Heather Badini LPC, CAC III Denver Springs Hoarding Heather Badini LPC, CAC III Denver Springs

Overview What is Hoarding Facts about Hoarding Contributing Factors Psychosocial factors that contribute Treatment for Hoarding Clutter Image Rating Scale Dealing with resistance/treatment approaches Safety factors

What is hoarding Signs of Hoarding Isolation Closed Door Policy Indecisive Behavior Unlivable Living Space When they ask for help Types of Items: Paper, books, Clothes, mail, personal items, containers, rare cases animals, etc. Contributing Factors to Hoarding: Indecisiveness Perfectionism Procrastination Avoidance behaviors Fear Difficulty organizing tasks

Facts About Hoarding 92% of those that hoard have a co-occurring mental health disorder It effects approximately 3-5% of the population (Thompkins 2011) Many people who hoard are not aware of the level of hoarding or that there is a problem Key Elements of Hoarding (Gimmiam, C., Tolin, D. 2010): Difficulty Discarding Excessive Acquiring Clutter Distress & Impairment due to Hoarding

Diagnosis and Symptoms Mental Health Diagnosis for Hoarding Symptoms of Hoarding Severity of Hoarding see next slide The DSM V has added Hoarding as its own diagnosis instead of a symptom for Obsessive Compulsive Disorder. It was identified to separate some of the specific symptoms of hoarding from OCD because the treatment for OCD looks very different than treatment for Hoarding and not all that hoard meet OCD diagnosis. Although there may be some overlapping of symptoms of OCD, Anxiety, and other mental health disorders hoarding itself needed to be separated as it is not always a symptom of each of these other diagnosis. Diagnostic Symptoms are on following slide: Symptoms: Persistent difficulty discarding or parting with possessions, regardless of their actual value. This difficulty is due to a perceived need to save the item & to distress associated with discarding them The difficulty in discarding possessions results in the accumulation of possessions that congest & clutter active living spaces. If active living space is uncluttered only due to 3rd party interference Hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning Hoarding is not attributable to another medical condition Hoarding symptoms may first emerge at age 11-15. The severity of hoarding increases with each decade which is why we see more prevalent and dangerous issues with those over the age of 55 years old Interventions with children and early 20’s have a higher success rate if taught appropriate saving and collecting behaviors. It is familial w/ 50% of those diagnosed reporting another family member who hoards so may have some genetic factors (same percentage in twins) along with environmental factors of not teaching children how to problem solve, make decisions, loss, or learn to prioritize and sort.

Contributing Factors Medical Brain Injury/TBI Developmental Major Mental Illness: Psychosis Major Depression OCD Other contributing causes that may be medically related or another mental health condition and not hoarding diagnosis: Some brain injuries cause hoarding behaviors so they were not present prior to brain injury/tumor or other brain damaging medical conditions If the hoarding is directly related to developmental delay or autism Psychosis: If the hoarding happens primarily when psychotic Major Depressive: If it is piling up due to lack of energy related to depression OCD symptoms related to fears specifically that they are keeping things out of a “fear” of something happening or to not interact in the OCD behaviors such as excessive cleaning.

Psychosocial Factors that contribute to hoarding Mental Health conditions Neurological Conditions Family History Trauma Feelings associated with possessions Social Skills Social Identity Mental Health conditions: Depression, Psychosis, Anxiety Neurological Conditions: Dementia, Brain Injuries, Brain Tumors Family History: Learned behavior & Biological components Trauma: No statistical significance to those that are from poverty or deprivation. There is a significant difference for those that have experienced a severe trauma especially due to serious loss Knowing the cause or feelings that the person experiences around their possessions & what reactions it elicits when talking about getting rid helps to work with the person to purge & how to cope when they want to bring things into the home or storage These people put more value on their possession than people They tend to be socially awkward or anxious around others Their possessions become a part of identifying whom they are. So when getting rid of stuff it triggers a lot of anxiety because they have feelings of “losing themselves” or feelings of “loss of someone they love” when getting rid of items

Treatment for Hoarding Individual must be engaged in treatment Treatment will be long and time-consuming Address Discarding and Acquiring Cognitive Behavioral Therapy (Boston University Research) Group In-Home Online Therapy Important to “complete sort” in home sessions Coach It is critical to remember that treatment is not just “cleaning out the space” If 3rd parties go in and clear out space this does not usually change the behavior and can actually cause the individual to have more trauma and their physical and psychological health can decline. However, there is effective treatment for individuals that hoard, but it is lengthy and time consuming. It can take several months and sometimes over a year of consistent intervention. With frequency being weekly to multiple times a week. The treatment is best done at the individual’s home and not through outpatient, office-based therapy Boston University (2009) study found that online therapy with the individual in the home while the therapist was viewing and walking them through the process on the computer was just as effective as someone present. Professional hands-on approach is beneficial and more so with Cognitive Behavioral Therapy as part of the intervention Relapse is also a part of process so check-ins every few months can be helpful to ensure the behaviors do not return and refreshers of the skills they learned is helpful for continued success

Cognitive Behavioral Therapy Use of Clutter Image Scale Feelings and Beliefs associated with items Planning treatment Exposure Downward Arrow Thought Record Maintenance Plan CBT in regards to Hoarding is about identifying what is the individuals thoughts, feelings, and beliefs around their possessions and/or specific things that they keep It is important to understand the feelings and beliefs to be able to teach sorting and organizing their possessions. Prior to doing any in-home work it is helpful to work with the client on planning for the event. During this time having them make lists of how and why things are important. It helps to do this out of sight of the possessions so they can think of the things without as much emotional connection in the moment when looking at them Paperwork example of how to do this: What is priority (have to keep) What are state laws or legal ramifications of discarding some paper How to also get these items again if they discard them i.e. internet Boston University has done extensive research on this topic & has multiple resources: http://www.bu.edu/ssw/research/hoarding/ Exploring their thoughts and beliefs around their possessions to get information about how they view their possessions so you can respond with CBT around those thoughts Teaching new acquisition processes: What can come in the house & how to restrain themselves with shopping or bringing items in Hands On approach to discard items in the home (On next slide) Support groups to help with process and to avoid relapse

Clutter Image Rating Scale Living Room

Clutter Image Rating Scale Bedroom

Rolling with Resistance It is helpful to have two individuals from different agencies involved. The best approach is collaborating using two different roles : One person is role of enforcer (police, landlord, social services, etc.). 2nd Person role is support (family member, therapist, friend, etc.) ENFORCER This does not mean that they are negative they still take a supportive approach to “let’s get you help so this consequence does not happen SUPPORT they remind of the enforcement but discuss how they are going to support and provide hands on support. It is important the two roles are consistent in communication with one another to best support the individual Sometimes families can help, but many also struggle or feel helpless to help the family member and may not have enough sway to get the person to make change. But families can help support them in getting mental health treatment

Ways to help without CBT Starting with organization of paper & teaching sorting Think twice about what they allow in their home Set aside a time each day to declutter Disposing of items not used in a year OHIO Rule: Only handle it once Get help if they cannot do this

How to help someone purge Begin by going prioritizing lists prior to be in home Start in a small section of the home & focus on a few items at time Create 4 separate piles (donation, keep, trash, recycle) Provide CBT interventions when putting in piles to include problem solving & sorting what is needed Celebrating & Recognizing gains: Treating & respecting the loss as grief & celebrating that they made it through the pain, stress, & anxiety Educate the individual about new additions

Finally SAFETY Sometimes homes are uninhabitable and can carry many diseases and sicknesses So use gloves and other protective devices when working with the individual Sometimes the place must be de-cluttered quickly for the individuals health, but this is not the long term solution

Resources www.coloradohoarding.com www.hoardingdisordergroup.education www.cluttertrucker.com

Reference Rolling with Resistance (Sorrentino, C & Burden, E; training in 2011) Bratiotis, C., & Schmalisch, C. (2011). The hoarding handbook a guide for human service professionals. Oxford: Oxford University Press. Steketee, G., & Frost, R. (n.d.). Treatment for hoarding disorder: Therapist guide (Second ed.). Tolin, D., & Frost, R. (2007). Buried in treasures: Help for compulsive acquiring, saving, and hoarding. Oxford: Oxford University Press. http://www.bu.edu/ssw/research/hoarding/ www.hoarders.org

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