Ask the Care Manager: About Hoarding
by: JoAnn Ellenberger, LCSW, NHA, C-ASWCM
Dear Care Manager:
“I am having difficulty identifying “strengths” of my client who hoards. She actually responds more to her fears of being evicted than anything else. She loves living independently. That has been my approach so far to managing “the stuff.” I help her tidy things up during my visits, and she is appreciative of the help. She has a cleaning lady once a month. Any other ideas?”
Dear Care Manager:
“I have been asked by a family to work with a client who has so many belongings in his house that he cannot get around and won’t have people over because he is embarrassed by the clutter. He cannot let go of anything and the family does not know what to do. Please help!!”
Two to five percent of the population is thought to have hoarding behaviors, with the prevalence increasing with the aging population. The above examples are typical of what families and professionals face with hoarding behavior. The individual who hoards tends to be single or divorced, and has hereditary factors with first-degree relatives who were hoarders. A stressful life event, such as a car accident or a death of a loved one, can often precede the behavior. Co-morbidities such as depression and anxiety, social phobias, schizophrenia, dementia, mental retardation and OCD can also be present.
Defined as a persistent difficulty discarding or parting with possessions, regardless of an item’s worth, hoarding is due to a perceived need to save the item and the distress related to discarding it. The result is clutter in active living areas, and the compromising of the items intended uses. Unsanitary conditions and health risks follow, along with the inability to perform daily tasks such as bathing and cooking, social isolation, fire hazards, and potential for falls.
Persons who hoard are described as indecisive, procrastinators, avoiders, and perfectionists. Hoarding is a symptom that is difficult to treat, especially if the client is resistant.
Animal Hoarding is another form of hoarding. With a hoarder’s accumulation of animals, the living space can have deteriorating conditions including minimal standards of sanitation, and lack of space, nutrition, and necessary medical care for the animals. The client has a denial of the welfare and living conditions of the animals and the people who live in the household.
Care Managers: Build Trust
As a care manager, understanding your role in the intervention process is critical. Engaging your client and building trust is of utmost importance. Using your skills of professional counseling, minimize any reaction you have to the clutter. Find something to compliment and be nonjudgmental. Ask questions. Do not touch. Acknowledge the difficulty your client is experiencing with having to part with his or her possessions. Evaluate for safety, and remain aware how important your relationship is with your client.
Use Assessment Tools for Hoarding
Next, perform assessments on the client and the home. There are several hoarding assessment tools you could use:
- Saving Inventory Revised Tool
- Saving Cognition Inventory
- Hoarding Rating Scale
- Clutter Image Rating Scale
Working through one or more of these tools can help you and your client recognize the problem and help both of you determine where the clutter comes from. Is it acquiring? Is the difficulty with discarding? Is it both?
Other Assessment Tools
Other needed assessments are:
- Medical Assessment
- Evaluation of Activities of Daily Living
- Geriatric Assessment – which includes determining safety of the home environment
- Neurocognitive Screens – such as the Montreal Cognitive Assessment or the Saint Louis University Mental Status.
The Engagement Stage
The engagement stage and goal setting follows the assessment stage. Work with your client to determine what their changes will look like. Would it be having a place to sleep or a table where they can eat? Help your client set realistic harm reduction goals that are specific, measurable, achievable, results focused and time bound (SMART). How will they monitor progress towards the goals? What strategies will they use? Finally, develop a written contract spelling out these goals and strategies, and specify what has been agreed upon.
Treatment for Hoarding Individuals
Medications, cognitive and behavioral therapies can have a positive impact on hoarding.
- Antidepressants are used to treat secondary mood disorders.
- Cognitive behavioral therapy creates experiences that allow the client to face situations that cause anxiety with adaptive coping skills such as relaxations skills. The client can explore issues behind the hoarding behavior and learn ways to organize and categorize possessions, and improve decision-making skills. These strategies to reduce clutter and monitor progress provide structure and positive reinforcement to manage any setbacks that may occur.
- Cognitive restructuring and exposure to challenge beliefs around objects and explore results of discarding are also shown to be an effective tool.
- Harm reduction therapy can work in tandem with a clean-up company or professional organizer to deal with a perception problem.
- Family or group therapy can be helpful if there are other persons included in the household. At times an inpatient hospitalization can be appropriate.
- Another up and coming approach is the community-based intervention with multi-agencies and task forces forming a cross system collaborative approach. Boston, Philadelphia and other cities around the country are using these approaches to address hoarding issues that create unsafe living conditions.
Hoarding Affects the Individual and the Community
Hoarding is a serious issue that affects the health and quality of life of the hoarder, their household members, their neighborhood and surrounding community. Early intervention at each level can result in long-term savings, better quality of life, and improved health outcomes for those who hoard, their families and their neighbors.
Buried in Treasure: Help for Compulsive Acquiring, Saving and Hoarding by Randy Frost and Gail Steketee. Boston: Houghton Mifflin Harcourt Press. (2010)
Digging out: Helping your Loved One Manage Clutter, Hoarding and Compulsive Acquiring. Michael A. Tompkins and Tamara L. Hartl. Oakland, California: New Harbinger Publications (2009)
The Hoarding Handbook: A Guide for Human Service Professionals. Bratiotis, C., Schmalisch, C., and Steketee, G. New York: Oxford University, (2011).
Compulsive Hoarding and Acquiring Treatment that Works, Workbook by Randy Frost and Gail Steketee. Boston: Houghton Mifflin Harcourt Press (2010)
Philadelphia Hoarding Task Force- Http://www.philadelphiahoarding.org
Compulsive Hoarding Rating Scale- www.Seniorconnection.org/pdfs/hoarding_survey.pdf
Hoarding Rating Scale – www.Philadelphiahoarding.org.
Clutter image rating scale – www.hoardingconnetioncc.org
Many thanks to Linda Shumaker, RN-BC, M.A. and the PA Behavioral Health and Aging Coalition for the bulk of this information.