Compulsive Hoarding, Housing Stabilization and Fair Housing: A Model for Intervention

1. Compulsive Hoarding, Housing Stabilization and Fair Housing: A Model for Intervention Jesse Edsell-Vetter Case Management Specialist Metropolitan Boston Housing Partnership Boston, Massachusetts

2. 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

3. What is Compulsive Hoarding?

4. 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)

5. 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

8. 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)

9. 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)

10. 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

11. 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.”

12. 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

13. Clutter / Disorganization Random piles Fear of putting things out of sight Indecisiveness Churning Goat Paths Fear of making wrong decision

14. Common health/safety violations, activities of daily living, impact of persons with disabilities Compulsive Hoarding and Safety

15. 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)

16. Using Fair Housing Laws to Address Compulsive Hoarding and Stabilize Tenancies Tenancy Preservation

17. 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)

18. 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.

19. 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

20. Fair Housing and Hoarding Refer to Fair Housing and Hoarding FAQ sheet

21. Addressing Compulsive Hoarding in Subsidized Housing Annual Inspections Statement of Family Obligations Termination MBHP's Model

22. 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

23. 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

24. 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

25. 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

26. 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

27. Developed by Steketee and Frost, 2007 A Compulsive Hoarding Model

28. 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

29. Emotions associated with Objects Positive Emotions Pleasure Excitement Pride Relief Joy Fondness Satisfaction Negative Emotions Grief/loss Anxiety Sadness Guilt Anger Frustration Confusion

30. 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.”

31. Why address hoarding? The tenant/client’s perspective Intervention roles The power dynamic Effective Communication Strategies Deciding to Intervene

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. Exposure: Practicing Sorting & Discarding, Non-Shopping Trips, Behavioral Experiments, Homework, Home Visits, Supported Cleanouts Tools You Can Use

42. 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

43. What is Being Avoided Distress Decisions Feelings of loss Feelings of vulnerability Making mistakes Losing opportunities Losing information Depression Worries about memory

44. 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

45. 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

46. 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

47. Strategies for Home Visits Time Limited (1-2 hours) Check-In Set collective agenda Exposure work Use of Pictures

48. Collaborative Intervention What works! Resources A Case Study: Maureen

49. 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

50. MBHP 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