Assessment Questions

In conjunction with the post on assessment and case formulation. I've included some example question prompts that can be asked either to the client to a relevant person/family member. In keeping with the other post,  I have structured it using the MOHOST headings,  as a means of organising the information. Although there may be a more logical way of ordering/asking  them, I've tried my best to avoid too much overlap and repetition . Obviously not all questions apply to everyone  and there may be better ways of phrasing the questions.  The intention would be that a comprehensive assessment would take place over a series of sessions (I normally would allow 4-6 assessment sessions), so I hope you are not too daunted by the long list.
I've also indicated after each section other complementary assessments. The OT tools I suggest are based on MOHO (Model of Human Occupation). I have suggested these because I am most familiar with this model, but there may be other suitable tools out there so please let me know any other ideas.

The hoarding-specific assessments can all be found in "Treatment  for   Hoarding  Disorder" (2nd ed)  G. Steketee and RO Frost ,2014 -alternatively most can be downloaded for free from the OC Foundation website www.ocfoundation.org/hoarding

Please let me know your comments and suggestions for improvement.

MOTIVATION FOR OCCUPATION Appraisal ·         How do you feel about the situation in relation to acquiring /keeping/ organising /discarding  items? ·         Do you feel you have any difficulties  with    acquiring/ keeping/ organising/discarding    items? ·         Are any of these aspects (acquiring/ keeping/ organising/ discarding) any easier/ harder to deal with than others? ·         Do you notice anything different in how you see objects compared to  most other people ( i.e do you see beauty / utility or  potential in objects that others don’t see?) Do you think this is an advantage  or a hindrance? Expectation of success ·         How much control do you have over urges to get / save things ? What are the hardest/easiest aspects to control? ·         If you were to do something   to tackle the problems ,how easy would it be ? What do feel are the main challenges  to overcoming these difficulties? ·         What do you feel would help you to tackle these difficulties? ·         How do you feel when you think about changing behaviours related to keeping/ getting and organising items? How intense are these feelings on a scale of 0-10? ·         Do you see any problems or risks  with the situation remaining as it is? How would the situation be in 1, 5 ,10 years if you didn’t change? ·         If you don’t feel ready to tackle the situation now, what (if anything?) might make you want to tackle this in the future? ·         Have you tried to tackle these problems before? What was the outcome? How does this affect how you feel about your ability to  deal with the problem now? ·         How would your life be different , should you  make changes  to these behaviours? ·         What would be the advantages and disadvantages to changing behaviours? ·         How good are you at carrying out goals/plans? How do you make plans?( ie keep in head/ write down/tell others?) Do you ever have plans that you don’t fulfil? What stops you from carrying out these plans? How do you feel if you don’t achieve your plans? Interests ·         What are your main interests ? Do you have the opportunity to pursue these interests? How does getting/keeping items affect your interests (helps/hinders)? ·         What are the priorities/most important things in your  life  at present.?  How do your priorities fit in with getting /keeping/discarding items? ·         Is there anything you do that makes you feel better or helps you cope with problems? Choices ·         What are your reasons for acquiring/ and keeping items? ( eg, financial/ usefulness / beauty/creative /sentimental/ information) ·         Do you ever change your mind about getting something? What makes you change your mind? ·         Do you have any “rules” about acquiring/ discarding items? ·         How do you feel (emotionally) when you get an item you want? Does this feeling change over time? ( 1 day , I year after getting it) Do you ever regret getting/ not getting something? ·         What (if any) are your goals or priorities in relation to acquiring/ keeping/ discarding? Do you have any other goals in life? ·         How would you know if you were successful in  tackling these problems/achieving your goals? -If  you   had  to  leave  your home  in an  emergency what   would  you  take and   why? Additional Assessments Occupational Therapy OCAIRS VQ/ Interest Checklist Hoarding-Specific Saving inventory Revised  (See Steketee and Frost, 2014) Saving Cognitions Inventory (“        “)

PATTERN OF OCCUPATION Routine ·         Tell me about your daily routine? Do you have regular routine? ·         How does acquiring / organising / discarding impact on your routine? Do any of these form the focal point of the day? ·         Are there any situations or places you avoid because of hoarding and why (e.g avoid staying indoors/ going to certain shops/socialising with certain people/ inviting people round)? ·         Are there any activities you carry out to avoid dealing with clearing /discarding items? ·         How do you typically acquire and discard items?(e.g purchase  /pick up/steal/ recycle/give to others/ give to charity)? ·         Do you plan what  to get in advance, or do you make impulsive decisions? Do you use a shopping list? ·         Are there regular places that you go to  acquire items? ·         Are there any times of the day/ or days of the week when you are more likely to acquire/clear  or discard? What factors influence these routines (eg presence of others/ energy levels/local sales/pay day )? ·         When did you ( or someone else) first notice that you may have a problem with acquiring/hoarding items? ·         Have there been any changes in your routines/habits related to  acquiring/keeping over time? What  triggered these changes (eg financial/ moving home/retirement/ traumatic event)? ·         Are there any other triggers that influence likelihood of acquiring/discarding items (eg loneliness/ boredom/ stressful events/threats of legal action)? ·         Do you have any very important routines (rituals) related to the storage and placement of items? (e.g do  they have to be organised in a particular way/do  items have to be checked or touched a certain number of times). What (do you think) would happen if these routines are not followed? Adaptability ·         How do you feel about making any changes in your routine either in general or specific to hoarding behaviours? ·         If you want to change your home environment,  what would it ideally look like for you? Can you visualise this?  How does it make you feel when you imagine this? ·         How would( do/did) you feel if someone touches/moves/ removes your possessions? What would (did) you do if this occurred? ·         How do/did you feel if something does not go to plan? ·         Have you tried doing anything differently in the past  to tackle hoarding? How did it go? What did you learn from the experience? How would you feel about taking a different/new approach to manage hoarding? Roles/Responsibilities ·         What  are the  important roles/responsibilities in your life (domestic/educational/ vocational/ familial/community/cultural)? ·         How does acquiring and  keeping objects  impact on the fulfilment of self care/productivity and leisure roles (help/hinder)? ·         Have you had  to give up roles/  responsibilities because of hoarding? ·         How would your roles/ responsibilities be affected if you were to make changes related to hoarding? Would it create/prevent certain opportunities? ·         Are there any threats to particular roles or responsibilities should the situation remain unchanged( ie tenancy/ child care/pet care/ work)? ·         Do you feel  equipped or ready to undertake/fulfil  valued roles /responsibilities? What would need to happen for  you to feel ready? Additional  Assessments Occupational Therapy OCAIRS OPHI II (MOHO)-To assess role development over lifespan Other Obsessive- Compulsive Inventory-Revised –(If OCD symptoms indicated) Foa , 2002 (see also Steketee and Frost, 2014)

COMMUNICATION Conversation ·         Are you able to focus or concentrate on a topic of conversation? ·         Do you ever find it difficult to express your thoughts? ·         Do you ever find it difficult to express yourself because you have a lot of thoughts going through your mind at once? ·         How do you feel about talking about hoarding? Do you ever avoid talking about it or change the subject? Relationships ·         Are there any important relationships in your life? ·         How has hoarding affected your relationship with others (help/hinders)? ·          How would your relationships be affected should the situation continue/ change (advantage/disadvantages)? Additional Assessments OT-Specific ACIS (MOHO)

PROCESS SKILLS Knowledge ·         How is your memory/ concentration and attention? Do you remember some things better than others? How do you remember best? ·         Is there anything you do to compensate for any memory /concentration difficulties (e.g keep everything in sight/ write lots of lists/not throw anything away/cut out clippings)? How helpful are these strategies? What would happen if you did not use these techniques?       Timing ·         How easy is it for you to start and finish tasks a) In general b) When clearing and organising? ·         What helps or hinders starting and finishing off an activity? ·         Do you ever re-do something you have started or completed because it does  not seem “right”? ·         Are you generally able to meet deadlines? Do you find deadlines helpful? ·         How do you go about deciding  priorities for tasks ? Do you stick to these priorities or get distracted? What are the main distractions for you? Is there anything that helps you concentrate/keep focussed? ·         How do you feel about your speed completing tasks (too fast/too slow/ ok)? Organisation ·         How do you go about arranging /organising your possessions? ·         How satisfied are you with your ability to do this? ·         Are there any strategies that have helped/hindered your ability to organise your possessions ? ·         How easy is it for you to find /use things you need? How would you go about locating something? ·         Are there any risks related to the organisation of objects? Have you ever had any accidents due to organisation of objects? ( e.g too crowded/piled high) Problem Solving ·         How easy is it for you to make decisions about acquiring/organising/ discarding items? (Scale 0=10) Do you ever avoid or put off making a decision? Do you often change your mind when making decisions? ·         Tell me about a recent problem you encountered and how you tackled it? ·         What do you normally do if something does not go to plan or you come across an obstacle ?(consider a recent example) · Do you ever give up if something seems too challenging? ·         What ideas do you have about how to deal with these problems? If someone else were in a similar situation what would you suggest they could do? Additional Assessments OT –Specific AMPS

MOTOR SKILLS Are there any physical difficulties that affect your ability to  clear or organise your living space (i.e energy/ strength/posture/ balance/co-ordination/mobility)? Additional Assessments OT –Specific AMPS

ENVIRONMENT Physical Space ·         How easy is it for you to use areas of your home? (consider each  room area in turn-also include communal and outdoor areas if applicable) ·         How comfortable do you feel at home? ·         How important is it for you to use these areas (highest priority/lowest priority)? ·         How does clutter/overcrowding affect your ability to carry out tasks (self care /productivity /leisure)? ·         Do you use any other spaces outside the home environment due to the clutter ( eg local swimming pool for showers/eat out only/communal lounge)? Are there any problems related to this (i.e too expensive/leads to conflict with others)? ·         Do you use any storage areas outside the home environment (paid /unpaid)? Does this lead to any problems?(egfinancil/conflict) ·         How safe and secure do you feel at home? ·         Are there any risks due to overcrowding (e.g. falls/fire/vermin/hygiene)?  Do other people share your view about risks? ·         Is anyone else affected by the clutter in your home? In what way? Physical Resources ·         What kind of objects do you acquire/keep? Have you always kept these kind of objects or has it changed over time? ·         Do you get to use all the objects you keep for their  intended purpose ? If not approximately what percentage do you actually use? ·         Do you feel you have enough/ not enough /too many possessions? Do other people share your view? · How would you know if you had too much of something? Do you ever use any replacement objects because you cannot find or use the most  suitable object ? (eg clothes as blankets/ fork as a spoon/sofa as bed/bath as storage area)? ·         Do you ever worry about running out of something or being without? What would the consequences be? ·         Do you ever get something and then realise you already own something similar? ·         Are there additional resources that you need to tackle hoarding (e.g money/storage space/use of a car/van)? Social Groups? ·         How do other people feel about your possessions (family/friends /neighbours/authorities/cultural groups)? Do you share these views? ·         How has it affected your social life? ·         Does anybody help you get or store possessions? ·         Does anybody help you get rid of items? ·         Do you think there are any other reasons (apart from hoarding) that people may  act against you? ·         Did anyone in your family have a similar problem? ·         Did you ever live or grow up in a cluttered/over orderly environment? How did this affect you? ·         How do you think others can help you? Who would you want to help you? ·         How have others responded to this problem in the past? Has it been helpful or unhelpful? Additional Assessments Hoarding –Specific Clutter Image Rating scale (Steketee and Frost,2014) ADL Scale (Steketee and Frost,2014)

OT Interventions

INTERVENTIONS

Below are some interventions that could fit into the OT role in  supporting  clients who hoard. They are very similar to standard OT interventions used  in other settings, and can also be used by other Therapists/ staff as part of an overall Cognitive Behavioural Therapy programme.

For more information, recommended reading would be  Compulsive hoarding and Acquiring: Therapist Guide,  G. Steketee & RO Frost (2007) , particularly Chapters  6 and 7.

It would be useful to hear any other suggestion of  strategies that would be relevant to  OT.

Approaches are roughly grouped under the following headings;  

1.Goal Setting

2. Planning

3.Problem solving

4.Grading

5.Developing organisational  skills

5.Role development

6.Postive coping strategies/ motivators

1.Goal Setting

Goals should be reflective of the assessment and case formulation, and go beyond just reduction in clutter, to encompass the client’s priorities and valued outcomes.

For example;

·         To be able to invite friends round for  dinner

·         To have more spending money

·         To take up a hobby or interest

·         To follow a structured routine

·         To feel less discomfort  when clearing

·         Increased positive feedback from family members

The complex nature of tackling hoarding   can seem overwhelming for both clients, family and staff, and it may take some time before changes in the environment are actually observable. Therefore the goals  and outcomes should also be sensitively graded to encompass small measure of change, in order to maintain motivation and provide a sense of progress.

Use of clearing diaries or acquisition records are also important to track change.

2. Planning

Many clients with hoarding problems  report difficultly with planning tasks  so some initial work may focus on planning;

a)    The organisation of the living space – use of floor plans or labels to indicate storage areas may be required

b)    Use of an interim area e.g. spare room or garage during the sorting process

c)    What to keep and what to discard-a series of question can be formulated to help in the decision process E.g Do I need this item? When will I use it ? Where will I keep it. What would the consequences of not having this (positive and negative)?

d)    How to store items- e.g files , shelves

e)    How to get rid of discarded items ie assistance required, collection?, local charity shops?

A Decision Tree can help in this process ( e.g Steketee and Frost ,2007)

3. Problem Solving

Introducing a systematic problem solving approach can ensure that clients are involved in developing effective strategies that work for them, as well as is learning a method to deal with problems and challenges. Problems may include , not having sufficient time, energy to clear, dealing with pressure from others.

The process would follow a standard problem solving approach ie

a)    Define the problem and contributing factors

b)    Brainstorm solutions- however far fetched

c)    Evaluate each of the solutions and select one or two of the most appropriate

d)    Break down the solution into achievable steps

e)    Implement the  action plan

f)     Review the outcome

g)    If necessary repeat the process with an alternative solution

4. Grading

Approaches could be graded in terms of ;

a)    Assistance provided,

For example;  Sorting and discarding with therapist or other

                      Sorting   with telephone prompt from therapist or other

                      Sorting with visual prompt/timetable etc

*If using a co-therapist or friend/family member as a “coach”  it is vital that a consistent approach is used by all . Some psycho-education and training for co-workers is usually    required.

b) Time engaged in sorting/ discarding . This may be for very short periods initially due to distractibility and discomfort

c) Discomfort/Difficulty

It is useful to rate different tasks in terms of perceived discomfort / anxiety or whatever negative emotion is felt when  completing challenging tasks such as  clearing or  avoidance of acquiring (0= no discomfort 10= maximum discomfort).  This can be used to make an exposure /task hierarchy  that can be  tackled in a systematic way. In cases of extreme distress or avoidance it may be necessary to use guided imagery of completing a clearance or sorting task prior to actual exposure..

d) Task Stages

People who hoard can struggle with completing all stages of a task, particularly those related to sorting and discarding ( although this can also  apply to other tasks). For some clients  who keep items mixed up (“churning”),  initial focus  may be on completing  a particular stage  of the task , such as organising items into categories  or areas prior to discarding. Alternatively for  clients who complete some stages ie  organise but don’t discard or use, the focus would be on completing more or all stages.

5. Developing Organisational skills and Problem solving

This can include;

a)    Daily Structure Planning

      Introducing  and maintaining a regular  structure  and routine can be a challenge  for a lot of clients. If there is limited  existing structure or routine, it is advisable to introduce regular tasks very gradually .  Devise appropriate ways to organise routines   i.e diary/ calendar / timetable –make sure they are not too complicated to use . Ensure  the structure/ timetable also includes pleasurable activities which may be used as rewards –post clearance.  Identify good times of day to complete tasks .

b)    Developing filing  systems for documents

This can include categorising items e.g, bills/ receipts and deciding how long items should be kept. Ways of reducing paperwork  e.g online bills, should also be explored.

c)    Use of Shopping lists , planning aids to minimise impulsive acquisition

6. Developing Alternative Roles

A thorough assessment and case formulation should help  clarify the  potential meaning and function of hoarding behaviours and well as core values and priorities. For example hoarding may be (partly) driven by a need to;

-feel useful to others (by collecting things that can be given away or fixed) ,

-feel  creative

-have a “project” or work role

Therefore the emphasis   may be looking at more productive and achievable roles that do not lead to build up of clutter. However it is  also important to consider any perfectionist traits or confidence issues which are often reported in hoarding clients, which may result in non completion   of tasks or role fulfilment.

7. Positive coping strategies and motivators

Hoarding is often characterised by a behavioural or emotional avoidance of any tasks or situations that may lead to distress. As part of therapy will involve introducing tasks that can present as extremely challenging to the client , it is important to ensure the client is equipped with skills to deal with unpleasant feelings or fluctuations in motivation;

e.g Anxiety management and relaxation

Use of visual prompts- eg photos of a cleared area or cue cards with meaningful motivating statements

Positive feedback from others

Ways of quantifying gains eg" I have saved X amount of money this month"

Environmental modifications which help with “homework”  tasks e.g clearing while listening to pleasant music or having no environmental distractions eg TV and phone off

Reviewing older clearing records to remind of gains achieved so far

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