Here's an article I wrote that was recently published about Hoarding and the Role of OT. Any comments would be welcome
The Management of Compulsive Hoarding and the role of Occupational Therapy
Compulsive hoarding and acquiring of items is an issue frequently encountered by staff in health , social care, housing and environmental services. However, hoarding still remains poorly understood and is often regarded as challenging or impossible to treat.
Throughout my career as an Occupational Therapist, I have frequently encountered hoarding in a range of clinical settings. This behaviour can impact on many areas of relevance to OT including functional independence, roles, and the social and physical environment. However, in spite of increasing research interest regarding the causes and treatment of hoarding, OT-specific guidance on assessment and interventions remains virtually non-existent.
The Definition and Causes of Hoarding
Hoarding presently is not a diagnosable disorder. However, research and literature refers to the operational definition proposed by Frost and Hartl, (1996). This describes compulsive hoarding as a behavioural syndrome with three key characteristics:
· The excessive acquisition of items regardless of their actual value, combined with an inability or unwillingness to discard
· The presence of clutter which prevents use of living/work spaces for their intended purpose
· Hoarding results in significant distress and /or functional impairment
Current research estimates one in twenty of the population has a significant problem with hoarding. Although hoarding behaviours have been observed in young children, it is believed to mainly develop in teenage years with an increase in severity over the life span.
Hoarding is linked with high rates of reported trauma, either as a precursor or contributor to an increase in hoarding behaviours. Research has also identified neurological differences in the brains of people who hoard, particularly in the frontal region. This may account for information processing problems frequently observed in people who hoard.
Hoarding and Mental Health
There is a strong association with mental health difficulties. Hoarding has traditionally been regarded as a type of Obsessive Compulsive Disorder (OCD) . It does appear that there may be a proportion of hoarders who also have OCD symptoms.
However , more recent research indicates increased co-morbidity with conditions such as Depression, Anxiety , Personality Problems and Attention Deficit Disorder. There also a smaller percentage of individuals who do not have a mental health diagnosis.
Psychological and Behavioural Features of Hoarding
The reasons for acquiring and retaining objects are generally similar to those of non-hoarders. However, people who hoard tend to express more intense beliefs about a greater range of possessions. These include fears of wastage, losing important information, opportunities or ideas about the creative potential of objects. Hoarding is also associated with perfectionist traits.
As previously mentioned, hoarding is linked to information processing difficulties such categorising, decision making, attention, concentration and impaired visual memory. People who hoard also commonly perceive themselves as having memory problems, which can necessitate a desire to keep information within easy reach.
Hoarding is also associated with a strong emotional attachment to objects that may provide a sense of safety or security. Alternatively there may be strong perceptions of beauty or utility in objects, which may not be shared by others. Acquiring can be accompanied by intense feelings of pleasure or it may function as a means of avoiding negative emotional states.
Hoarding is frequently associated with low motivation to change and avoidance of sorting or discarding items, in spite of significant safety risks or legal action.
Assessment of Hoarding
Due to the complexity of the disorder, coupled with low motivation and awareness of the problem, assessment usually needs to be extended over a series of sessions. It should be multi-factorial including self report, observation, home visits and collateral accounts from family and relevant others. It is also important to assess and , if possible, treat other mental health conditions which may exacerbate hoarding behaviours such as depression or dementia.
Various standardised assessment tools have been developed within a cognitive behavioural framework (See Steketee and Frost , 2007 or the OC Foundation website). This includes the ADL Scale which rates the impact of clutter on ADLs within the home environment.
There have so far been no standardised hoarding assessment tools developed for and by OTs. However, I have found MOHOST can provide a helpful framework for assessment and conceptualising the impact of hoarding on occupational performance. OPHI II has also been used by OTs working in this area as a means of exploring the occupational roles of clients.
Non-standardised tools and rating scales can also be utilised to ensure client-centred focus and provide subtle indicators of change. These can include;
· Before and after photographs
• Detailed floor plans to indicate areas of clutter
• Self report ratings such as 0=10 discomfort rating when discarding or resisting acquisition
• Frequency counts of acquiring
Treatment Interventions
A cognitive behavioural (CBT) approach developed by Steketee and Frost (2007) currently provides the strongest current evidence base for treatment. This modified programme includes key CBT techniques such as cognitive restructuring, behavioural experiments, graded exposure and response prevention. In addition to this, there is a strong emphasis on motivational interviewing as an integral part of therapy.
Of particular relevance to OT, the approach also focuses on practical strategies and skills development to deal with information processing problems. Techniques can include improving organisational skills, use of prompts and reminders, daily routine planning, graded support in clearing and modifying the home environment and goal setting.
The CBT programme also includes exploring alternative roles and helpful coping strategies to deal with distress, such as anxiety management. The approach also advocates carer or family interventions including psycho-education , and the use of individuals as “coaches” to support the treatment or clearance process.
Evaluation of the CBT approach has indicated that 50-70% of treatment completers show gains in standardised measures over a 6-9 month period of intervention(Tolin, Frost adn Steketee, 2007). However, symptoms of hoarding remained in all clients, raising questions about sustainability of therapeutic gains over time. Completion of homework tasks is most strongly associated with reduction in symptom severity.
Other non – CBT interventions include the use of medication, namely the SSRI family of anti-depressants. Trials have indicated promising results particularly when used in conjunction with the CBT approach.
Enforced clearances or “blitz cleans” are most frequently used to manage excessive clutter. However, there is no evidence to indicate that these lead to a reduction in hoarding behaviours. Furthermore, this can result in strong feelings of loss or violation potentially precipitating a deterioration in a client’s mental state or disengagement with support services.
Current research is examining the use of a harm reduction approach for clients with an emphasis on negotiating a safe, if not comfortable living environment. There has been recent interest in the application of cognitive rehabilitation techniques in treatment which has provided some promising preliminary results.
Considerations in Clinical Practice.
OTs may be involved working with hoarding clients on a short or long-term basis. Therapists in acute services may focus on brief assessment and interventions to ensure safe discharge home or referral onto other services. Having a basic understanding of hoarding to identify key features or a differential diagnosis is useful to ensure that other mental health problems or cognitive deficits are not impacting on hoarding behaviours.
OTs in acute settings may also be involved in capacity assessments regarding acceptance of interventions or modifications to the home environment. Although services specifically designed to address hoarding still remain thin on the ground in the UK, it is important to be aware of any local follow-up services such as Cognitive Behavioural Therapies or professional de-clutterers.
OTs working in non- acute services such as community mental health or rehabilitation teams may be referred clients for treatment of hoarding. In this current socio-political climate characterised by developments such as payment by results, it is vital to consider the following factors:
• Motivation and awareness of the client of the problems. Use of a motivational interview framework could be helpful in identifying whether a client is ready to make changes in their routines and behaviours . If this is not indicated, a harm reduction approach may be more appropriate.
• Multi-disciplinary support and inter-agency working . Due to the complexity of the disorder and potentially long duration of interventions, it is recommended that involvement of other professionals or agencies is established at the outset. These may include co-working with a psychologist who could focus on identifying and modifying unhelpful thoughts and beliefs underlying hoarding. Support workers , relatives or staff in housing schemes may have a role in monitoring progress or carrying out recommended interventions.
• Extended assessment. In my experience at least 4-6 sessions of assessment are required to get a full understanding of the development and maintenance of hoarding behaviours. This would also help to establish whether a client will respond to interventions prior to allocation onto a caseload or team.
It is hoped that increased understanding of hoarding and a growing evidence base will support professionals such as OTs to provide effective assessments and interventions for clients, families and communities affected by this complex disorder.
References and Resources
Frost, R.O., & Hartl, T.L. (1996). A cognitive-behavioural model of compulsive hoarding . Behaviour Research and Therapy, 34, 341-350
Steketee, G. & Frost R.O. (2007) Compulsive Hoarding and Acquiring: Therapist Guide Oxford University Press
Tolin, D.F., Frost, R.O, & Steketee, G. (2007). An open trial of cognitive-behavioural therapy for compulsive hoarding. Behaviour Research and Therapy, 45, 1461-1470.
www.ocfoundation.org/hoarding
