Article: The Role of the OT in the Management of Compulsive Hoarding

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