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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
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
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

definition
Definition

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)

hoarding squalor and animal hoarding
Hoarding, Squalor and Animal Hoarding

Hoarding and squalor are not the same

Squalor is defined as filthiness or degradation from neglect

Hoarding is related to the volume of clutter in the unit, not the cleanliness of the unit

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

more on hoarding
More On Hoarding

Hoarding is a mental health disorder

Hoarding is not a moral issue; It is not caused by laziness, lack of standards, lack of responsibility

It is often characterized by low insight: others are often more aware of/bothered by the clutter than the individual

92% of individuals with hoarding have 1 or more other mental health (e.g., depression, generalized anxiety, obsessive-compulsive disorder, social phobia)

demographics prevalence
Demographics & Prevalence

Saving begins in childhood ~ age 13

Average age in treatment = 50

Marital Status: tend to be single

Low marriage rate, high divorce rate, tend to live alone

Education: ranges widely

Family history of hoarding is common

Emerging Research: ~ 3-5% of US Population (15 million people)

course of compulsive hoarding
Course of Compulsive Hoarding

Little evidence for history of material deprivation

Hoarding may be precipitated by loss

Chronic or worsening course

Insight fluctuates

Severity range from mild to life-threatening

reasons for saving
Reasons for Saving

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

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

Intrinsic - “This is beautiful.”

insight
Insight

People with hoarding problems have varying levels of insight about the extent of their problem and the ways that it impacts them & those around them

Non-insightful

Insightful but unmotivated

Insightful, motivated, but noncompliant

clutter disorganization
Clutter / Disorganization

Random piles

Fear of putting things out of sight

Indecisiveness

Churning

Goat Paths

Fear of making wrong decision

common code violations
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)

fair housing and hoarding
Fair Housing and Hoarding

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)

fair housing and hoarding18
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.

slide19
To Whom It May Concern:

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

I will immediately clear an egress path for emergency purposes.

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

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

Sincerely,

Example: Reasonable Accomodation Letter

fair housing and hoarding20
Fair Housing and Hoarding

Refer to Fair Housing and Hoarding FAQ sheet

addressing compulsive hoarding in subsidized housing
Addressing Compulsive Hoarding in Subsidized Housing

Annual Inspections

Statement of Family Obligations

Termination

MBHP's Model

tools in subsidized housing
Tools in Subsidized Housing

Annual Inspections

Statement of Family Obligation

Termination from the subsidized housing program

Appeal of termination with the opportunity to be reinstated with conditions

annual inspection
Annual Inspection

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

Opportunity to monitor concerns about a potential hoarding problem over time

statement of family obligations
Statement of Family Obligations

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

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

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

termination and appeals
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

slide26

Metropolitan Boston Housing Partnership's Model

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

beliefs meaning of possessions
Beliefs &Meaning of Possessions

Beauty/aesthetics

Memory

Utility/opportunity

Opportunity/ uniqueness

Sentimental

Comfort

Safety

Identity/potential identity

Control

Mistakes

Responsibility/waste

Completeness

Validation of worth

Socialization

emotions associated with objects
Emotions associated with Objects

Positive Emotions

Pleasure

Excitement

Pride

Relief

Joy

Fondness

Satisfaction

Negative Emotions

Grief/loss

Anxiety

Sadness

Guilt

Anger

Frustration

Confusion

quotes from clients
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.”

slide31
Why address hoarding?

The tenant/client’s perspective

Intervention roles

The power dynamic

Effective Communication Strategies

Deciding to Intervene
primary intervention roles
Primary Intervention Roles

There are two primary roles when intervening in a compulsive hoarding case:

The enforcement role: clarifies what is causing code violations, could lead to eviction,

The support role: offers the assistance needed to meet codes, prevent eviction, address underlying causes, access resources

power dynamics
Power Dynamics

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

ineffective communication strategies
Ineffective Communication Strategies

Make decisions (about a plan of action) for a tenant/client

Argue or Persuade

Pressure the tenant/client to discard

Tell the tenant/client how to feel

Give verbal and non-verbal cues that are judgmental or negative in nature

effective communication strategies
Effective Communication Strategies

Be clear about expectations and limitations

Ask open-ended questions

Reflectively listen

Use respectful, non-judgmental language

Mirror the language used by the tenant/client

“Work with” the tenant instead of “doing for” them

what makes hoarding so difficult to treat
What Makes Hoarding so Difficult to Treat?

Beliefs and Emotions associated with possessions

Core beliefs

Vulnerabilities (Time, Family History, Trauma, etc.)

Co-morbid Conditions (Mental and Physical Health)

Problematic Thinking

Motivation

problematic thinking in hoarding
Problematic Thinking in Hoarding

All-or-nothing thinking

Most, everything, nothing

Overgeneralization

Always, never

Jumping to conclusions

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

problematic thinking in hoarding38
Problematic Thinking in Hoarding

Moral reasoning

Waste not, want not

I’m responsible for other people’s well being

Labeling

I’m an idiot

She’s just greedy

Under- and over-estimating

I can read all these eventually

I won’t be able to handle getting rid of those

motivational challenges
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?

ConfidenceImportance

strategies for enhancing motivation
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

slide41
Exposure: Practicing Sorting & Discarding, Non-Shopping Trips, Behavioral Experiments, Homework, Home Visits, Supported CleanoutsTools You Can Use
exposure sorting organizing discarding
Exposure: Sorting, Organizing & Discarding

Exposure (practice) is the only way to overcome avoidance and begin to solve the clutter problem

Avoidance is fueled by anxiety

Anxiety during exposure should be expected at first

what is being avoided
What is Being Avoided

Distress

Decisions

Feelings of loss

Feelings of vulnerability

Making mistakes

Losing opportunities

Losing information

Depression

Worries about memory

gradual exposure for sorting and discarding
Gradual Exposure for Sorting and Discarding

Work in easier locations first (with highest motivation)

Work on easier objects first; set aside harder objects into box “to be sorted later”

Objects saved for sentimental reasons are often more difficult

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

sorting in 3 piles
Sorting in 3 Piles

Keep- Discard- ‘I Don’t Know’

All items in Keep pile need to have a final location by end of sorting session

Discard can mean: recycle, sell, give away, donate, garbage, etc.

‘I Don’t Know’ pile is intended as temporary during sorting process to keep things moving quickly; a decision about all items in this pile must be made before the end of the sorting session

helpful hints for sorting
Helpful Hints for Sorting

Keep to 3 piles/ do not sub-divide until the end of sorting

Limit amount of time for each sorting session

Use a timer to help monitor time- start & stop

Sort in an un-cluttered area (sometimes an area will need cleared for this purpose); this is called a staging area

strategies for home visits
Strategies for Home Visits

Time Limited (1-2 hours)

Check-In

Set collective agenda

Exposure work

Use of Pictures

maureen
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

case study team work
MBHPCase 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

a collaborative or team based approach
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
what works
Early identification and intervention

Setting specific and realistic timeframes

Helping tenant/client learn to set limits and self-monitor their hoarding

Work to understand why the ‘stuff’ is important to the client

Post-compliance monitoring

Staff and community education

Building community and provider partnerships

What Works
what does not work
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

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