OT Assessment and Case Formulation

In an attempt to develop a more OT- focussed approach to assessment and case formulation in hoarding- I've developed a list of prompts based on the Model of Human Occupation using similar headings to the MOHOST incoporating features of hoarding according to current research findings.

The intention is that the information would come from a range of assessments including OT specific (such OPHI II, VQ or any other models/functional assessment) and hoarding-specific assessments if available such as "Savings Cognition Inventory" "ADL Scale" (See clinicians guide  for Compulsive Hoarding and Acquiring, Steketee and Frost, 2007) and would provide an occupationally focussed framework for organising and analysing information from assessments to identify OT-specific goals and interventions.

I've only listed prompts specific to hoarding because if I included all MOHO prompts it would be a very long list! -but it is important to also consider all non-hoarding domains to identify occupational strengths that may facilitate change. Also consider contrasts with other aspects of a person's functioning e.g a person may have difficulty making decisions in relation to acquiring/discarding items but may be able to make decisions in other aspects of his/her life.

I've used the MOHO framework as it's the one I'm most familiar with but it seems to work quite well in capturing processes not just enviromental features of hoarding. As it's something I've just developed on my own , it would be good to get any feedback, suggestions for improvements etc or any other ideas for OT assessments/conceptual frameworks.

ASSESSMENT AND CASE FORMULATION OF HOARDING USING THE MODEL OF HUMAN OCCUPATION

MOTIVATION FOR OCCUPATION


Appraisal

·         Appraisal of hoarding situation and associated behaviours (e.g clutter, difficulty discarding, excessive acquiring, disorganisation)and  extent to which this is perceived as a problem. Any inconsistencies between self report and therapist observation / reports of others

·         Perception of key strengths and difficulties in acquiring/organising and discarding items-tendency to underestimate/overestimate abilities to tackle hoarding -related problems

·         Identification of “special/unique” skills associated with hoarding    i.e hoarding is due to being more creative/ talented / resourceful etc  than the majority of the population

Expectation of Success

·         Sense of  control and efficacy  over behaviours related to hoarding

·         Perception of abilities to tackle behaviours/environment associated with hoarding (eg motor/process etc)

·         Perception of risk associated with hoarding  in relation to skills (motor /process) and environment (social and physical)

·         Emotional and behavioural responses when anticipating  challenges to tackling hoarding

Interests

·         Relation of hoarding behaviours to interests  and values(consistent or inconsistent with interests/values)

·         Perceived impact of changing hoarding behaviours on the pursuit of  interests/ adherence to values

Choices

·         Goals regarding  hoarding behaviours and environment

·         Priority of goals related to hoarding in relation to other occupational goals

·         Disadvantages and advantages of implementing changes in hoarding behaviours

·         Ability to realistically  set and appraise goals in relation to hoarding behaviours

·         Perceived impact of hoarding behaviours on self care , productivity and leisure roles, pattern of occupation, environment and skills

·         Factors that enhance or impede motivation to change hoarding behaviours

·         Factors influencing choices/reasons  for acquiring and keeping objects (e.g utility, sentimental value, comfort , aesthetics, future opportunity, useful information, reflection of identity/achievements, fear of wastage, opportunities for socialising or helping/ being valued by others, preventing disaster)

·         Emotional responses when acquiring or discarding an item and how that impacts on choices

PATTERN OF OCCUPATION

Routine

·         Impact of hoarding behaviours   on routine or activities (positive /negative)

·         Routines related  acquiring/discarding  items and consistency of these

·         Any historical changes in routine and habits over time in relation to hoarding behaviours and factors that have contributed to the development of routines related to hoarding behaviours (eg trigger events/physical or social environment)

·         Any rituals related to hoarding behaviours (eg OCD traits such as checking, symmetry, touching objects)

·         Any activities carried out to avoid tackling hoarding

Adaptability

·         Emotional  and behavioural responses to potential or actual changes in hoarding routine/activities or environment  (e.g accommodating/fearful/ resistant/ avoidant)

·         History of coping with changes related to hoarding behaviours (e.g enforced clearances) and emotional and behavioural responses to these

·         Ability to cope with disappointment in an activity or unmet goal related to acquiring /discarding or organising items

·         Capacity to modify performance in activity related to acquiring, discarding or organising items-key approaches that support adaptability (e.g practical support/verbal prompts etc)

Roles

·         Consistency of hoarding behaviours with role identity (congruent/incongruent)

·         Impact of hoarding on maintaining self care /productivity /leisure roles

·         Any role imbalance as a result of hoarding

·         Impact of hoarding on sense of belonging

Responsibility

·         Impact of hoarding behaviours on role fulfilment (support or hinders ability to fulfil valued roles)

·         Ability to take responsibility in a task related to tackling hoarding behaviours (e.g clearance /organising)

·         Any risks associated with lack of responsibility as a consequence of hoarding  e.g care of children or pets, compliance with tenancy agreements,  or other legal requirements

COMMUNICATION


Assess all areas as per regular MOHO  headings( ie non-verbal and vocal expression)  but may need to pay particular attention to the following;

Conversation

·         Clarity , ability to keep to a  topic, avoidance of topics of conversation related to hoarding behaviours,  any evidence of distractibility, circumstantial/tangential speech

·         Ability to respond to structured questioning

Relationships

·         Cooperation with others in relation to interventions to tackle hording (verbal versus actual cooperation)

·         Impact of  hoarding on interaction with others (eg. avoidance of certain social settings or individuals/hoarding behaviours support contact with certain individuals/organisations)

·         Awareness of needs of others in relation to hoarding behaviours

·         Respect of therapeutic boundaries

·         Any other factors which may influence /support /hinder cooperation and collaboration with  others (e.g setting/type of approach)

PROCESS SKILLS


Knowledge

·         Ability to be selective in seeking  information in relation to acquiring/organising and discarding items- use of seemingly irrelevant/excess  information when making decisions

·         Ability to retain information  in assessment /therapy sessions- means of effectively retaining information (verbal/visual/auditory)

·         Confidence in ability to retain information and  how this relates to hoarding behaviour (e.g fear of losing important information/keeping all items visible rather than storing)

·         Influence of hoarding on use of tools (e.g  delay in  selection/delay in locating tools due or lack of recall regarding location/ inappropriate or idiosyncratic use of tools/hygiene and safety issues re. use of tools)

·         Need for prompts/aids to retain information and concentration  (eg lists /diaries) and actual effectiveness of these

Timing

·         Initiation of  tasks in relation to clearance/organisation (needing prompts/  planned or  impulsive )

·         Ability to maintain concentration during clearance /sorting tasks

·         Repetition of stages in a task (i.e completes a task or stage then goes back to it as it is not “right”)

·         Response to time limits in relation to a task/able to meet deadlines

·         Speed of working

·          Completion of a task through a series of stages

·         Excessive numbers of stages in a task/sequences in an activity  delaying  progression or completion

·         Ability to prioritise  tasks related to sorting/clearance

Organisation

·         Arrangement of home environment and items (orderly or disorganised )

·         Ability to categorise items ( value/ function/location)

·         Ability to respond to instruction or assistance in organisation tasks/strategies that support this

·         Efficiency of searching/locating and gathering  objects

·         Risk issues related to  organisation of objects

Problem Solving

·         Ability to make decisions  in relation to sorting/clearance and acquisition and object location

·         Ability to utilise/consider relevant information to make a decision (eg excessive or inadequate attention to detail)

·         Response to environmental cues when making a decision or solving problems in relation to hoarding

·         Awareness of problems that arise and responses to these when sorting , organising and discarding

·         Ability to generate  solutions related  hoarding behaviours

·         Ability to learn strategies /approaches and learn from mistakes related to hoarding

MOTOR SKILLS

Consider all areas  per regular MOHO assessment (ie posture and mobility/coordination/strength and effort/energy)

·         Do motor skills allow completion of tasks relating to clearance and organisation or is additional assistance required for certain physical tasks?

ENVIRONMENT

Physical Space

·         Access and available space in home environment-including all rooms/ communal and external spaces

·         Impact of clutter /overcrowding on performance of self care, productivity  and leisure roles

·         Impact of clutter on motor skills i.e restricted mobility/falls/ injury

·         Other environmental risks/features  compromising safety or tenancy regulations e.g vermin, dust/dirt/structural damage/odours

·         Use of alternative spaces due to clutter in home environment (e.g. communal areas or work spaces for self care activities/eating out only/alternative storage spaces)

·         Satisfaction and perceived comfort/privacy in home environment

Physical Resources

·         Impact of hoarding behaviours on financial resources

·         Financial and physical resources available to tackle hoarding (eg use of car/funds to  pay for private support)

·         Match of availability of possessions to actual self care/productivity/leisure  needs (inadequate or excessive)

·         Types of items hoarded (e.g clothing/papers/ all categories)and actual use of these items for their intended purpose

·         Condition of possessions (including food items)  and any associated risks

Social Groups

·         Impact of hoarding behaviours on social environment (i.e. behaviours accepted or rejected/  exclusion from social groups/impact on emotional atmosphere/presents risks to others)

·         Perception and understanding of hoarding behaviours by those in the client’s  social environment/any variation in these

·         Approach used by those in social environment (i.e /rejecting/directive/empathic) and impact of approach  on occupational challenges associated with hoarding (i.e supports/detracts/exacerbates)

·         Role of social groups in development of behaviour (i.e changes in  behaviour according to social environment over lifetime-see also routine section/ role models influencing hoarding behaviours e.g a hoarding parent)

·         Access to support  to tackle hoarding (e.g neighbours, family , voluntary and statutory sector)

Occupational Demands

·         Match of current activities associated with hoarding  with actual abilities/interests/energy and time 

·         Overall level of satisfaction and enjoyment of current activities

·         Relationship of hoarding behaviours to cultural conventions of relevance to the client

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Hoarding and the Mental Capacity Act

I have been thinking about some of the complex  issues related to  assessing someone in relation to accepting treatment or support for hoarding under the UK Mental  Capacity Act (MCA) 2005 particularly given that it is not a diagnosable disorder.

I contacted a couple of Mental Capacity Act leads in my work area to ask the following questions;

1) If hoarding is not diagnosable condition, should it still be be regarded as a "Disturbance of functioning of the mind or brain " which would warrent assessment under the MCA. Plus if hoarding does become diagnosable (as proposed for the DSM V) would that change assessment  under the MCA?

Both respondents felt that someone with hoarding behaviours could be assessed under the MCA as do other conditions  which do not have a diagnosis e.g cognitive impairment without a diagnosis of dementia. Although the code of practice does state that you need clear proof of this disturbance and its impact on the ability to make a specific decision to establish that there something affecting the way the mind is working and not just a case of "eccentricity".

 I'm guessing from this  an  example would be  a strong fear of wastage resulting in a refusal to discard seemingly worthless items/rotting food  and associated distress which. may count as an example of an impairment of the brain- but it sounds like it requires careful assessment and documentation.

It was felt by both respondents that making hoarding diagnosable would help to clarify assessment under the MCA as I imagine staff working in acute settings such as medical wards   would not necessarily have the time or training to identify the specific impairment.

My second question related to the tricky area of weighing up the pros and cons of a particular decision in relation to risk.
 
2) In some situations I have come across, although there are concerns about  potential risk due to excess clutter, no adverse event  has occurred and the client demonstrates some awareness of risk eg "I don't smoke and I'm careful when I walk around" or "If I ever have an accident I will get help". I asked whether that would demonstrate some ability to weigh up the pros and cons under the MCA.

Both respondents thought that  in that type of situation, it could be argued that the person does have capacity to weigh up the pros and cons- although it is very important to be clear about each risk and how likely it would occur.In some cases the evidence of imminent risk is so overwhelming - e.g events such as fires,infestations , falls have occurred and if the client denies this event has or will occur again,  it could be argued that they do not have capacity make a decision about action to reduce risk.

Both respondents felt it was a very interesting and complex area and  is not straight forward.  It would be great to hear about any thoughts , experiences , questions regarding this complex area of practice.