Hoarding presentation 2

Hoarding Assessment and Intervention at HOC

1HOC Housekeeping In Service

Training Objectives

Understand the complex reasons for hoarding Learn to identify hoarding behaviors Learn about effective and ineffective intervention

strategies when treating hoarding Have a better understanding of roles of all HOC staff

involved, as well as outside agencies. Be able to effectively communicate with other staff and

across the agency regarding specific situations.


Compulsive Hoarding:Proposed DSM-V Criteria Persistent difficulty discarding or parting with personal

possessions, even those of apparently useless or limited value, due to strong urges to save items, distress, and/or indecision associated with discarding.

The symptoms result in the accumulation of a large number of possessions that fill up and clutter the active living areas of the home, workplace, or other personal surroundings (e.g., office, vehicle, yard) and prevent normal use of the space. If all living areas are uncluttered, it is only because of others’ efforts (e.g., family members, authorities) to keep these areas free of possessions.

Compulsive Hoarding:Proposed DSM-V Specifiers Specify if with Excessive Acquisition

If symptoms are accompanied by excessive collecting or buying or stealing of items that are not needed or for which there is no available space.

Specify whether hoarding beliefs and behaviors are currently characterized by: Good or fair insight: Recognizes that hoarding-related beliefs and

behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.

Poor insight: Mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

Delusional: Completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

Failing to Discard Items

Items appear useless to others Identifying value

Instrumental Sentimental Intrinsic

This results in the growth of items and interferes with the functionality and use of living spaces.

Why is hoarding a problem? Safety of individual:

1. Fire

2. Falls

3. Health hazards

4. Increased social isolation Safety of the community

1. Fire

2. Infestations Legal: Violation of code and HUD regulation. Financial: Cleaning up is expensive, buying items create

debt


Illustrations…..

Where is the stove?????


Bedroom

I am sure my bed was somewhere in this room!


Stairwell

Goat path…


Estimated Prevalence Rates

26 in 1000 - Whole Spectrum of Hoarding 169,000 estimated cases in Massachusetts 16,180 estimated cases in Boston HOC has 50 cases “on record” in its residences

.5 in 1000 - Diogenes SyndromeGross self-neglect, domestic squalor, hoarding of trash 3250 estimated cases in Massachusetts 310 estimated cases in Boston

(Based on overall populations of 6,500,000 for MA and 622,351 for Boston)

Co-Morbid Diagnoses

Major Depression (57%) Social Phobia (29%) Generalized Anxiety Disorder (28%) Obsessive Compulsive Disorder (17%) Specific Phobia (12%) Post-Traumatic Stress Disorder (6%) Dysthymia (4%) Panic (2%) No Other Diagnosis (8%)

Frost, Steketee, Tolin, & Brown, 2006

Conceptual Model of Compulsive Hoarding

Personal & Family Vulnerability Factors Information Processing Problems

Thoughts & Beliefs

Emotional Responses

Efforts to Obtain Pleasure by Saving(Positive Reinforcement)

Escape & Avoidance of Unpleasant Emotions(Negative Reinforcement)

Cluttering and Difficulty Discarding

Steketee & Frost, 2007

What can be done?

Each situation is different An accurate assessment is essential In most situations, hoarding does not have a cure –

it is a chronic condition. Research show that a multidisciplinary approach is

the most effective method of intervention. Some therapy techniques have been successful in

reducing hoarding behaviors. This is a long term treatment, which requires insight and motivation.


Thoughts: Decision Making

Perfectionism Fear of making

mistakes Missed opportunities Being caught

unprepared Distorted perception of

others’ spaces Focus on benefit of

saving and risk of letting go

All-Or-Nothing Cluttered Space Spartan Room

Decisions are complicated by fears

Avoidance of regrets, pain, or mistakes

“But what if…”

Emotional Attachment

Possessions as extension of self Attach greater

sentiment Comforted by

possessions Fear of losing part of

oneself or one’s identity

Reaction to losses Grief-like reactions Ruminations Emotional discomfort

Evaluation Process:Assessment of Individual Appearance Cognitive status Executive functioning ability Medical and mental health symptoms Insight into hoarding behaviors Motivation to address hoarding behaviors Relations with others Family history - mental health and hoarding behaviors Ability to consent to and participate in treatment

interventions (Capacity-Risk Model; Soniat & Micklos, 2010)

Who should be involved?

Housing Management (inspectors, managers) Federal Programs Resident Services County’s Health & Human Services (e.g., CPS,

APS, case management) County’s Code Enforcement and Fire Department Community mental health providers


Housing Management

Housing Management Mission Description The Housing Management Division is responsible for managing the

affordable properties in HOC's housing portfolio that receive State, Federal and local subsidies.

Through both in-house management and contractual arrangements, the division:

Ensures occupancy by qualified households under numerous Federal, State and local affordable housing programs.

Ensures that all dwelling units are maintained at or above community norms, and in compliance with Federal housing programs.

Enforces the terms and conditions of residents' leases. Performs preventive maintenance on all units and building systems in order

to extend their useful life. Conducts frequent resident surveys.

HOC Housekeeping In Service 18

Roles I: Housing Management1. Conduct annual inspection.2. Respond to complaint from neighbors.3. In known cases of previous violations, inspections are done,

when possible, together with on-site RS staff.4. Managers have a relationship with residents and express

concerns directly to resident5. Follow up with a letter and request an office conference,

usually within two weeks.6. Time frame for re-inspection will be decided, usually within 30

days. 7. A service agreement will be used to define the necessary steps

to resolve situation.8. If service agreement is not effective, a referral is made to FP

for a supervisory conference.9. Close collaboration between Housing Management and

Resident Services is KEY to success.


Roles II: Inspectors for HCV1. Conduct an annual inspection. Residents with a history of late

inspection get 180-day notice.2. Respond to landlords, community or HOC staff’s complaints.3. Determines the degree of violation.4. Verbally explains to resident the nature of the violations and follows up

with a letter copied to landlord.5. Notifies RS, usually via email.6. Do not refer to Disability Services directly. This will be decided by RS

staff.7. Give 30 days to remedy violations, then follows up with another

inspection.8. If situation not resolved, refer to Federal Programs9. If resident can provide documentation for inability to follow up with

inspection process, inspector may grant extension.10.Communicate with RS and FP staff to ensure follow up and positive

outcome. Collaboration is KEY. RS will update inspector on status of progress.


Resident Services

Resident Services links HOC clients to a wide range of services intended to allow individuals and families to achieve self-sufficiency, gain independence, assimilate into the broader community and to successfully retain their housing .

Resident Services also provides counseling support and service linkage to assist elderly and disabled residents to live independently in comfort and with dignity.


Role IV: Site-Based Counselors1. Conduct a home visit (routine visit or in response to a complaint/referral). A

complaint home visit is often conducted with onsite Housing Management.2. Perform an assessment of the severity of condition and mental status of the

resident, using a hoarding scale when applicable.3. Identify available resources for resident.4. Determine which referrals need to be made and which agencies need to be

involved (e.g. Adult and child Protective Services).5. Participate in an Office Conference with Housing Management and resident. 6. Assist in establishing a plan of action (e.g. Service Agreement) and follow up

on plan in collaboration with other HOC staff and outside entities.7. Send a formal letter to resident to address issues subsequent to the Office

Conference.8. Monitor weekly/bi-weekly/monthly to ensure progress is made toward goals.9. If progress is not made, collaborate with Housing Management. Referral to

FP.10. Prepare a Social Summary & Chronology for the FP Supervisory Conference.11. If notice to vacate is recommended, the counselor will continue to work with

resident in an attempt to resolve the issue and to avoid eviction.12. If termination is enforced, the counselor will seek to engage resources and

services toward a safe alternative housing plan.


Roles V: Federal Programs

For HCV Residents:1. Becomes involved after 2nd failed inspection.2. Assigns an investigator to begin termination process.3. Send termination letter to resident. Copy RS manager/supervisor.

Resident has 10 days to request an informal hearing.4. Resident Services will attempt to contact resident to offer supportive

services.5. If appeal is not received FP notifies HRD to terminate.6. If resident requests a hearing, investigator will schedule and notify

resident and RS staff.7. Hearing Officer will render decision within 30 days.8. If hearing officer upholds termination resident has the right to request

a hearing board.9. Hearing board will render decision.


Roles V: Federal Programs cont.For Public Housing:1. Becomes involved if resident does not follow through with

recommendations from case conference .2. Supervisory conference scheduled. RS, HM and resident invited.

It is held with or without the resident.3. Staff in supervisory conference attempts to reach a consensus

decision.4. Recommendations range between a service agreement, consent

judgment or Lease Enforcement Panel (LEP).5. LEP may decide to send case back to FP with recommendation or

may agree to issue a notice to vacate.6. If a notice to vacate is issued resident can request a hearing

board.7. Hearing board will render decision.


Role VI: County Fire, Inspection & Police: Respond to calls from neighbors and Housing Management. If entry is permitted by the occupant, by administrative search

warrant or due to an emergency incident where chain of custody is maintained, enter the premises and inspect for compliance of all fire and life safety codes. This would include proper smoke detection, access to and operation of “Escape” windows, as well as the “safe” operation of all water, heating and cooking appliances.

Inspect all the common areas and act on a concern found there. Can condemn a unit if conditions are deemed unsafe. Work with

property management to address issue.


Role VII: Health & Human Services The role of Adult and Child Protective Services: APS and CPS only intervene in extreme cases of

abuse or neglect and/or when loss of home is imminent for a vulnerable adult. Resident Counselors are mandatory reporters, but anyone can make a referral. HHS has resources for services in the face of imminent eviction and offers emergency shelter.

County Social Services to adults may also be involved. They provide case management and assistance in accessing resources. They are limited in capacities and have a wait list.


HOC goals for working with chronic cases:

1. Prevent repeated crises.

2. Improve collaboration internally.

3. Collect data on prevalence and severity.

4. Foster a long term plan for stability.


Now, let’s look at some case studies..


How to de-clutter


1. Select target area2. Assess possessions3. Create categories4. Select a starting spot5. Start sorting and de-cluttering6. Continue until target area is cleared7. Use space appropriately8. Prevent new clutter

Do Be safe (gloves, wash hands, look where you touch) Be positive Make supportive comments Foster self determination Be creative Let the person lead the process Come ready for hand on experience Believe in the client’s ability Highlight strengths Stay calm Take care of yourself Stay in touch with other staff and work as a team


Do not

Touch items without the person’s explicit permission Be judgmental Give negative comments Let the amount of stuff overwhelm you De-clutter behind the client’s back Minimize the challenges faced Make decisions Equate the clutter with the person Argue or try to persuade


Challenging, not Confronting

How many do you already have? Is that enough? Do you have enough time to use, review, or read it? Have you used this during the past year? Do you have a specific plan for this item? By when? Does this fit with your values and needs? Is it important because you’re looking at it now? Is it current, of good quality, accurate, reliable? Would you buy it again if you didn’t already own it? Do you really need it? Could you get it again if you really needed it? Do you have enough space for this?

Hoarding presentation 2

Health & Medicine

Transcript of Hoarding presentation 2