Tips for organising

As  OTs  we  would  tend  to   focus  on organisational  skills.  Here  are a  few   tips   which  people  have  found  helpful. Please  comment   with  any  additional ideas  which  are  not  on  the  list.

Tips  for  sorting  and  organising

Before  you  start

·         Before  you  start   try make  categories-  these  could  be   very   basic  eg  1)  Things  let  go  of  2)  things  to  keep.

·         If  you  are  making a longer list  of  categories  of   things  to  keep-   make  sure  you   list  where  you are   planning  to  store them. E.g Books- large  bookcase in living  room.

·         Some people   label  drawers  or  cupboards with  categories to  keep  focussed  while  sorting.

·         Try  to  identify  the  items  or  categories  which  are most  important  you  and  the  items  which  are  less   important.

·         Identify  a few very  important things (VITs) eg  passport ,  bank  card   and  make  sure  that  they  are kept  somewhere  you  can  find  them.

·         Make  a  list  the  tasks   you  need  to  do  and  rank  them  in order of   easy  to   difficult.  Start with the  easy  tasks  first.

Develop  rules for   sorting

The  rules  will  depend  on  the  individual’s  situation.

Some  examples;

·         -OHIO -Only   Handle  IT  Once

·        - One  in  two  out etc (If  you  bring   one  item  into  the  house  discard  two)

·         -Only  keep   something if  you know  you   are  going to or  have  used  use it  in  6  months/  one  year etc.

·        - What’s  cleared   stays  cleared

·        - Don’t  bring  in  things  to  give  to  other  people

Develop  a  list  of   questions  to   ask  yourself   when you are deciding  what  to keep you  may  want  to  put  them somewhere  you  can  see e.g

-Do  I  already  have  one  of  these?

-Do  I  have  time to   use  it ?

-Do  I  have  space  for  it?

-Have  I  used it  in  the past  year?

-How  does  it  compare  with the  things I  value  highly?

-Does it  seem  more important  because   I am looking at  it  now?

Establish a  routine around clearing

·         Identify   times  of  the  day   when   your   concentration  may  be  better and try  to  start   during  these  times.

·         Identify  a set  time  for  sorting.

·         Start  with   shorter periods  first - even if  it is   10  minutes  and slowly  build  it  up.

·         Some people  set an  alarm  to  time  them  while  they  are  clearing.

Keep  organised

·         Avoid  re-populating  areas you  have   already  cleared unless  it  is  a  temporary  “staging” area  for  sorting .If  appropriate you could fence  off    cleared areas   for a  short  time  e.g a  desk  or   a   corner  as  temporarily   “no  go”.

·         If  there  are  a lot of  things that  need   organising   think  about 4  or  5   key  categories that  you keep  maintained  whatever  happens e.g  laundry,  recycling ,  washing  up and post and  make  sure  that these  are  kept  in  order  on  a daily  basis.

·         If  the   floor  is  covered   in    objects  think  of  putting  them  in  a  box   first   to  create   more  floor  space  and  sort  from   the   box.

·         Try  and   make  sure  the   objects    to  be  sorted  are  at a  reachable  level to minimise repetitive  strain   of reaching  .

Keep  focussed

·               If  you  have a  clear  idea   how  you   would  like  your  place  to  look –plan  it    out   in  your  mind  as  carefully  as  possible.  Draw  a picture  or   find  one  of  a place  that  looks  similar   and  post  it   where  you  can  see  it

·         Decide  on  the  area  or  category  you are going  to  sort  and stick to  it.

·         Consider  covering  areas  that  you are not  working  on with  a  sheet so  that  you  are not  distracted by  other  areas  you  have  to  clear.

-          Use a brightly  coloured piece  of  card or   cloth  to   identify  the  area  you  need  to  clear,  ideally  choose  a  colour  of  your   choice  which  either  makes  you  feel  calm or  motivated.

·         Working   with  your  back  to   the  areas  you  are not  working on  so   you  don’t  get distracted  or   overwhelmed.  

·         Finish   one  task properly  before starting  the   next  task.

Keep    motivated

·         If  you  have a  clear  idea   how  you   would  like  your  place  to  look –,plan  it    out   in  your  mind  as  carefully  as  possible.  Draw  a picture  or   find  one  of  a place  that  looks  similar   and  post  it   were  you  can  see  it.

·         Keep a  record  or  diary  of  what  you  have  achieved each  day    so   you  can  remind  yourself  of  your  progress.

·         Tell someone   what  you are planning  to   do - sometimes  talking  about  it   makes  it  more  likely  to  happen.

·         If  appropriate   identify  someone   who  will help  motivate you - you   should  feel  comfortable with  them.  Agree  together  the  best  way  of  helping you  such as  being  with  you,  helping  you  carry  or  giving  you  an encouraging phone  call.

·         Link up  with  others   who  are in a  similar  situation to  help   motivate you. Consider  social  networking sites  such as “Help  for  hoarders”  where you can  share  your  progress  and  challenges  and tips  with   others.

·         Some people  find  listening  to music  helpful while  they  clear.

·         Take  a  photograph  of  your  possessions  and  have  a look  at  the  photo  both  in  and  out  of   your  home-  sometimes  looking  at  it   in a  different  environment  can  give a  new  perspective.

·         Think  of  a symbol or mantra or picture  that  will help you achieve  your  goals-  you  could  post  it   around  the  home around  to  remind  you.

·         Making  it   fun  -roll  a  dice  for  the  day  and  let   go   or  as  many  items  as the   number .

·          If  it  is  hard  to  get  going  think  about   a  five  minute   mini-  challenge  to  get   quick  results for example

-        Pick  up   all  the  pens  you  can  find   and only  keep the   ones   that   are  working

-       Collect or  your   loose   coins lying  and put  in  collection  box  or for  charity

-       Sort out   your  handbag  or   main  bag  -  weigh   it   before  and  after

·         Reward  yourself  afterwards .

Sources  of  information

No  more clutter- Sue Kay

Buried In  Treasures- David F  Tolin; Randy O Frost; Gail  Steketee (2d  Ed)

Digging Out-Michael  A  Tompkins;  Tamara  A.  Hartl

Help for  Hoarders website

Capacity to Do

I wrote   an  earlier   post about   hoarding  in  relation  to  the  Mental  Capacity  Act  (2005)  which  is  used  in  the  UK  to  assess  an  individual’s  ability  to make  a decision about  a  specific  course  of  action  if  there  is  an  indication  of  a  disturbance  of  the  mind  or  brain.

However, what  the  Act  does  not    describe adequately is  an  individual’s  executive  capacity i.e  the  ability  to act   on a  decision. This  has  been   identified  as  being  important      when  considering  areas  such as  hoarding  and  self  neglect (SCIE, 2011).

To clarify  what  is  meant  by  the  term. Naik et al (2008) describe  decisional capacity as

…“the  process of  making  decisions for  oneself or  extending that power  to  another  individual” p.27

In  contrast executive  capacity  is  described  as ;

“ the  process  of  putting  one’s  decision into  effect either  alone  or by  delegating those  responsibilities  to  another more physically  able  individual” p.27

 I  guess  in simple terms, executive  capacity  is concerns the   ability  to  walk  the  walk in  contrast  to  talking  the  talk (decisional capacity).

It  has  been  argued that when  assessing  capacity particularly in relation  to  self  neglect,   decision  making  capacity  is  often  given  more  attention  than  executive  capacity (SCIE, 2011).  However, some  people may  have  decisional  capacity  but   lack  the   ability  to  put   their decisions  into  action  due  to  executive  dysfunction.  Naik  et  al (2008) therefore  argue  is  important  for  professionals  assess both  decisional and  executive  capacity   when     planning  care  for   adults at  risk of  self  neglect.  The  same  authors  describe an “Articulate-Demonstrate “ approach  to  capacity  assessment. This   may  involve  a  combination  of  standardised    assessments including  psychometric and  OT  assessments  and  more  individualised observation  of clients'  day  to  day  functioning. The authors argue  that  OTs  and  Nurse  Practitioners  are  in a good position  to assess  abilities to  carry out  agreed  decisions  in  areas  such as  managing medication,  maintaining  personal  care   etc   with  or  without  additional  support.

In  relation  to  hoarding, research  has   identified  that  people who  hoard  are more  likely  to  have problems   in  executive  functioning  such as problems with  categorisation and  decision making, reduced  concentration  and  increased  impulsivity   ( eg Hartl et al 2004; McMillan  et al 2012). This  can result in problems such as accumulation of  excess  clutter and  behaviours  such  as  “churning” whereby  the  hoarding individual   picks  up  an  item   from  a  pile  and  cannot  decide  what  to   do  about  it so puts  it  on another  pile , meaning that  the  pile  of  clutter  just  moves   from  one  area  to  another.  (Tolin  et  al, 2014)

To  give  the  following  case example.

 I  have  been  working  with  an older  age   client    who  was  diagnosed  with  Alzheimer’s   disease  about  a  year previously and  presents   with moderate cognitive  impairment.  She  is  however  very   articulate  and is  keen  to maintain  her  independence .  She  has  always   lived  alone  and  is  fiercely independent . On  assessment   it  appears   that  she  has  had  long  standing  hoarding  traits,  but  these  have  worsened   due  to  recent   cognitive  decline. She  lives  alone  in  a  cluttered   studio flat  but  can  just  about  negotiate  her  way to  key  areas  of  the  flat  such as the  kitchen and  the  bathroom  sink  and  toilet  but  often  has  to  move  items  out  of  the  way  as  she  moves  around.

She  has  had  falls  and there  is an  ongoing  fire  risk  as  areas  on  her  floor  are  covered  with  piles  of  paper. She  recognises  that  there  is  a  risk  should  her  environment become  more  cluttered,   but  she  is    keen  to address  this  issue  herself.  Over the several  months  I  have  known  this  client,  I always  arrive  to  find  her  busily working  through  piles  of  paperwork  which  never  end  up getting  filed or  organised  in  a  systematic  way so  the  piles never  reduce just  move from  place  to place  ie “churning”. Although  she  has   been very  careful  in  the past about  ensuring  she  pays  bills  on  time,  she  has  started to experience difficulties  managing finances, for  example writing  out  a cheque for  a bill  but  forgetting  to post  it. Her  bathroom floor  is  full  of  clothes  that  were  taken  to  the  laundry but  not  put away, so they  have  subsequently  become  dirty  again and lie in piles  waiting  to be  washed  again. In  summary  she   now  struggles  to  carry  out goal directed actions  through a  series  of  stages.

In  discussing  the  situation   with the  client,   it  appears  that she  has  the  decisional  capacity to  understand  the  risks  associated  with the  clutter  in  the  flat.  However  she  lacks  the  executive  capacity to  manage the  build  up  of  clutter  without  support.

Having   become  more  aware of the  concept of  executive  functioning in  relation  to mental  capacity  relatively  recently, I  think  there  are  two  clinical main implications relating  to  OT   practice.

•     For  OTs  carrying  out  capacity  assessments (as  with  other  members  of the MDT),  executive  capacity  as  well as  decisional  capacity  should  be  highlighted when considering areas of  self  neglect  and  hoarding.
•      In  considering  the  role  of   OT  for hoarding,  there  is  potential  role for  OT  in  carrying out  standardised and   non-standardised  assessment  of  functional  abilities (executive capacity)   to  help clarify  an  individual’s  mental capacity regarding  actions  to  manage  hoarding.

As  always  any  thoughts  or  comments  are  welcome.

References

Hartl, T.L., Frost, R.O., Allen, G.J., Deckersbach, T., Steketee,G., Duffnay, S.R. & Savage, C.R. (2004). Actual and perceived memory deficits in individuals with compulsive hoarding. Depression and Anxiety,20, 59-69.

McMillan SG, Rees CS, Pestell C (2013) An  investigation of  executive  functioning, attention and  working  memory  in  compulsive  hoarding,  Behavioural  and  Cognitive 

Psychotherapy, 41, 610-625.

Naik, A.D., Lai,JM and  Dyer,CB (2008) Assessing  capacity in  suspected  cases  of  self  neglect. Geritrics, 63 (2), 24-31  accessed  online http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2847362/

Social Care  Institute  for  Excellence (SCIE). (2011) Adult  Service  CSIE Report  46 “Self neglect  and  adult safeguarding: findings  from  research” p-26-38 accessed  online http://www.scie.org.uk/publications/reports/report46.asp  

Tolin,DF; Frost, RO and Steketee, G. Buried  in Treasures: Help for  Compulsive Acquiring,  Saving,  and  Hoarding (2014) 2^nd  Ed. Oxford  University Press 

Suggestions for OT-based research topics

I get contacted from time to  time  by mainly students looking to  do projects/dissertations on OT and hoarding. This is fantastic and hopefully will gain momentum  to lead to published research and an evidence base for the profession. Basically the door seems wide  open in terms of research  needed into OT and hoarding , however I've put down a few thoughts below of  questions /areas that  could  be explored and developed further. Please  feel free to add other  suggestions for research topics.


- Potential use of  OT models - how do they relate to the current  evidence base? Is there a need for a specific model  in OT?

- Are OT interventions  cost -effective?

- Interventions focussing on restructuring of roles and routines and the evidence base for these?

-Are  OTs  too   focussed on the physical environment  when  working  with people who hoard?

- Are there certain hoarding traits or behaviours  which OTs are well placed to  work with?

-S.User/family experience   of OT interventions


Lets hope  we'll  be able to answer some of these questions  further down the line

Has anyone used the KAWA model?

I'd be interested to know whether anyone has used the KAWA model in the assessment/ treatment of hoarding. It  looks like a potentially  useful way of establishing  clients' perspectives and priorities as well as establishing more of a therapeutic rather than directive  relationship. So would be great to hear about  any clinical   experiences. Obviously if I get the chance to use it  myself, I will keep you posted. 

Motivational Interviewing Questions

Although motivational interviewing  is not  specific to OT or hoarding , I have found the following  questions helpful to take along along to assessments or sessions  as a prompt sheet to  establish readiness for  change or introduce the possibility of change in hoarding behaviours. As always, please feel free to make  any comments or suggestions.

Motivational Interviewing Questions

DARN may elicit change talk

D- Desire   What do you wish/hope etc?

A- Ability    What can you do?   What is possible? How confident are you that you can change?

R- Reasons  Why would you make this change?  What risks would this decrease?  What benefits ?

N-Need       How important  is this change? How much do you need to do it?

Change Questions

Why might you want to make this change?

If you did decide to make this change how would you do it?

What are the 3 most important benefits to making this change?

Rating Scales

How ready/confident  so you feel (0-10) ? How important is it  making this change (0-10)?

What would need to happen for the number to go up?

Why did you not answer lower?

Decisional  Balance

What is good about the situation staying as  it  is ?
What is not so good?
What concerns   do  you  have  about  the  change?
What  are  the  good  thing  about  change?

Summarise pros and cons

Follow up  “Where does that leave you now ?”

What do you intend to do?

If not ready to make changes.......

Hypothetical questions?

What might it take for you to make a change?

Let’s imagine you did. How would your life be different?

Suppose you continue without making any change . How would your life be in 1 year , 5  years , 10 years ?

 If you were in my shoes ,what would you be saying?

Giving  information  and  advice
Remember  to  try  eliciting  a person's   understanding  before   providing   information or  advice.

E.g   What  do  you  understand   about  the  risks  of  the  current   situation?
         What   do  you  know  about  strategies  to   manage  situations  like  this?

As permission  to  give  advice
Is  it  ok  if  I  tell  you  about....?

If  you have  to   give information  or  advice try  to prefeace   it  and offer  an  element  of   choice of  when  to  receive  the information.

Eg  There  is  something  I need  to  tell you  ....  would  you  like  me   to  tell  you  now  or  later  in  the  session?

This  may  or   may  not   concern  you  but.........

References

Miller,  WR and Rollnick S. (2013) Motivational  Interviewing:  Helping  People  Change.  (3rd  ed) New  York: The Guilford  Press

Rollnick, S., Miller, W.R., and Butler, C.C. (2008)  Motivational Interviewing in Health Care: Helping Patients Change Behaviour.  New York: The Guilford Press

Readiness for Change

Having recently completed  training in OCAIRS, I was inspired to think more  about Readiness for Change which is embedded in the OCAIRS assessment. Obviously this is a crucial factor when considering working with someone  with a history of hoarding , particularly in the current economic climate. Below I've highlighted a few points  related to readiness to change which can be considered as part of the assessment process (they are also included in the case formulation/assessment prompts on another posting). It does not mean that someone has to "tick all boxes" in order to be  ready for  change, but it may highlight useful starting points or potential barriers.  This also may assist in articulating to your  team or your manager  reasons why  or why not you  feel the client may be ready to engage with interventions   to tackle hoarding.

READINESS FOR CHANGE

	COMMENTS
·         Appraisal of hoarding situation and associated behaviours and  extent to which this is perceived as a problem
·         Perception of risk associated with hoarding  in relation to skills (motor /process) and environment (social and physical)
·         Goals regarding  hoarding behaviours and environment. Priority these goals  in relation to other goals or plans
·         Emotional  and behavioural responses to potential or actual changes in hoarding routine/activities or environment  (e.g accepting/fearful/ resistant/ avoidant)
·         Capacity to modify routine or performance in activity  related to acquiring, discarding or organising items
·         Approach and attitudes  by others in social  environment (i.e /rejecting/directive/empathic) and capacity  of others to adapt approach to support change
·         History of coping with changes related to hoarding behaviours (e.g enforced clearances/therapy) and emotional and behavioural responses to these
·         History of coping with other major changes /difficult situations
·         Access to  support  to tackle hoarding (e.g neighbours, family , voluntary and statutory sector, finances)
·         Engagement in current assessment process
·         Other factors influencing readiness to change

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