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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