safety day: an application of disaster psychology...

SafetyDay:AnApplicationofDisasterPsychologytoHoardingCleanouts

JenniferSampson,PhD,LMFTTheHoardingProject

AntiochUniversitySeattle

2016HoardingAwarenessConferenceTukwila,WA

October28.2016

Copyright2016.Allrightsreserved.

Outline

Ê  ApplicationofDisasterPsychologytoHoardingCleanoutInterventions

Ê  SafetyDayInterventionProcess

Ê  Implications

Copyright2016.Allrightsreserved.

Cleanout….OrElse!!

•  HoardingisamentalhealthissueANDcanresultinpublicsafetyconcerns

•  23%ofindividualsseekinghelp

forhousingproblems,includingeviction,metcriteriaforhoardingdisorder(Rodriguezetal.,2012)•  32%currentlythreatened

withimminenteviction

•  Bythetimehoardingcasescometopublicattention,theylikely:

Requireintensive,lengthy,costly,strategicandcomplexresponses

Copyright2016.Allrightsreserved.

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TheProblemAsWeSeeIt…

Ê  Cleanouts:Ê  Arenoteffectiveorsustainable

Ê  Theycanbetraumatizing

Ê  Theyoverlookthecrisis/disasternatureofacleanouteventonahomeowner

Ê  BUT,sometimestheyarenecessaryinordertopreservepublicsafety

Ê  HistoryÊ  UMMedicalReserveCorps&

PsychologicalFirstAid

Ê  Hoardingclean-outs

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CleanoutsasTraumaticCrisis???

DiffusePhysiological

Arousal

DisasterSurvivors

HoardingCleanouts

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HoardingCleanoutsasDisasterEvents

Ê  Thinkingabouthoardingcleanoutsthroughthelensofdisasterpsychologyallowsusto:Ê  Makesenseofthestrongemotionalandpsychological

responsesexperiencedbypeoplewhohoardbefore,during,andafteraforcedcleanout

Ê  Applyevidence-basedknowledgeandpracticesfromotherfieldstothisnew,developingfieldofinterventioninordertominimizethedamagewhenhoardingcleanoutsarenecessary

Copyright2016.Allrightsreserved.

BackgroundonDisasterorCrisisPsychology

DevelopmentofCrisisInterventionfollowingaTraumaticEvent

Ê  1942CoconutGrovenightclubfireinBoston(493peoplekilled)

Ê  Lindemann-Generalandpredictableemotionalandphysicalpatternsofresponse->focusedonreactionstotheeventofthetragedy

Ê  Certainclinicalstrategies(e.g.facilitationoftheexpressionofgrief)werehelpfulwithawiderangeofclientsincrisis

Ê  Createdstandardproceduresforhelperstotreatandpreventproblemsfollowingacrisis

Trepper&Papay,1996

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Definitionofa“TraumaticCrisis”

Ê  Aneventthatisexperiencedorwitnessedinwhichpeople’sabilitytocopeisoverwhelmedÊ  ActualorpotentialdeathorinjurytoselforothersÊ  SeriousinjuryÊ  Lossofcontactwithfamilymembersorclosefriends

Ê  Destructionoftheirhomes,neighborhood,orvaluedpossessions

AdaptedfromCERTBasicTraining,2011Copyright2016.Allrightsreserved.

PossibleSymptomsofTraumaticStress

PsychologicalSymptoms

Ê  CognitivefunctioningdifficultiesÊ  IrritabilityorangerÊ  Self-blameorblamingofothersÊ  IsolationandwithdrawalÊ  FearofrecurrenceÊ  Feelingstunned,numb,oroverwhelmedÊ  FeelinghelplessÊ  MoodswingsÊ  Sadness,depression,andgriefÊ  DenialÊ  ConcentrationandmemoryproblemsÊ  RelationshipconflictsÊ  RigidthinkingÊ  Difficultydecision-making

PhysicalSymptomsÊ  Lossofappetite

Ê  Headachesorchestpain

Ê  Diarrhea,stomachpain,ornausea

Ê  Hyperactivity

Ê  Increaseinalcoholordrugconsumption

Ê  Nightmares

Ê  Inabilitytosleep

Ê  Fatigueorlowenergy

AdaptedfromCERTBasicTraining,2011

Symptomsoftraumaticstressarenormalhumanresponsestoabnormalevents.

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WhathappenstoourbodyinCrisis:DiffusePhysiologicalArousal(DPA)

Ê  AllpeopleexperienceDPAorflooding.

Ê  Heartrateover90-100bpm:adrenalineentersbloodstream

Ê  Flight,fight,orfreeze(intenseanxietyorfear)

Ê  Wehearandseesignalsofdanger,nothingelse.

Ê  IndividualsinDPAcannotmakebasicdecisions

Ê  Limbicsystemonoverload

Ê  Forphysiologicalreasons,whenwearefloodedweareunabletocommunicateeffectively.

Ê  ProcessingcrisiseventswhileweareinDPAmayresultintraumatization

Ê  SympatheticNervousSystem(SNS)responsetostress

Ê  Fight,Flight,orFreeze

Diffuse

• Manypartsofthebodyareaffectedatonetime

Physiological

•  “ofthebody”,aphysicalphenomenon

Arousal

•  Stirringupoftheneurologicalsystem,makingreadyforaction

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MediatingFactors:Whysomepeopleresponddifferentlyto

particulareventsthanothers

Ê  Thestrengthandtypeofpersonalreactiontoatraumaticeventvariesdependingonseveralfactors:Ê  Person’spriorexperiencewithsameor

similarevent

Ê  Intensityofdisruptioninperson’slife

Ê  Meaningoftheeventtotheindividual

Ê  Emotionalwell-beingandresourcesavailabletotheindividual

Ê  Lengthoftimethathaselapsedsinceeventandpresent

AdaptedfromCERTBasicTraining,2011Copyright2016.Allrightsreserved.

WhatisImportanttoKnowaboutDisaster/CrisisEvents?

Ê  Psychologicalresearchhasshownthatdisasterscancauseseriousmentalhealthconsequencesforvictims

Ê  PTSD,Depression,Anxiety,HealthConcerns.(Norrisetal.,2002)

Ê  Themorestress,definedinavarietyofways,withinthedisaster,themorelikelytherearetobeemotionalconsequences(Sundin&Horowitz,2003)

Ê  FirstrespondersanddisasterworkersareatspecialriskforPTSDandothernegativeemotionalconsequencesofdisaster(Gibbs,Lachenmeyer,

Broska,&Deucher,1996;Norris,2002)

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WhatisImportanttoKnowaboutDisaster/CrisisEvents?(continued)

Ê  Caplan(1964)proposedthatacrisisisaturningpoint.Individualsincrisiscaneither:

Ê  Copesuccessfullyandtherebyenhancetheirabilitytocope,or

Ê  Makemaladaptiveattemptstocope,andtherebydeclineintheirpsychologicalfunctioning

Ê  Availabilityofresourcesandstressreductioniscriticaltopostdisasteradjustment(Caplan,1964)

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PreventionApproachestoCrisisIntervention

Ê  Caplan(1964):modelofpreventionofnegativepsychologicalsymptoms(psychopathology)

SecondaryPrevention

IdentifyPeopleatRisk,conductrapidscreeningafterdisasters,andtobegininterventionsassoonaspossible

PrimaryPrevention

ReduceStressoftheEnvironment

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ApplicationofDisasterPsychologytoHoardingCleanouts

HoardingCleanoutsandTraumaticStress

Ê  Wecan’tdotherapyinthemiddleof“atornado”

Ê  IndividualsincrisiscannotmakebasicdecisionsorcommunicateeffectivelyÊ  Limbicsystemonoverload:diffusephysiologicalarousal(DPA)

Ê  Additionally,individualswhohoardalreadystrugglewith:Ê  Decision-making

Ê  Co-occurringdiagnoses

Ê  Cognitivedifferences

Ê  Partingwithitemsduetoemotionalattachment

Ê  Approachingcleanoutsfromarational,confrontationalperspectivenotonlywillnotwork,butitcanactuallydomoredamagethangoodinthelongrunÊ  Mayprovokeanincreaseinstress,whichinturnmayworseneffectsoftraumatic

event

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TranslatingPhasesofCrisistoHoardingCleanouts

ImpactPhase

Survivorsgenerallydonotpanicandmay,infact,shownoemotion

InventoryPhase

Immediatelyfollowsevent;survivorsassessdamageandtrytolocateothersurvivors;focuson

function

RescuePhase

Survivorswillingtotakedirectionfromgroupswithoutprotest;likelyto

behelpful

RecoveryPhase

Survivorsappeartoturnagainstrescuers(emergencypersonnel);

expressanger/blame

PreparationPhase

Participantsmayexperienceintenseanxietyattheanticipationoftheimpendingeventortheymay

experiencedenialaboutthedifficultyoftheupcomingday

AdaptedfromCERTBasicTraining,2011

DuringtheCleanout

Participantsgenerallydonotpanicandmay,infact,shownoemotion;howeverindividualsaretypicallyveryclosetoemotionalfloodingthreshold;similartoRescuePhase,maytakedirectionfromteamwithoutprotestandmay

behelpfulduringtheprocess

ImmediatelyFollowing

theCleanout

Participantsassessdamageandtrytolocatetheiritems;focusonfunction;maybeeagertousenew

space

HourstoDaysFollowingCleanout

Participantsbegintorealizetheoutcomesofthecleanoutandmaynotbeabletolocatepossessions;mayturnagainstteam,expressingangerandblame

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Phasesof“SafetyDay”Intervention:Trauma-InformedHoardingCleanoutInterventions

PreparatoryPhase

• AnticipatoryPlanning;logisticalplanningforcleanoutevent(harmreductionapproach)• Informedconsent• SpecificDecisionMakingrelatedtoHarmReductiontasks• TeachingStressmanagementtechniques• DevelopCrisisPlans

CriticalPhase

• Stressmanagement(keepclientoutofDPA)• Coordinateclean-outefforts/reachharmreductiongoals• Ifwecanattendtotheneedsofthehomeowners,weshouldbeabletocountoncooperation

InventoryPhase

• Anticipateparticipantconcernsre:locationofpossessions;makeplansandbeavailableforde-escalationasneeded

RecoveryPhase

• Processcleanoutascrisis;cananticipatestrongemotions(anger/blame)• Processclean-outasifrespondingtotraumaticevent• Transitiontomentalhealthcare

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Goalsof“SafetyDay”

Ê  ProcessandApplicationofCriticalIncidentStressManagementÊ  Adaptive,short-termpsychologicalhelping-

processthatfocusessolelyonanimmediateandidentifiableproblem.Itcanincludepre-incidentpreparednesstoacutecrisismanagementtopost-crisisfollow-up.

Ê  Additionally,needtounderstandtheimportanceofpreservingteammemberspsychologicalwell-being

Ê  Bringclient’shometosafetytoreducethreatofevictionandcomplywithhousingcodesusingaHarmReductionApproachÊ  Mitigatenegativeeffectsof

stressfulandpotentiallytraumaticevent

Ê  Onlydiscardwhatisnecessarytoreachgoals

Ê  KeepclientoutofDiffusePhysiologicalArousal

Ê  UsePsychologicalFirstAidÊ  Recognizeandrespondto

symptomsofpsychologicalcrisis

Ê  Mitigatethemediatingeffects

PreparatoryPhase

CriticalPhase

InventoryPhase

RecoveryPhase

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ProcessofSafetyDay

HarmReduction(Tompkins,2014)

Ê  Setofpracticalstrategiesthatreducethenegativeconsequencesofaparticularhealthissue(HarmReductionCoalition,2010)

Ê  Goal:nottoeliminatebehavioritselfbuttominimizenegative,unwantedconsequencesthataccompanybehavior

Ê  Doesnotrequiretheindividualtohave“insight”intoreasonsforhoardingÊ  Onlyrecognizethepotentialforharmtothem,others,orneighbors

andtoagreetominimizetheriskÊ  Doesn’tpreventnewitemsfromcominginorincreasediscarding

Ê  Helpfulforindividualwithcognitiveimpairmentsorforpeoplewhoareunwillingtoseektreatment

Copyright2016.Allrightsreserved.

Phasesof“SafetyDay”:Trauma-InformedHoardingCleanout

Interventions

PreparatoryPhase

CriticalPhase

InventoryPhase

RecoveryPhase

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PreparatoryPhaseforClient

Ê  PrimaryFocus:Buildtrustingrelationshipwithclient

Ê  Sessionwithclienttoreviewtheprocessoftheday:Ê  Whatwillhappen

Ê  Stress-managementteamwillbewithclientÊ  Onlyitemsthatposethreattohealth/safetywillbediscarded

Ê  Whatwon’thappenÊ  Decision-makingrelatedtokeepingorgettingridofgeneralitems

Ê  Feelingstheymayhaverelatedtovolunteersintheirhomeandwhatishappening

Ê  Stressmanagementplan(similartoCrisisPlan)Ê  Prepfor“hoardinghangover”(InventoryPhase:emotionalresponse

followingtheSafetyDay)-developanotherstressmanagementplan

PreparatoryPhase

CriticalPhase

InventoryPhase

RecoveryPhase

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PreparatoryPhaseforTeam

OrganizationalTeamÊ  Clearideaofharmreductiontargets

Ê  Makeaplanforcategorization,labeling,discarding,etc.

Ê  Gathervolunteers

Ê  Trainnewvolunteers

Ê  Schedulepre-meetingandpost-debriefing

Ê  Reviewexpectationsfortheday

Ê  Gatherneededitemsfortheday:

Ê  Boxes,packingtape,sharpiesforlabeling

StressManagementTeam

Ê  PsychologicalFirstAidÊ  Supportresilience:

Ê  PromoteSafety

Ê  Calm&Comfort

Ê  Connectedness

Ê  Self-Empowerment

Ê  PreventionStrategies

Ê  Self-Care

Ê  KeepclientoutofDiffusePhysiologicalArousal

PreparatoryPhase

CriticalPhase

InventoryPhase

RecoveryPhase

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CriticalPhase–DayofSafetyDay

Ê  Pre-meetingwithvolunteers

Ê  Coordinationofefforts–teamsoftwoworkingtogetherinspecificareasofthehome

Ê  OrganizationalTeam

Ê  CarryoutHarmReductionGoals

Ê  Onlyitemsindirectviolationofhealth/safetyshouldleave/bediscarded

Ê  Anyitemsthatneedtobedecideduponshouldnotleavethehomethatday(ideally)inordertominimizestress

Ê  Developre-organizationstrategyforsortingintoboxes(e.g.labeling,categorizing,etc)

Ê  StressManagementTeam

Ê  KeepclientoutofDPAthroughouttheday

Ê  Reducepotentialofstressors

Ê  Debriefwithvolunteerteam(provideanoption)

Ê  Howdiditgo?

Ê  Whatdidyounotice?Preparatory

PhaseCriticalPhase

InventoryPhase

RecoveryPhase

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CriticalIncidentStressDebriefing

Mustbeofferedasanoptionforteammembers,notarequirement

1.  Introductionsanddescription

2.  Reviewoffactualmaterial

3.  Sharingofinitialthoughtsandfeelings

4.  Sharingofemotionalreactionstoincident

5.  Instructionaboutnormalstressreactions

6.  Reviewofsymptoms

7.  Closingandfurtherneedsassessment

AdaptedfromCERTBasicTraining,2011PreparatoryPhase

CriticalPhase

InventoryPhase

RecoveryPhase

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InventoryPhase

Ê  DayOf/After:Ê  Providea“visualmap”ofnewlocationofpossessionsinhome

Ê  Workwithorganizationteamtocreateeasilyvisiblelabelsthroughoutthehome

Ê  Implementpre-setCrisisPlanasneeded

Ê  Follow-upwithclientbyphoneÊ  Feelings

Ê  Concernsrelatedtotheday

Ê  Whatarenextsteps?Ê  SetHarmReductionCheck-inScheduletopromotemaintenance

Ê  Ifnotalreadyinlong-termmentalhealthcare,connectclienttodounderlyingworkaswellasaddressbehavioralissues

Ê  Possiblereferraltoaprofessionalorganizer

PreparatoryPhase

CriticalPhase

InventoryPhase

RecoveryPhase

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RecoveryPhase–Days/Weeks/MonthsFollowingSafetyDay

Ê  ProcessEventwithClientwiththeunderstandingthattheclienthasgonethroughatraumaticeventÊ  CreatespaceforunderstandingandprocessingÊ  Donottrytorationalizeclient’sstrongfeelingsaway

Ê  Thiswilltakeaslongasitneedstotake

Ê  Mayrequiresometraumaprocessinginterventions

Ê  WorkwithteamtodevelopHarmReductionandMaintenancePlantocontinueprogressbeyondSafetyDay

Ê  Consult,consult,consult

PreparatoryPhase

CriticalPhase

InventoryPhase

RecoveryPhase

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Implications

Implications

Ê  Weneedamajorre-haulofinterventionapproachesforseverehoardingsituationsÊ  Wecan’tdotherapyinthemiddleofastorm

Ê  ApplyingdisasterpsychologytohoardingcleanoutswillhelpustodevelopstrategiestoworkingwithindividualswhohoardÊ  Helptoavoidordecreasetheintensityoftraumaticoutcomesforthe

homeowner

Ê  ReframingthiseventwillhelpprofessionalsandfamilymembersdevelopcompassionforindividualswhohoardinanewwayÊ  Recoveryprocessesareexpectedandaccommodatedinotherareasof

traumaticcrises

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Questions?

www.thehoardingproject.org

Weoffernationalphoneconsultationservicesforprofessionals,familymembers,

andpeoplewhohoard.

Contactusbyemailtoscheduleaconsultationtoday!

info@thehoardingproject.org

References

Ê  Caplan,G.(1964).Principlesofpreventivepsychiatry.NewYork:BasicBooks.

Ê  CERTBasicTraining,2011

Ê  Gibbs,M,Lachenmeyer,J.R.,Broska,A.andDeucher,R.(1996).EffectsoftheAVIANCAAircrashonDisasterWorkers.InternationalJournalofMassEmergenciesandDisasters14(1):23-32.

Ê  Lindemann,E.(1944).Symptomatologyandmanagementofacutegrief.AmericanJournalofPsychiatry,101,141-148.

Ê  Norris,F.H.,Friedman,M.J.,Watson,P.J.,Byrne,C.M.,Diaz,E.,&Kaniasty,K.(2002a).60,000disastervictimsspeak:Part1.Anempiricalreviewoftheempiricalliterature,1981-2001.Psychiatry,65,207-239.

Ê  Rodriguez,C.I.,Herman,D.,Alcon,J.,Chen,S.,Tannen,A.,Essock,S.,&Simpson,H.B.(2012).PrevalenceofHoardingDisorderinIndividualsatPotentialRiskofEvictioninNewYorkCity:APilotStudy.TheJournalofNervousandMentalDisease,200(1),10.1097/NMD.0b013e31823f678b.http://doi.org/10.1097/NMD.0b013e31823f678b

Ê  Sundin,E.C.&Horowitz,M.J.(2003).Horowitz'sImpactofEventsScale:Evaluationof20yearsofuse.PsychosomaticMedicine,65,870-876.

Ê  Tompkins,M.(2014).Clinician'sGuidetoSevereHoarding:AHarmReductionApproach.Springer.