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Compulsive Hoarding, Housing Stabilization and Fair Housing: A Model for Intervention. Jesse Edsell-Vetter Case Management Specialist Metropolitan Boston Housing Partnership Boston, Massachusetts. Today’s Objectives. Define compulsive hoarding

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Compulsive hoarding housing stabilization and fair housing a model for intervention l.jpg
Compulsive Hoarding, Housing Stabilization and Fair Housing: A Model for Intervention

Jesse Edsell-Vetter

Case Management Specialist

Metropolitan Boston Housing Partnership

Boston, Massachusetts


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Today’s Objectives A Model for Intervention

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? A Model for Intervention


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Definition A Model for Intervention

Compulsive 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 A Model for Intervention

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 A Model for Intervention

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 A Model for Intervention

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 A Model for Intervention

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 A Model for Intervention

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 A Model for Intervention

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 A Model for Intervention

Random piles

Fear of putting things out of sight

Indecisiveness

Churning

Goat Paths

Fear of making wrong decision


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Common health/safety violations, activities of daily living, impact of persons with disabilities

Compulsive Hoarding and Safety


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Common Code Violations impact of persons with disabilities

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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Using Fair Housing Laws to Address Compulsive Hoarding and Stabilize Tenancies

Tenancy Preservation


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Fair Housing and Hoarding Stabilize Tenancies

The 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 Stabilize Tenancies

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: Stabilize Tenancies

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 Hoarding Stabilize Tenancies

Refer to Fair Housing and Hoarding FAQ sheet


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Addressing Compulsive Hoarding in Subsidized Housing Stabilize Tenancies

Annual Inspections

Statement of Family Obligations

Termination

MBHP's Model


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Tools in Subsidized Housing Stabilize Tenancies

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 Stabilize Tenancies

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 Stabilize Tenancies

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 Stabilize Tenancies

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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Metropolitan Boston Housing Partnership's Model Stabilize Tenancies

Property Owner

Referral is received

Code Enforcement

Housing Inspector

Case Managers

Home Visit Conducted

Case Management Plan Developed

Re-inspection with Case Manager Present

Voluntary Compliance

Non-Compliance


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Developed by Steketee and Frost, 2007 Stabilize Tenancies

A Compulsive Hoarding Model


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Beliefs &Meaning of Possessions Stabilize Tenancies

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 Stabilize Tenancies

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 Stabilize Tenancies

“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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Why address hoarding? Stabilize Tenancies

The tenant/client’s perspective

Intervention roles

The power dynamic

Effective Communication Strategies

Deciding to Intervene


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Primary Intervention Roles Stabilize Tenancies

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 Dynamics Stabilize Tenancies

Because 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 Stabilize Tenancies

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 Stabilize Tenancies

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? Stabilize Tenancies

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 Stabilize Tenancies

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 Stabilize Tenancies

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 Stabilize Tenancies

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?

    ConfidenceImportance


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    Strategies for Enhancing Motivation Stabilize Tenancies

    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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    Exposure: Practicing Sorting & Discarding, Non-Shopping Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts

    Tools You Can Use


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    Exposure: Sorting, Organizing & Discarding Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts

    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 Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts

    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 Trips, Behavioral Experiments, Homework, Home Visits, Supported CleanoutsSorting 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 Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts

    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 Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts

    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 Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts

    Time Limited (1-2 hours)

    Check-In

    Set collective agenda

    Exposure work

    Use of Pictures


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    Collaborative Intervention Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts

    What works!

    Resources

    A Case Study: Maureen


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    Maureen Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts

    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 Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts

    Case Study: Team work

    Flexible Funds for cleanout

    Substance Abuse Treatment

    Home Visits

    Inspection Dept reasonable accommodation

    Boston University Clinician

    Organizational Supplies

    Group Therapy

    Occupational Therapist

    Visiting Nurse

    Monitoring

    Individual Therapy


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    A Collaborative or Team Based Approach Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts

    • 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 Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts

    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 Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts

    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


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