compulsive hoarding, housing stabilization and fair housing: a model for intervention jesse...
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Compulsive Hoarding, Housing Stabilization and Fair Housing: A Model for Intervention
Jesse Edsell-VetterCase Management Specialist
Metropolitan Boston Housing PartnershipBoston, Massachusetts
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Today’s Objectives Define compulsive hoarding Understand the health and safety risks for
those living in cluttered homes Discuss the role of reasonable accommodation
and fair housing in preventing eviction Explore strategies for addressing compulsive
hoarding Identify the role of community partnerships in
addressing compulsive hoarding
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What is Compulsive Hoarding?
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DefinitionCompulsive hoarding is: the acquisition of, and failure to discard, a large
number of possessions that appear to be useless or of limited value
living spaces are sufficiently cluttered so as to preclude activities for which those spaces were designed
significant distress or impairment in functioning caused by the hoarding (Frost & Hartl, 1996)
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Hoarding, Squalor and Animal Hoarding Hoarding and squalor are not the same Squalor is defined as filthiness or degradation
from neglect Hoarding is related to the volume of clutter in the
unit, not the cleanliness of the unit Animal hoarding involves the hoarding of
animals. It is best to contact the MSPCA or Tufts University Animal Hording Consortium if you have concerns about animal hoarding
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More On Hoarding Hoarding is a mental health disorder Hoarding is not a moral issue; It is not caused by
laziness, lack of standards, lack of responsibility It is often characterized by low insight: others are
often more aware of/bothered by the clutter than the individual
92% of individuals with hoarding have 1 or more other mental health (e.g., depression, generalized anxiety, obsessive-compulsive disorder, social phobia)
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Demographics & Prevalence
Saving begins in childhood ~ age 13 Average age in treatment = 50 Marital Status: tend to be single
Low marriage rate, high divorce rate, tend to live alone Education: ranges widely Family history of hoarding is common Emerging Research: ~ 3-5% of US Population (15 million
people)
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Course of Compulsive Hoarding
Little evidence for history of material deprivation
Hoarding may be precipitated by loss
Chronic or worsening course
Insight fluctuates
Severity range from mild to life-threatening
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Reasons for Saving
Sentimental - “This represents my life. It’s part of me.”
Instrumental - “I have a need this. I could use this.”
Intrinsic - “This is beautiful.”
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Insight People with hoarding problems have varying
levels of insight about the extent of their problem and the ways that it impacts them & those around them
Non-insightful Insightful but unmotivated Insightful, motivated, but noncompliant
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Clutter / Disorganization
Random piles
Fear of putting things out of sight
Indecisiveness
Churning
Goat Paths
Fear of making wrong decision
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Compulsive Hoarding and SafetyCommon health/safety violations, activities of daily living, impact of persons with disabilities
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Common Code Violations Blocked egress Fire load
Fire hazards (items in oven, near heat source, etc)
Trip hazards Crush hazards Infestation Plumbing not functioning Sanitation concerns (rotting food, feces, needles, etc) Structural safety (weight of items)
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Tenancy PreservationUsing Fair Housing Laws to Address Compulsive Hoarding and Stabilize Tenancies
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Fair Housing and HoardingThe Fair Housing Act defines persons with a
disability to mean those individuals with mental or physical impairments that substantially limit one or more major life activities (US Dept. of Justice website)
Compulsive hoarding is a mental impairment that, in most cases, limits a persons ability to conduct one or more major life activities (ex. Showering, cooking, etc)
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Fair Housing and Hoarding Compulsive hoarding is a disability Clients with a compulsive hoarding problem have the right to
request a reasonable accommodation from their property owner or housing subsidy provider
A reasonable accommodation would still require that minimum health and safety requirements are met by the client
Reasonable accommodation requests will likely primarily be requests for additional time to come into compliance with housing codes.
Reasonable accommodation plans will also help to hold the client accountable.
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To Whom It May Concern:
I am writing to request a reasonable accomodation because of a disability. I would like to propose the following plan to address the issues you have raised in my home:
I will immediately clear an egress path for emergency purposes.
I request an additional time to bring the living room, bedroom and kitchen into compliance. I request an initial 6 weeks to bring the living room into compliance and will work with you and those assisting me to determine appropriate timelines moving forward based on the progress made
I will work with local organizations to reduce clutter in my home and develop a plan to ensure that it will not become re-cluttered moving forward.
Sincerely,
Example: Reasonable Accomodation Letter
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Fair Housing and HoardingRefer to Fair Housing and Hoarding FAQ sheet
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Addressing Compulsive Hoarding in Subsidized Housing
Annual InspectionsStatement of Family ObligationsTerminationMBHP's Model
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Tools in Subsidized Housing Annual Inspections Statement of Family Obligation Termination from the subsidized housing
program Appeal of termination with the opportunity to
be reinstated with conditions
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Annual Inspection
Ability to require tenant caused violations to be addressed in order to pass inspection (including clutter/hoarding)
Opportunity to monitor concerns about a potential hoarding problem over time
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Statement of Family Obligations
The Section 8 program and other subsidized programs require recipients to sign a Statement of Family Obligations
The Statement of Family Obligations outlines the basic requirements of participation in the subsidy program
The Statement of Family Obligations includes maintaining the unit in a clean and safe manner
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Termination and Appeals
Program participants can be terminated for failure to meet their responsibilities under the Section 8 and other subsidized programs
Subsidy recipients receive information about reasonable accomodation and the appeal process
Appealing with a specific, supported plan offers an opportunity for the unit to come into compliance and for the tenancy to be stabilized
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Referral is received
Metropolitan Boston Housing Partnership's Model
Property Owner
Housing Inspector
Code Enforcement
Case ManagersHome Visit Conducted
Case Management Plan Developed
Re-inspection with Case Manager Present
Voluntary Compliance
Non-Compliance
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A Compulsive Hoarding ModelDeveloped by Steketee and Frost, 2007
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Beliefs &Meaning of Possessions Beauty/aesthetics Memory Utility/opportunity Opportunity/
uniqueness Sentimental Comfort Safety
Identity/potential identity
Control Mistakes Responsibility/waste Completeness Validation of worth Socialization
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Emotions associated with Objects Positive Emotions
Pleasure Excitement Pride Relief Joy Fondness Satisfaction
Negative Emotions Grief/loss Anxiety Sadness Guilt Anger Frustration Confusion
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Quotes from Clients “The idea of being homeless is like death for me.
But after so much loss in my life, I can’t imagine parting with my things – they are all I have left. They are my memories and life.”
“I am a man of knowledge. What would I be if I got rid of my library and other things?”
“What friends? I’ve spent the past 15 years playing with my stuff. I don’t have any human relationships only my stuff.”
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Deciding to InterveneWhy address hoarding?
The tenant/client’s perspective
Intervention roles
The power dynamic
Effective Communication Strategies
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Primary Intervention Roles
There are two primary roles when intervening in a compulsive hoarding case: The enforcement role: clarifies what is causing
code violations, could lead to eviction, The support role: offers the assistance needed to
meet codes, prevent eviction, address underlying causes, access resources
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Power DynamicsBecause of power dynamics a tenant/client may:
Discard items they are not ready to get rid of Say yes to a cleanout when they are not ready Act to please others (including YOU) Act defensively Act out of fear rather than internal motivation
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Ineffective Communication Strategies Make decisions (about a plan of action) for a
tenant/client Argue or Persuade Pressure the tenant/client to discard Tell the tenant/client how to feel Give verbal and non-verbal cues that are
judgmental or negative in nature
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Effective Communication Strategies Be clear about expectations and limitations Ask open-ended questions Reflectively listen Use respectful, non-judgmental language Mirror the language used by the tenant/client “Work with” the tenant instead of “doing for”
them
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What Makes Hoarding so Difficult to Treat? Beliefs and Emotions associated with
possessions Core beliefs Vulnerabilities (Time, Family History, Trauma, etc.)
Co-morbid Conditions (Mental and Physical Health)
Problematic Thinking Motivation
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Problematic Thinking in Hoarding All-or-nothing thinking
Most, everything, nothing Overgeneralization
Always, never Jumping to conclusions
I’ll need this just as soon as I don’t have it anymore
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Problematic Thinking in Hoarding Moral reasoning
Waste not, want not I’m responsible for other people’s well being
Labeling I’m an idiot She’s just greedy
Under- and over-estimating I can read all these eventually I won’t be able to handle getting rid of those
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Motivational Challenges Factors Influencing Motivation
How much social support? Are there any home visitors? Can anyone monitor homework? How depressed is the client? Can client tolerate discomfort?
What makes people motivated to change? Confidence Importance
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Strategies for Enhancing Motivation Ask open-ended
questions Listen with reflection Summarize Affirm self-efficacy Ask evocative
questions Explore pros & cons
Ask for elaboration Use extreme contrasts Look forward Look back Reframe Provide feedback Encourage change talk
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Tools You Can UseExposure: Practicing Sorting & Discarding, Non-Shopping Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts
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Exposure: Sorting, Organizing & Discarding Exposure (practice) is the only way to overcome
avoidance and begin to solve the clutter problem Avoidance is fueled by anxiety Anxiety during exposure should be expected at first
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What is Being Avoided Distress Decisions Feelings of loss Feelings of
vulnerability
Making mistakes Losing opportunities Losing information Depression Worries about memory
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Gradual Exposure for Sorting and Discarding
Work in easier locations first (with highest motivation)
Work on easier objects first; set aside harder objects
into box “to be sorted later”Objects saved for sentimental reasons are often more difficult
For dependent decision-makers, gradually reduce assistance in making decisions
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Sorting in 3 Piles Keep- Discard- ‘I Don’t Know’ All items in Keep pile need to have a final location
by end of sorting session Discard can mean: recycle, sell, give away, donate,
garbage, etc. ‘I Don’t Know’ pile is intended as temporary during
sorting process to keep things moving quickly; a decision about all items in this pile must be made before the end of the sorting session
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Helpful Hints for Sorting Keep to 3 piles/ do not sub-divide until the end of
sorting Limit amount of time for each sorting session Use a timer to help monitor time- start & stop Sort in an un-cluttered area (sometimes an area will
need cleared for this purpose); this is called a staging area
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Strategies for Home Visits Time Limited (1-2 hours) Check-In Set collective agenda Exposure work Use of Pictures
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A Case Study: MaureenCollaborative Intervention
What works!
Resources
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Maureen Single, Caucasian woman, age 60 Department of Mental Health and SSDI client Total of eleven Axis I and Axis II diagnosis Currently takes 13 mental health medications Lives independently; MBHP holds housing
voucher Substance Abuse and Trauma History
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MBHP
Case Study: Team work
Boston University Clinician
Individual Therapy
Group Therapy
Substance Abuse Treatment
Home Visits
Occupational Therapist
Visiting Nurse
Flexible Funds for cleanout
Inspection Dept reasonable accommodation
Organizational Supplies
Monitoring
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A Collaborative or Team Based Approach Shared responsibility for case management
Greater opportunity for resource identification
Increases range of knowledge and skills available to the client/tenant
Reduce resources required for any one agency to resolve crisis situation
Increases the networking potential for all organizations that can be used to address future needs
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Early identification and intervention Setting specific and realistic timeframes Helping tenant/client learn to set limits and self-monitor
their hoarding Work to understand why the ‘stuff’ is important to the client Post-compliance monitoring Staff and community education Building community and provider partnerships
What Works
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What Does Not Work
Avoiding addressing the hoarding problem Removing the clutter Working in isolation- as a person or agency Finger pointing or turf issues Unsupported clean outs without client present Lack of follow-up monitoring