3 ConfidentialityWe will be discussing live and historic case work as such it is important to feel that we are working safely. We agree:As much as possible to keep the identity of the client anonymisedTo maintain the confidentiality of other participants if we are discussing their case work in our own workplaceTo treat discussions about clients (professionals, family, etc.) with respectOthers?
5 Collector? Clutterer? Compulsive Hoarder? Normal savingCollectingClutteringHoarding
6 Social Problem? Yes. Isolation Risk Annoyance Illegal (due primarily to risk)ExpensiveRecurrentStigmaWe’ll spend more time on these later.
7 Psychological Problem? Yes. Hoarding disorder is previously recognised clinically under Obsessive Compulsive Personality Disorder on Axis II and Obsessive Compulsive Disorder on Axis IComorbid (found along side) with most recognised mental disordersHoarding disorder now has its own clinical recognition in Diagnostic and Statistical Manual of Mental Disorders V (American) and will be published the International Classification of Diseases (ICD) in 2014/15.Source: Singh, 2012/Mataix-Cols, 2012
8 Current Diagnostic Criteria Diagnostic and Statistical Manual of Mental Disorders criteria:Persistent difficulty discarding or parting with personal possessions, regardless of their actual value.The difficulty is due to a perceived need to save the items and distress associated with discarding them.Source: Mataix-Cols, et. al. 2010
9 Current Diagnostic Criteria (cont.) The symptoms result in the accumulation of a large number of possessions that congest and clutter active living areas and substantially compromise their intended use. If all living areas are uncluttered it is only because of the interventions of third parties (e.g. family members, cleaners, authorities)Source: Mataix-Cols, et. al. 2010
10 Current Diagnostic Criteria (cont.) The symptoms cause clinically significant distress or impairment in social, occupations or other important areas of functioning (including maintaining a safe environment for self and others).The hoarding symptoms are not due to another medical condition (e.g. brain injury, cerebrovascular disease, Prader-Willi Syndrome)Source: Mataix-Cols, et. al. 2010
11 Current Diagnostic Criteria (cont.) The hoarding is not better accounted for by the symptoms of other DSM-5 disorder (e.g. hoarding due to obsessions in Obsessive Compulsive Disorder (OCD), decreased energy in Major Depressive Disorder, delusions in Schizophrenia or another psychotic disorder, cognitive deficits in Dementia, restricted interests in Autism Spectrum Disorder)Source: Mataix-Cols, et. al. 2010
12 PrevalenceSome research finds that it hoarding disorder is more common in males but more females present for support (this has also been found to be equal in terms of how many of each gender hoard)No distinction between age, gender, ethnic group, socio-economic status, educational, occupational tenure92% of compulsive hoarders have at least one other mental health disorderSource: Singh, 2012/Sorrentino, 2007
13 Prevalence (cont.)Often family history of OCD and or hoarding (50% in three studies identified parent, sibling or offspring)Potentially only 5% of hoarders come to the attention of professionals.Source: Singh, 2012
14 Commonly hoarded items Old clothesMagazinesCD/Video/DVDPostPensOld notesBillsNewspapersReceiptsCardboard boxesBeadsFabricsPinsRagsOld medicationCanned foodOCD related: body products (nail, hair, excrement); rotten food; animalsSource: Pertusa et al, 2008
15 Development Hoarding often begins in adolescence Hoarding becomes significant problem for most people in their 30′sHowever, the average age of people seeking treatment is about 50, ranging mainly from early 40s’ to elderly adults. Source: Steketee, 2010
16 Where else?Other than their own environment, the person who compulsively hoards:May have storage spaces (or several)May be using space of other family, friends, etc.May be using external areas of private or other property including hallways, yards, vehicles, etc.
18 Conceptual Model Core beliefs and vulnerabilities Information processing deficitsProblems with emotional attachmentsBeliefs about possessionsEmotional reactionsReinforcement propertiesFrost/Steketee, 2007
19 Treatments largely ineffective ‘Therapist Guide’ details 43 clients entering a trial, notes a 14% dropout rate before commencement and a 26% reduction in hoarding symptoms at week After 26 sessions, with only 17 patients remaining, the result was a 45% reduction in hoarding behaviours. (Frost and Steketee 2007)Findings have consistently shown that people who hoard respond poorly to Exposure and Response Prevention (ERP), CBT and Selective Serotonin Reuptake Inhibitors (SSRI) medications (Starcevic and Brakoulias 2008).
20 What’s WorkedIntroducing other services who are able to help, including using the family and personal relationships as a route inConsistently working in an open and transparent way (ways to do that, and to fix it if it goes wrong)Working collaboratively (good cop/bad cop)Regular contactMotivational Interviewing has been found effective in joining up professional’s goals with user’s autonomy.
22 Our vision of support Hoarder Family Community Mental Health Social SupportEmergency ServicesLegal SystemsMedia
23 Their perspective Family Community Mental Health Social Support HoarderFamilyCommunityMental HealthSocial SupportEmergency ServicesLegal SystemsMedia
24 Reflective practice in action Deliberate pauseOpen perspectiveThinking processesExamination of beliefs, goals, practicesNew insights and understanding leading to actionBrett, 2012/York-Barr, et al, 2001
25 Hard enough for you…When we talk about the person who hoards, what do we mean by outcomes?Getting it safeKeeping it clearOthers?
27 What are the risks? Increased Risk of Fire The accumulation of combustible materials, such as newspapers, clothing and rubbishIncreased Risk of Structural DamageStructural damage threatens the occupants, public safety personnel and adjacent buildingsIncreased Risk of Disease, Injury and InfestationThe storage of hoarded items makes cleaning nearly impossible, which can lead to unsanitary living conditions and increases the risk of diseaseSource:
28 How do we assess risk? In terms of our discussion let’s look at: Is there a process at all?What is the process?How is it measurable?Is it hoarding specific?HoarderBehaviouralRiskPsychologicalRelational
29 CIR RatingsWith a show of hands how many people chose which rating on the CIR?We’ll have a brief discussion about why looking at:Subjective nature of assessmentPersonal standardsPersonal beliefs about cleanliness
30 When in doubt, check it out! While all tools (not all discussed today) work as a basic way of beginning the process of assessing risk, ensure that evaluations are not being made solely on the basis of ‘how it looks’ or ‘what could happen if…’Fire brigade assess for fire, environment assess for environmental issues, mental health services, advocacy, etc.Try to engage the client, all evidence points to this improving outcomes (albeit taking longer-but also lasting longer!).
31 Risk is real!As much as HoardingUK advocates for engaged practice that allows time and encourages real change, this is not always possibleRisk to others significantly highImpact on neighbours significantChildrenAnimalsKeep it safeCover your butt
32 Origins Trigger moves person from disorderly or over tidy to chaotic The cycle begins: acquiring behaviours override ability to discardShifts from manageable to unmanageable
33 We meet (or they’re discovered) Tenancy agreementsCouncil/Private processesAnti-social behaviour
35 MI Core PrinciplesClarifying contracts (additional principle to those identified by Miller and Rollnick)Expressing empathyDeveloping desire to change (develop discrepancy)Avoiding argument (roll with resistance)Supporting self-belief and self-responsibility (self-efficacy)Fuller and Taylor 2005
36 Open questionsQuestions that cannot be answered with a limited response, (i.e. “yes‟, “no”, “maybe”, “seven”, “next week”, etc.)Encourages individuals investigate and explore their own thinking, and moves Facilitators away from giving or offering “advice”.Members to do most the talking, with the goal to elicit statements that develop discrepancy and reflect self- efficacy.People tend to believe what they hear themselves say
37 AffirmationsAffirming statements help individuals acknowledge their positive behaviors and strengthsBuilds confidence in their ability to change.Allows for both recognition of difficulties and support of their strengthsValidates concerns and issuesConvey respect, understanding and support, and need to be both genuine and appropriate.
38 Reflective listeningMirrors individuals’ comments by repeating back what was said.Confirms understanding of what was saidClarifies sure you heard what you think you heardDeepens the conversation by allowing the individual to hear (again) what they said, which will help them understand their own thoughts better
39 Readiness questions What’s different for you now? Who else would like to see this change? Do you feel pressure from that person?Is there any risk to change?What do you feel might be some obstacles to that change?Is there any other information you need or skill you need to acquire to make this change?
40 SMART goals questionsTell me 3 reasons why this would be a good change and 3 reasons why it would be difficult.When you bring about this change, how will it look?If you’ve tried this before, what worked for you? What didn’t work? What do we need to do to overcome the previous obstacles?
45 ‘Precontemplation’-Gibberish alert! Can be thought of as ‘pre-change’“What appears to be ‘denial’ is often a normal stage in the change process which occurs prior to feeling ready to contemplate change (precontemplation), rather than a personality trait.”The facilitator can make the position worse by giving advice, etc.Establishing rapport is vital at this stageFuller and Taylor 2005
47 Contemplation-Gibberish alert! Thinking about changingSeeds of doubt have been sown.Awareness of some of the advantages of change and the disadvantages of their present behaviour is clearerHowever, a clear decision to change has not been made; they enjoy their current behaviour and know it will be difficult to change.Fuller and Taylor 2005
49 Gibberish alert! Okay, everyone knows what decision means… When there is a clear decision to change you will hear increased self-motivating language and reduced resistance talkMore willingness to make clear contracts for change and explore with you how to overcome any barriers.The mistake is to rush into action planning too quickly.Fuller and Taylor 2005
51 Active changes skills Most useful: Remember ambivalence may still be presentMonitor small stepsAppropriate information givingContinue to explore and work to remove barriersActive helpingCelebrate successFuller and Taylor 2005
52 Active change skills (cont.) Least useful:Assume the problem is solvedOver emphasise the negatives of previous behaviourProvide all the solutionsFuller and Taylor 2005
54 Maintenance skills Most useful: Be aware when support may still be required and when to let goBuild regular support for the new behaviourPositive feedback on progressAffirm and praiseBuild new skills/behavioursPlan for coping and lapseReinforcement of longer term goalsFuller and Taylor 2005
55 Maintenance skills (cont.) Least useful:Let go too earlyOver emphasise exploring previous behaviourHold them in dependencyFuller and Taylor 2005
57 Relapse skills Most useful: Frame as a part of learning Explore how the lapse occurredBuild strategies for next timeEmpathy/explore ambivalenceExplore strengths and who can helpReflect back self-motivating statements concerning desire ad confidence to learn from the experienceReturn to contemplation stageFuller and Taylor 2005
58 Maintenance skills (cont.) Least useful:Label as a failureSee your own work as a failureLecture, criticise, blameGive unwanted adviceGive up hopeFuller and Taylor 2005
60 Ready or not! L earn E xplore S low Down S upport It may be difficult to begin the process of moving things out, but a good place to start is by lessening (ideally stopping) acquisition.L earnE xploreS low DownS upport
61 Reasons for change Costs to staying the same Gains of staying the same Gains of changeCosts of changeFuller and Taylor 2005
62 Acquistion Anything new? Negotiate Hold for discussion Understand meaningAnything new?Keep this or notIf kept remove something elseNegotiate
63 Saving Behaviours Since worn Since used Two years? Seven years? How longSince wornSince usedSet a dateTwo years?Seven years?DiscardAnything older than
64 Motivation-Picture this! Take a photoMake changeSingh
65 Inability to discard Create hierarchy: What is important to the person?Highest risk priority?LESS IMPORTANTMOST IMPORTANTLEAST IMPORTANTLESS IMPORTANTMOST IMPORTANTSingh
66 Levels Mark a spot on the wall with something bright Clear in the area Watch the mark become more and more visibleSingh
67 Difficulty organising/decision making BREAKItDOWNTimeTaskProcess
68 SOMETHING I LIKE TO DO, USE, ETC. Attachment-Me spaceIdentify an ‘I want’Identify theareaClearUse thespaceSTUFFSOMETHING I LIKE TO DO, USE, ETC.Singh
69 Active change-Can/May/Won’t Three piles:Goes out immediatelyRemoved completelyCAN GOMoves to agreed spaceUsed, or discarded laterMIGHT GOStaysPut away appropriately or usedWON’T GOSingh
70 An ‘Open Relationship’? Fire brigade assess for fire, environment assess for environmental issues, etc.Mental Health treats the psychological disorderSupport groups break down stigma, increase social engagement, support changeAdvocacy works to ensure that professionals across a range of services are giving the client what they needRole playing e.g. Good Cop/Bad CopProfessionals are getting the support they need
71 It doesn’t happen Client will not engage Others demand ‘now’ Time runs outOthers?Fuller and Taylor 2005
72 It’s got to go! Removal Support in Identifying Time for labelling Oversight on the day
73 Treatment Group in London National Hoarding Treatment groupmeets once a month- the last Wednesday ofeach month from pm at:The Wordsworth Health Centre19 Wordsworth AveLondon, E12 6SUIslington support group (Islington Residents Only)Westminster Society for People with LearningDifficulties.More details can be obtained from the website: