Survey
584 Family and friends of individuals with reported hoarding problems
Tolin et al. (2010b)
Quantitative Connecticut, USA
Internet Survey
751 Adults with self-reported hoarding symptoms
Tompkins (2011) Qualitative San Francisco, USA
2 Case Studies
2 People who compulsively hoard
Wilbram et al. (2008)
Qualitative South Yorkshire, UK
Interviews 10 ‘Key carers’ for a hoarding family member
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Table 2
Main findings of qualitative papers
Reference Methodology Theme 1 Theme 2 Theme 3 Theme 4 Theme 5
Kellett et al. (2010)
Interpretive Phenomenological Analysis
Childhood factors
The participants' relationship to their hoarded items
Cognitive and behavioural avoidance of discard
The impact of hoarding on self, others and home environment
Plimpton et al. (2009)
Not specified Wide range of hoarding behaviours (difficulties discarding and maintaining control over possessions)
Onset and course (some episodic and stress-related)
Comorbidity (ADHD, OCD, problems with perfectionism)
Attachment and personification of objects
No insight
Sampson et al. (2012)
Content analysis Psychoeducation
Support Appropriateness of the Ambiguous Loss Framework
Interruption of Family Relationships
Loss of Childhood Home
Sampson (2013)
Interpretive Phenomenological Analysis
Negative feelings toward the persons who hoard
Lack of understanding of hoarding behaviour
Experiences of loss
Internal barriers to seeking support
Internal conflicts
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Tompkins (2011)
2 Case Illustrations
Harm Reduction Approach helpful because many people who hoard refuse help
Harm Reduction Approach helpful because hoarding is too big a problem for any one person to manage
Families as the clients along with the hoarders
Wilbram et al. (2008)
Interpretive Phenomenological Analysis
Loss of normal family life
The need for understanding
Coping with the situation
Impact on relationships
Marginalisation
house but also the chronicity of the hoarding and made comparisons
between the past and the present environmental situation. These
descriptions included their sense of a loss of ‘normal’ family life and a
departure from the family values that they desired. Eating together at a
table, inviting friends to visit or decorating the house for Christmas had
become impossible for these families. Similarly, in a study by Sampson
(2013), family members of people who hoard expressed their own feelings
of grief and loss due to the hoarding behaviours of their relatives. Family
members described the loss of family rituals such as traditions, the loss of
future opportunities such as relationships between their children and the
hoarding family member and the loss of the ‘home’ as the safe
environment that it once was. The loss of the childhood home was
particularly difficult for those who had a parent with problematic hoarding
behaviours (Sampson, 2013). The loss of a childhood home was also
expressed by participants in a study by Sampson, Yeats and Harris (2012) which
evaluated a psychoeducational support group for family members of
people who hoard, based in an ‘ambiguous loss’ framework. Ambiguous
loss was defined as psychological or physical loss which, unlike more
typical loss or grief, is not recognised by the sufferer as legitimate. When
evaluating this group, the participants stated that the ambiguous loss
framework enabled them to acknowledge all the losses they had
experienced due to the hoarding behaviours of their loved ones. These
losses included loss of normal family experiences which were similar to
those described by Wilbram et al. (2008) and Sampson (2013) but also
included a role reversal between parents with compulsive hoarding and
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their adult children who described feeling a lot of responsibility for the
safety of their parents.
Impact on relationships. Kellett, Greenhalgh, Beail and Ridgway (2010) found
that compulsive hoarders repeatedly spoke about the negative impact
that hoarding had on their family, friends and neighbours, recognising the
impact that hoarding has on their relationships and describing the guilt
they felt in relation to this. Sampson et al. (2012) found that family
members of people who hoard also believed compulsive hoarding had
interrupted family relationships. Participants wished to maintain a
relationship with their family member who hoards but felt a lot of
confusion and discomfort at the prospect of maintaining relationships
whilst simultaneously feeling many negative emotions toward the
hoarding. Sampson (2013) also described ‘negative feelings towards the
person who hoards’ as a major theme in their study. These negative
feelings included frustration, anger, embarrassment, hopelessness,
disgust and even feeling unappreciated. Wilbram et al. (2008) also
described feelings of anger and frustration as well as family conflicts
which resulted in the complete breakdown of relationships in some cases.
Family members in this study attempted to lay blame with the hoarding
behaviour rather than the individual who compulsively hoards, however,
this was difficult when the behaviour was seen as selfish or disregarding
of others.
Marginalisation. One part of the impact hoarding has on the relationships within
families is marginalisation, which occurs for both the person who hoards and their family
115
members (Wilbram, 2008). The families of hoarders reported that their loved ones who hoard
often withdrew from other social life and emotionally distanced themselves from their family
members, potentially as an attempt to neutralise others’ efforts to manage the clutter.
Withdrawal from other social life and potential sources of support by the hoarder was
reported to leave feelings of increased ‘duty’ and even ‘entrapment’ with their families. In
some cases this led to the family members, as well as the person who hoards, becoming
socially isolated from friends and neighbours (Wilbram, 2008). In using an ambiguous loss-
based psychoeducational support group for family members of people who hoard, Sampson
et al. (2012) found that family members were able to combat some of this marginalisation by
giving social support to the other group members and by beginning to talk to their families at
home. Participants reported that the support group enabled them to engage with their loved
ones who hoard in ways that increased positive interactions.
The participants in Wilbram et al.’s (2008) study described themselves as ‘key carers’
with sole responsibility for supporting their relative who hoards. Family members described
trying various strategies to manage clutter and becoming resigned when all attempts were met
with opposition (Wilbram et al., 2008). Tompkins (2011) describes two case examples in
which several adult children had become marginalised from their parents who had difficulties
with hoarding. In such cases, Tompkins (2011) suggests that a Harm Reduction Approach
can be helpful precisely because many people who hoard refuse help and distance themselves
from those attempting to assist them. ‘Harm reduction’ involves an attempt to manage risk by
decreasing the consequences of harmful behaviours without requiring the person to stop the
behaviours completely.
This marginalisation of those attempting to help may have been born out of a mistrust
of carers’ intentions which Wilbram et al. (2008) found was particularly difficult for those
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family members not living with the person who hoards. Those who did reside with the person
who hoards felt physically marginalised by the clutter and resultant loss of living space.
Marginalisation may also be exacerbated by a lack of insight on the part of the person who
compulsively hoards.
Insight. Plimpton, Frost, Abbey and Dorer (2009) reported on six case studies of
children with compulsive hoarding and found that few of the children had any insight into
their behaviours. They did not understand it to be a problem and whilst most tried to give
some explanations as to why they saved things, many of these reasons contained no
information. Their parents reported having to manage difficult situations and making many
accommodations for their children’s behaviour due to the children’s lack of insight.
Understanding (need for/lack of). Family members experienced a lot of distress as a
result of not understanding compulsive hoarding. They made attempts to decipher the
meaning of hoarding behaviours for their loved ones but reported finding the behaviours
inexplicable (Sampson, 2013). Wilbram et al. (2008) described this as a “search for a
meaningful explanation of hoarding behaviour” (p. 65). Family members believed that
change or control might be achieved over the hoarding if some understanding were gleaned,
although they reported no luck in attempts made so far.
Psychoeducation helped the participants in a study by Sampson et al. (2012) to move
away from thinking that hoarding was due to laziness or unwillingness, to a better
understanding where hoarding could be seen as an illness or a coping mechanism. This
increased understanding was reported to have decreased some of the family members’
distress associated with not comprehending the hoarder’s perspective. For Wilbram et al.
(2008), however, the need for understanding extends to the others around the family members
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of people who hoard to include service providers who should be knowledgeable and
sympathetic.
Support for families (why it is needed and challenges to it). Tompkins (2011)
argues that compulsive hoarding is a problem which is too big for any one person to manage.
He suggests that it often requires on-going assistance and therefore recommends that a team
be used in order to manage the problem. Tompkins (2011) believes that the families must be
seen as the clients alongside the person who compulsively hoards in order for change to be
achieved. This can be a challenge, however, as the family members of people who hoard may
experience internal barriers to seeking support. For example, Sampson (2013) found that
family members may struggle with embarrassment, shame and worry about how they might
be perceived by others outside the immediate family due to the social invisibility of hoarding.
Some also discussed fears that they might struggle with their own compulsive hoarding
behaviours in the future and experienced guilt and anxiety due to this internal conflict which
might inhibit family members from seeking support from others.
Quantitative Findings
Table 3 shows the main findings of each of the eleven quantitative
studies included in this review. As with the qualitative studies in this
sample, these findings have been synthesised, revealing five main
themes.
Burden. The Family Impact Scale for Hoarding (FISH) was recently
created by Nordsletten, Fernández de la Cruz, Drury, Ajmi, Saleem and
Mataix-Cols (2014). The scale examines accommodation and burden in
the family and was found to have
118
119
Table 3
Main findings of quantitative papers
Reference Analysis Finding 1 Finding 2 Finding 3 Finding 4 Finding 5
Drury et al. (2014)
T-tests and regressions
Relatives of people with hoarding disorder reported greater carer burden than relatives of collectors t = 7.9, p < .001, d = 1.7
Relatives of people with hoarding disorder reported greater accommodation than relatives of collectors t = 4.76, p < .001, d = 1.13
Perceived level of squalor was a predictor of carer burden and functional impairment β = .56, p < .001 and β = .46, p < .001
Co-habiting was a predictor of carer burden and functional impairment β = .29, p = .011 and β = .47, p < .001
Increasing age of the hoarder was a predictor of functional impairmentp = .014
Frost et al. (2000b)
ANOVAs Compared to non-hoarding OCD and anxiety disorder patients, OCD hoarding patients scored higher on family disability F(3, 96) = 41.9, p < .001
Compared to non-hoarding OCD and anxiety disorder patients, OCD hoarding patients scored higher on social disability F(3, 96) = 36.2, p < .001
Frost et al. (2011) ANOVAs Spouses had sig. higher clutter scores than children F (2, 1295-1298) = 405.6, p < .001
Spouses had higher distress scores than children F (2, 1295-1298) = 580, p < .001
Spouses had higher interference scores than children F (2, 1295-1298) = 554, p < .001
Adult children had higher compulsive buying scores than spouses F (2, 1295-1298) = 330.6, p < .001
Adult children had higher fears of making decisions than spouses 1295-1298) = 301.5, p < .001
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Gomes et al. (2014)
Spearman’s correlations and regression
Most family members accommodated patients’ symptoms at least once a week (98.2%)
Patient OCD severity positively associated with family accommodation rs = .34, p < .001
Patient obsessions positively associated with family accommodation rs = .28, p = .002
Family member's hoarding score positively associated with family accommodation rs = .19, p = .041
Being the patient's spouse was a predictor of family accommodation β = .29, p
Nordsletten et al. (2014)
Exploratory factor analysis and logistic regressions
16 items loaded onto two factors (burden and accommodation), accounting for 67.41% of variance
Blood relatives had higher burden scores than spouses (relatives of hoarders M = 12.37; 95% C.I.: 11.16–13.59; relatives of collectors M = 2.81; 95% C.I.: 1.62–4.00; p = 0.002)
The FISH correlated with hoarding severity r = 0.63, p = 0.001
Correlation of the FISH with caregiver burden r = 0.74, p < .001
Correlation of the FISH with functional impairment 0.67, p < .001
(Tolin et al. (2008a)
T-tests and regressions
Living with an individual who hoards during childhood was associated with elevated reports of childhood distress t = 5.07, p < .001
Family members of hoarders reported higher levels of patient rejection attitudes than family members of OCD patients t = 6.65, p < .001
Rejecting attitudes were predicted by severity of hoarding symptoms β = .21, p < .001
Rejecting attitudes were predicted by theindividual’s perceived lack of insight into the behaviour β = .36, p < .001
Those reported greater clutter in the home during childhood had higher rejecting attitudes than those who reported less clutter during childhood 2.75, p = .007
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Tolin et al. (2010a)
Correlations Family/friend informants described the hoarder on average as having fair to poor insight (M = 2.55 where 2 = fair insight and 3 = poor, SD = 1.04)
Hoarders described as showing less distress about the hoarding were described as showing poorer insight r = -0.22, p = .002
Tolin et al. (2010b)
Odds ratios Changes in relationships were associated temporally with periods of symptom onset or exacerbation, OR = 1.92 (95% CI = 1.71–2.17), p < .05
Interpersonal violence was associated temporally with periods of symptom onset or exacerbation OR = 1.44 (95% CI = 1.22–1.69), p < .05
Storch et al. (2007)
Mann Whitney U tests
Relative to non-hoarders, youths with hoarding symptoms had worse insight
Family accommodation not different between children with non-hoarding OCD and children with OCD and hoarding behaviours Z = -1.11, p = 0.27
Storch et al. (2011)
Correlation Hoarding was directly correlated with family accommodation r = .27, p = .01
Note. CI = Confidence Interval; OR = Odds Ratio; FISH = Family Impact Scale for Hoarding
good internal consistency (α = 0.86). Sixteen items accounted for 67.41%
of variance and successfully distinguished between people identifying as
the relative of someone with hoarding problems and people identifying as
the relative of someone with normative collecting behaviours. The FISH
was found to correlate with measures of caregiver burden, caregiver
functional impairment and caregiver quality of life. Similarly, in a study by
Drury, Ajmi, Fernández de la Cruz, Nordsletten and Mataix-Cols (2014), relatives of
people with hoarding disorder reported significantly greater carer burden
than relatives of collectors using both the FISH and the Caregiver Burden
Inventory (Novak & Guest, 1989). Family members of people with hoarding
problems reported high levels of rejecting and hostile attitudes towards their family members
who hoard; higher than rejecting and hostile attitudes reported by family members of OCD
patients, which suggests that hoarding specifically can cause frustration within families
(Tolin, Frost, Steketee, & Fitch, 2008a).
Impact on relationships. Hoarding behaviours specifically may have a significant
impact on relationships within families. OCD patients with hoarding behaviours, compared to
non-hoarding OCD patients and anxiety disorder patients, have reported significantly higher
disability scores in the areas of family and social life. Moderate levels of family disruption
were reported, on average, by hoarding patients (Frost et al., 2000b). Co-habiting with a
person who hoards was found to be a significant predictor of carer burden and functional
impairment (Drury et al., 2014) and similarly, living with an individual who hoards during
ones childhood was associated with elevated reports of childhood distress, family strain and
rejecting attitudes towards the person who hoards (Tolin et al., 2008a). In a sample of 864
hoarding participants and 655 family informants it was reported that 0.1–3.0% of hoarders
had a child or elder removed from the home (Tolin et al., 2008b).
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The impact of hoarding may be different depending on the type of relationships being
investigated. Nordsletten et al. (2014) found that blood relatives (e.g. parents, children) of
hoarders endorsed higher burden scores than spouses. Despite this, Frost, Tolin, Steketee and
Oh (2011) found that spouses, rather than children of compulsive hoarders, had significantly
higher distress scores. It is unclear from the current research why these findings seemingly
contradict each other. The discrepancy between studies may reflect the fact that burden and
distress are discrete categories, or may be due to other, as yet unknown, factors which
differentially affect blood relatives and spouses of people who hoard. For example, spouses
were reported to have significantly higher interference scores than children, whereas adult
children of compulsive hoarders, compared to spouses, had significantly higher compulsive
buying scores, fears of making decisions, and scores on an inventory measuring OCD
symptoms. Changes in relationships may also impact the person who hoards and their family
members. For example, Tolin et al. (2010b) found that changes in relationships, and violence
within relationships, were associated with periods of hoarding symptom onset and
exacerbation.
Family accommodation. Five of the studies in this sample investigated family
accommodation, however, these studies used a variety of different measures of family
accommodation. Nordsletten et al. (2014) developed their own measure, the FISH, which
contains a factor called ‘accommodation’. Drury et al. (2014) found that relatives of people
with hoarding disorder reported significantly greater accommodation, as measured by the
FISH, than relatives of collectors. Similarly, Storch et al. (2011) found that family
accommodation, rated via questions devised by Calvocoressi et al. (1995), was directly
correlated with hoarding in children, as rated on the Child Saving Inventory.
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Storch et al. (2007) reported that family accommodation, as measured by the Family
Accommodation Scale, was not significantly different between children with non-hoarding
OCD, and children with hoarding behaviours and OCD. Gomes et al. (2014) measured family
accommodation of OCD symptoms via the interviewer rated Family Accommodation Scale
for Obsessive-Compulsive Disorder and found that accommodation of OCD was positively
associated with the family member's own score on a hoarding subscale of the Obsessive-
Compulsive Inventory.
Insight. Rejecting attitudes held by family members of people who hoard was found
to be predicted by a perceived lack of insight by the hoarding individual, into their hoarding
behaviour (Tolin et al., 2008a). Family informants described the hoarders in their families, on
average, as having fair to poor insight. The majority (36%) were reported to have “poor
insight”. In particular, hoarders described as showing less distress about their hoarding were
described as showing poorer insight (Tolin, Fitch, Frost, & Steketee, 2010a). This may also
be the case when comparing hoarding in OCD as Storch et al. (2007) found that relative to
non-hoarding adolescents with OCD, youth with hoarding symptoms and OCD had worse
insight. If worse insight does indeed predict rejecting attitudes by family members (Tolin et
al., 2008a), and most people who hoard have low insight into their disorder (Tolin et al.,
2010a), it is easy to see how some relationships become interrupted or lost.
Severity. Three studies from this sample investigated the impact that severity of
hoarding has on families. Nordsletten et al. (2014) found that impact, as measured by the
FISH, correlated with a measure of hoarding severity. Drury et al. (2014) reported that
perceived level of squalor (as reported by both hoarding participants and family informants)
was a significant predictor of carer burden and functional impairment for family members.
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Rejecting attitudes by family members of those who hoard were also found to be predicted by
severity of hoarding symptoms (Tolin et al., 2008a).
Quality Assessment of Papers
The standard quality assessment criteria for evaluating primary
research papers from a variety of fields (Kmet et al., 2004) and the Critical
Appraisal Skills Program (CASP, 2013), were used to evaluate all studies
included in the final sample. Four of the six qualitative papers in this
sample were rated to be of a high quality. The papers which were judged
as being of high quality were generally able to acknowledge their own
limitations. Sampson (2013), for example, listed the limitations of the study in a
transparent manner, acknowledging the potential problems involved in having a self-selected
purposive sampling method. They suggested that elevated levels of distress could have been
the motivator for participants who volunteered. In addition to recognising that purposive
sampling may have caused the sample to be representative of carers of hoarders who are
experiencing a lot of distress, Wilbram et al. (2008) stated that this type of sampling could
have excluded participants experiencing a lot of shame. On the other hand, most interviews
were conducted in the home of the hoarders which may have generated more data in relation
to shame and embarrassment due to the irrefutable evidence of the extent of hoarding in these
environments. In contrast, interviews conducted in neutral locations may have mitigated
some of the shame and embarrassment felt by the interviewees because the hoarding
behaviours would have been less visible. An advantage of interviewing participants in their
homes, however, is that compulsive hoarding is then evident to the researchers without the
need for any standardised measures to screen for hoarding disorder (Kellett et al., 2010).
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Sampson et al. (2012) were not able to acknowledge any relevant limitations;
however, two were evident. Firstly, two of their eight participants declined to be interviewed
after attending the six psychoeducational support groups. These participants may have
represented different views to those interviewed. Secondly, the interviews were conducted by
the same people who facilitated the six-week support group being evaluated, which may have
influenced the participants towards giving socially desirable, positive feedback.
The best quality studies used verification procedures in order to establish credibility.
Sampson et al. (2012) peer reviewed their themes as a method of verification, and the
verification measures Wilbram et al. (2008) used to establish credibility were transparent and
abundant. The papers by Plimpton et al. (2009), and Tompkins (2011), conversely, lacked
much of the quality of the other qualitative papers because no appropriate study design was
utilised. Systematic data collection through sampling, as opposed to case illustrations, would
have been beneficial in both cases, as would a transparent data analysis strategy and use of
verification procedures to check credibility. The article by Tompkins (2011), however, did set
out a clear objective as well as describing context and connection with the theoretical
framework and wider literature. Plimpton et al. (2009), on the other hand, discussed very
little in the way of limitations and was not particularly reflexive in its description of the
impact of various influences on the data such as recruiting through clinicians working with
the families. The conclusions drawn from this article should therefore be considered with
caution.
Most of the quantitative papers in this sample were rated as being
of a high quality, although some limitations were noted. The studies by Frost et
al. (2000b), Storch et al. (2007), Storch et al. (2011) and Gomes et al. (2014) used samples of
people with OCD and compulsive hoarding which does not allow generalisation of findings
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to groups with hoarding behaviours in the absence of OCD. Other articles included here may
have also studied ungeneralisable samples, for example, the samples in studies by Tolin et al.
(2008b) and Tolin et al. (2010b) were predominantly white and female. However, it remains
unclear whether or not this is representative of the hoarding population.
Recruitment of participants was a weakness for four of the studies in this sample.
Tolin et al. (2008a), Tolin et al. (2008b), Tolin et al. (2010a) and Tolin et al. (2010b) all
recruited their samples via the use of a database of people who had contacted the researchers
for information about compulsive hoarding following some media coverage. This means that
the sampling methods may have been biased towards participants with more severe hoarding
behaviours as the participants self-selected by contacting the authors. High numbers of
discontinuations during the internet surveys could also mean that the sample was not
representative of all compulsive hoarders and their family members.
Several of the quantitative studies relied on self-report measures by participants, and
used no verifications of hoarding status that were objective or confirmed by the researcher
(for example, Frost et al., 2011; Tolin et al., 2008a; Tolin et al., 2008b; Tolin et al., 2010a;
Tolin et al., 2010b). Objective measures such as clinical interviews may be more reliable
indicators of hoarding status, however, this is a common problem with internet survey
designs. Across studies, several different measures were also used to assess hoarding which
did not allow for comparison across all studies. Tolin et al. (2008a) and Tolin et al. (2010b)
also used retrospective reports of stressful life events which may be biased. Retrieval may
have been mood-congruent or simply contained errors.
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Discussion
The findings of this review give a conceptual overview of the current literature but
suggests that there is a lack of research on families and carers of people who compulsively
hoard. The experiences of family members of people who hoard must be investigated further
and particular interest must be paid to the creation and evaluation of either psychological
interventions for family members, or the provision of psychological interventions for people
who hoard which includes their family members.
Evaluation and synthesis of qualitative studies exploring the impact of hoarding on
family members and carers revealed six major themes: loss, impact on relationships,
marginalization, insight, understanding, and support for families. The quantitative studies in
this area revealed themes including: burden, impact on relationships, family accommodation,
insight, and severity. Some of these themes clearly overlap or support one another. Hoarders’
‘insight’ has been assessed in both qualitative and quantitative studies as being poor
(Plimpton et al., 2009; Tolin et al., 2010a) and predictive of rejecting attitudes by family
members (Tolin et al., 2008a). The term ‘insight’ has been used diagnostically to determine
whether or not an individual is aware of the impact and extent of their problematic
behaviours; however, it may not fully capture the complex experience of having an awareness
of ones difficulties with hoarding. In these studies ‘insight’ was subjectively measured by
family members, who may perceive continued hoarding as a lack of ‘insight’. As such,
research might benefit from more nuanced means of defining and measuring ‘insight’.
The ‘impact on relationships’ that compulsive hoarding can have was also discussed
in both qualitative and quantitative studies. This supports the theme of ‘shattered families’
found by Büscher et al. (2013) which referred to the conflicts which occurred within the
families of people who hoard. Changes in relationships were found to affect the person who
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hoards (Tolin et al., 2010b) and their families were found to be distressed and burdened by
the hoarding behaviours (Kellet et al., 2010; Sampson et al., 2012; Sampson, 2013; Wilbram
et al., 2008). The type of relationship a person has with someone who compulsively hoards
(co-habiting or living apart, spouse or child) affected the amount of strain they experienced
(Drury et al., 2014; Tolin et al., 2008a). This supports the assertion by Frost et al. (2000a)
that hoarding behaviours pose serious risks for both the individual and those around them.
‘Loss’ of a childhood home or current home environment, as reported in qualitative
studies (Sampson et al., 2012; Sampson 2013; Wilbram et al., 2008), is similar to some
aspects of ‘family accommodation’ and ‘burden’ described by quantitative studies.
Nordsletten et al. (2014) developed a measure containing accommodation as a factor. This
accommodation included items determining the degree to which family members physically
accommodated clutter caused by a person who hoards. The loss of ‘normal’ family life may
also be part of the way in which families accommodate the hoarding behaviours (Sampson et
al., 2012; Sampson 2013; Wilbram et al., 2008). This supports the theme identified by
Büscher et al. (2013) which described how families reported colluding with the person with
hoarding disorder as a potential response strategy. The family burden of hoarding may also
be similar to the theme of ‘loss’, as it has been correlated with caregiver functional
impairment and quality of life (Nordsletten et al., 2014) and is greater than that experienced
by the families of those with normative collecting behaviours (Drury et al., 2014; Nordsletten
et al., 2014). Severity of hoarding and the level of insight held by the hoarder, have also been
correlated with impact on the family, carer burden, carer functional impairment and rejecting
attitudes by family towards those that hoard (Drury et al., 2014; Nordsletten et al., 2014;
Tolin et al., 2008a).
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The theme ‘marginalization’ was only reported by qualitative studies in this area but
describes an important part of what is happening for both hoarders and their relatives.
Hoarders were reported to distance themselves both from their families and other sources of
social support, potentially in order to neutralize attempts by these supporters to manage the
clutter (Sampson et al., 2012; Tompkins, 2011; Wilbram et al., 2008). This may lead to
families feeling an increased sense of ‘duty’ and ‘entrapment’ in the caring role as well as
becoming socially isolated themselves (Wilbram et al., 2008). Interventions which increase
social support for the families of people who hoard may therefore be very beneficial
(Sampson et al., 2012).
Psychoeducation may also be an important component of interventions for the
relatives of people who hoard as ‘understanding’ was a theme present in three of the
qualitative studies (Sampson et al., 2012; Sampson, 2013; Wilbram et al., 2008). Distress
may be caused by a lack of understanding. Gaining increased understanding, through
attending a psychoeducational support group, was reported to have alleviated some of the
family members’ distress.
‘Support for families’ and support seeking by families has thus far only been
discussed in qualitative studies in the area of hoarding; however, this should be a central
consideration for future research. Tompkins (2011) reported that families should be seen as
the clients alongside the person who compulsively hoards in order for change to be achieved.
Families of those who compulsively hoard experience embarrassment, shame and worry
linked to the hoarding, and struggle with compulsive hoarding behaviours or urges of their
own which may therefore cause them to avoid seeking help from others (Sampson, 2013).
Families may also require support in the form of strategies to reduce family accommodation
130
of hoarding behaviours as this is positively associated with high carer burden and functional
impairment and negatively correlated with quality of life (Nordsletten et al., 2014).
Very few of the findings reviewed here were conflicting. This was attributed to the
small number of papers investigating a broad scope of ideas about the impact of compulsive
hoarding on families and carers. The only inconsistent findings were concerned with the
relative distress or burden experienced by the spouses and blood relatives (such as children)
of hoarders. One study found that blood relatives experienced more burden than spouses
(Nordsletten et al., 2014) but another found that spouses reported higher interference and
distress than children (Frost et al., 2011). Other differences between spouses and children of
people who hoard, such as their own hoarding tendencies and relative level of
accommodation toward, or interference in their loved one’s hoarding behaviours, could have
affected these somewhat contradictory findings that children report higher burden whereas
spouses report higher distress. This difference in findings may have implications for theory
on this subject, however, more research will need to be completed in order to determine the
relationship between family burden and distress, and the relative experiences of spouses and
blood relatives of hoarders.
Limitations
Only four out of seventeen (24%) of the papers reviewed here were conducted in the
UK, which limits the implications for clinical practice in the UK. This review also included
papers from a variety of methods which provided a range of evidence on this topic; however,
not all of these papers were of ideal quality. Common limitations of the studies presented
here include self-selected purposive sampling and the use of ungeneralisable samples. Self-
selected participants may mean the samples included a high number of people experiencing
elevated levels of distress, more extreme hoarding or a smaller number of people
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experiencing a lot of shame. The people who do not volunteer or who drop out of purposive
samples may represent views which are then not represented in the results.
The use of samples of people with both OCD and hoarding behaviours does not allow
generalisation of findings to groups with hoarding behaviours in the absence of OCD (Gomes
et al., 2014; Storch et al., 2007; Storch et al., 2011). ‘Hoarding disorder’ is now a discreet
diagnostic category and is no longer viewed as a symptom of OCD (American Psychiatric
Association, 2013), therefore, it could be argued that it is not possible to infer information
about hoarding in OCD to hoarding behaviours seen in the absence of OCD. Other articles
included here also used ungeneralisable samples which were predominantly white and female
which may not be representative of the hoarding population (Tolin et al., 2008b; Tolin et al.,
2010b).
Two of the qualitative papers (Plimpton et al., 2009; Tompkins, 2011) were narrative
case illustrations which contained no appropriate study design, method of data collection,
method of analysis, and verification procedures. The rationale for this review was to use
broad inclusion criteria in order to obtain as much information as available on the family and
carers of people who hoard and make recommendations for future research. These studies
were therefore included in this report, despite their limitations in terms of quality, because
they provided insight into an under-researched area.
Despite these limitations, there were several common strengths among the papers and
many of the studies were of a high quality. Many of the qualitative studies used multiple
verification procedures in order to establish credibility of their findings and the papers in
general used appropriate study designs and were able to acknowledge their own
limitations.
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Future Research Recommendations
Sampson (2013) stated that, “it is important for researchers to investigate further the
experiences of non-caretaking family members in order for a deeper understanding of their
experiences to inform more effective interventions for them” (pp. 389). This statement is
supported by the current review. Research undertaken on the burden experienced by this
group of people is sparse, and research evaluating effective interventions for them is even
more limited. Many studies have utilised family members of people who compulsively hoard
as mere informants in order to research hoarding without the need for recruiting hoarders
directly. Some have failed, however, to employ the opportunity to study the distress and
burden experienced by the family of hoarders. Tolin et al. (2008b) for example, used family
informants to provide information about their hoarding relatives and investigated psychiatric
work impairment days taken by hoarders but missed an opportunity to ask the same questions
of the family informants. Doing so would have investigated the burden on family members
by producing information on the number of missed or interrupted work days caused by caring
for their relative with compulsive hoarding. Future work conducting this recommended
research could also help verify reports that carers incurred financial losses of their own
through an inability to work due to being the ‘key carer’ for someone who hoards (Wilbram
et al., 2008).
Similarly, four studies mentioned in this review investigated the insight that people
who hoard have into their disorder. We can hypothesise that a lack of insight may be
detrimental to recovery or treatment success, and that this may be very challenging for the
families or carers of hoarders; however, none of the studies sought to investigate whether
there was an association between carer distress or burden and the hoarders’ lack of insight.
Tolin et al. (2008a) were able to show that a lack of insight by the hoarder predicted rejecting
133
attitudes by their family members but we do not know whether these rejecting attitudes were
associated with family distress.
Linked to these rejecting attitudes found by Tolin et al. (2008a), is the finding by
Sampson (2013) that families reported many negative feelings towards the person who
hoards. Sampson et al. (2012), on the other hand, described negative feelings towards the
hoarding behaviour itself rather than the hoarder. Future research should better distinguish
between the negative feelings toward those who hoard and the negative feelings toward the
hoarding behaviour. Wilbram et al. (2008) found that family members reported difficulty
distinguishing between the two but no research to date has explored the nuances of these
experiences.
Family burden and rejecting attitudes were both correlated with severity of the
hoarding and living with an individual who hoards during ones childhood (Tolin et al., 2008).
It would therefore be interesting to know whether carer burden and rejecting attitudes are
correlated with each other. If they were found to be related, practitioners could target family
members experiencing high levels of burden without needing to assess rejecting attitudes
which may be more open to reporting biases. An association between carer burden and
rejection of the hoarder would also provide support for the implementation of interventions
which reduce carer burden by revealing the ways in which it could be beneficial, not just for
the carers, but also for their hoarding family members.
As previously stated, a limitation of some of the studies reviewed here was the
inability to generalize findings from studies using samples of people with hoarding as a
symptom of OCD, to those who experience hoarding in the absence of OCD. Therefore,
future research should seek to replicate and verify the findings of Storch et al. (2007), Storch
et al. (2011) and Gomes et al. (2014), using samples of people with hoarding behaviours
134
without OCD, as they may be distinct from people with a primary diagnosis of OCD who
also exhibit hoarding behaviours.
Other study limitations should also be addressed by future research, for example,
Nordsletten et al. (2014) suggested that larger samples be used in future studies in order to
verify their findings that the FISH is an appropriate measure of the impact hoarding disorder
has on families. Longitudinal studies have also yet to be conducted in this field but are
required for the verification of findings on the future impact of living with a person who
hoards during childhood, such as those by Tolin et al. (2008a).
Finally, certain themes which emerged from this review of the literature are poorly
understood, have only been investigated by a small number of studies or have only been
studied via one research methodology. ‘Marginalization’, ‘understanding’ and ‘support for
families’ were all themes reported in qualitative studies which have not been researched
using quantitative methods. Conducting quantitative investigations into these experiences
would greatly further our understanding of families and carers of people who compulsively
hoard.
135
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Clinical Experience
Mole Valley Community Mental Health Recovery Service
A year-long adult mental health placement providing psychological therapy for complex and
enduring mental health problems, including one-to-one and group therapies. Presentations
worked with include: personality disorder, psychotic depression, panic disorder, obsessive
compulsive disorder, depression, and social anxiety. I have facilitated a Systems Training for
Emotional Predictability and Problem Solving (STEPPS) group and several trans-diagnostic
coping skills groups. A service-related research project was also completed which evaluated
the knowledge and practice of recovery-focused approaches in mental health staff.
North West Surrey Child and Adolescent Mental Health Service
A 6 month-long child and adolescent mental health placement using both CBT and Systemic
models of therapy. Supervision was conducted by an EMDR consultant psychologist working
in child trauma and therefore I was able to observe much of this work. One-to-one, family
and group therapies were conducted on this placement as well as consultation work with
schools.
Sutton Community Mental Health Team for Older People
A 6 month-long older adult placement working with mental health problems, dementia and
challenging behaviour through CBT, neuropsychological assessments and consultation to
staff teams.
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East Surrey Community Team for People with Learning Disabilities
A 6 month-long Learning Disability (LD) placement providing neuropsychological
assessments for LD and dementia, specialist extended assessments, adapted CBT and
consultation to staff teams.
Traumatic Stress Service
A 6 month-long specialist placement working in a traumatic stress service delivering trauma-
focused CBT, comprehensive assessments and formulations for Post-Traumatic Stress
Disorder and co-morbid presentations.
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PSYCHD CLINICAL PROGAMME
TABLE OF ASSESSMENTS COMPLETED DURING TRAINING
Year I Assessments
ASSESSMENT TITLE
WAIS-IV WAIS-IV Interpretation Report.
Service-Related Project Evaluation of the knowledge and practice of recovery focused approaches in staff working in a Community Mental Health Service.
Practice Case Report Cognitive-behavioural assessment and formulation with Emma (pseudonym), a female service user in older adolescence, with diagnoses of social anxiety and borderline personality disorder.
Problem Based Learning – Reflective Account
‘Relationship to change’ reflective account.
Qualitative Research Project
Trainee clinical psychologists’ perceptions of unpaid assistant psychologist positions.
Major Research Project Literature Review
The impact of compulsive hoarding on families and carers: A systematic review.
Adult – Case Report 1 Cognitive-behavioural assessment, formulation and intervention with Bethany (pseudonym), a woman in her 40’s, with a diagnosis of mixed depression and anxiety, suffering from panic attacks.
Adult – Case Report 2 Neuropsychological assessment and formulation with Hannah (pseudonym), a woman in her twenties, who reported memory problems.
Major Research Project Proposal
A grounded theory analysis of animal hoarding.
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Year II Assessments
ASSESSMENT TITLE
Professional Issues Essay
“Successfully promoting psychological services to men, working class young people and cultural minorities present considerable challenges to clinical psychology where the majority of practitioners are white European females”. What challenges do you anticipate there will be for you as a clinical psychologist in attempting to reach out to these groups?
Problem Based Learning – Reflective Account
PBL reflective account – the Stride family.
People with Learning Disabilities/Child and Family/Older People – Case Report
Systemic and cognitive-behavioural assessment, formulation and intervention with a six year old girl suffering from encopresis and fear of medication, and her family.
Personal and Professional Learning Discussion Groups – Process Account
PPLDG process account.
People with Learning Disabilities/Child and Family/Older People – Oral Presentation of Clinical Activity
Oral presentation: Assessment, complex collaborative formulation and staff consultation work for an older adult with vascular dementia referred due to verbally and physically aggressive behaviour and refusal to take medication.
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Year III Assessments
ASSESSMENT TITLE
Major Research Project Empirical Paper
Professional perspectives on animal hoarding.
Personal and Professional Learning – Final Reflective Account
On becoming a clinical psychologist: A retrospective, developmental, reflective account of the experience of training.
Child and Family/People with Learning Disabilities/Older People/Specialist – Case Report
Cognitive-behavioural assessment, formulation and intervention with Nell (pseudonym), a woman in her 30’s, suffering from post-traumatic stress disorder to witnessing the death of a child under her medical care.
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