1. Hoarding Assessment and
Intervention at HOC
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2. Training Objectives
 Understand the complex reasons for hoarding
 Learn to identify hoarding behaviors
 Learn about effective and ineffective intervention
strategies when treating hoarding
 Have a better understanding of roles of all HOC staff
involved, as well as outside agencies.
 Be able to effectively communicate with other staff and
across the agency regarding specific situations.
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3. Compulsive Hoarding:
Proposed DSM-V Criteria
 Persistent difficulty discarding or parting with personal
possessions, even those of apparently useless or limited
value, due to strong urges to save items, distress, and/or
indecision associated with discarding.
 The symptoms result in the accumulation of a large
number of possessions that fill up and clutter the active
living areas of the home, workplace, or other personal
surroundings (e.g., office, vehicle, yard) and prevent
normal use of the space. If all living areas are
uncluttered, it is only because of others’ efforts (e.g.,
family members, authorities) to keep these areas free of
possessions.

4. Compulsive Hoarding:
Proposed DSM-V Specifiers
 Specify if with Excessive Acquisition
 If symptoms are accompanied by excessive collecting or buying or
stealing of items that are not needed or for which there is no available
space.
 Specify whether hoarding beliefs and behaviors are currently
characterized by:
 Good or fair insight: Recognizes that hoarding-related beliefs and
behaviors (pertaining to difficulty discarding items, clutter, or excessive
acquisition) are problematic.
 Poor insight: Mostly convinced that hoarding-related beliefs and
behaviors (pertaining to difficulty discarding items, clutter, or excessive
acquisition) are not problematic despite evidence to the contrary.
 Delusional: Completely convinced that hoarding-related beliefs and
behaviors (pertaining to difficulty discarding items, clutter, or excessive
acquisition) are not problematic despite evidence to the contrary.

5. Failing to Discard Items
 Items appear useless to others
 Identifying value
 Instrumental
 Sentimental
 Intrinsic
 This results in the growth of items and
interferes with the functionality and use of
living spaces.

6. Why is hoarding a problem?
 Safety of individual:
1. Fire
2. Falls
3. Health hazards
4. Increased social isolation
 Safety of the community
1. Fire
2. Infestations
 Legal: Violation of code and HUD regulation.
 Financial: Cleaning up is expensive, buying items
create debt
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7. Illustrations…..
 Where is the stove?????
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8. Bedroom
 I am sure my bed was somewhere in this
room!
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9. Stairwell
 Goat path…
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10. Estimated Prevalence Rates
 26 in 1000 - Whole Spectrum of Hoarding
 169,000 estimated cases in Massachusetts
 16,180 estimated cases in Boston
 HOC has 50 cases “on record” in its residences
 .5 in 1000 - Diogenes Syndrome
Gross self-neglect, domestic squalor, hoarding of trash
 3250 estimated cases in Massachusetts
 310 estimated cases in Boston
(Based on overall populations of 6,500,000 for MA and 622,351 for Boston)

11. Co-Morbid Diagnoses
 Major Depression (57%)
 Social Phobia (29%)
 Generalized Anxiety Disorder (28%)
 Obsessive Compulsive Disorder (17%)
 Specific Phobia (12%)
 Post-Traumatic Stress Disorder (6%)
 Dysthymia (4%)
 Panic (2%)
 No Other Diagnosis (8%)
Frost, Steketee, Tolin, & Brown, 2006

12. Conceptual Model of Compulsive
Hoarding
Personal & Family Vulnerability Factors Information Processing Problems
Thoughts & Beliefs
Emotional Responses
Efforts to Obtain Pleasure by Saving Escape & Avoidance of Unpleasant Emotions
(Positive Reinforcement) (Negative Reinforcement)
Cluttering and Difficulty Discarding
Steketee & Frost, 2007

13. What can be done?
 Each situation is different
 An accurate assessment is essential
 In most situations, hoarding does not have a cure –
it is a chronic condition.
 Research show that a multidisciplinary approach is
the most effective method of intervention.
 Some therapy techniques have been successful in
reducing hoarding behaviors. This is a long term
treatment, which requires insight and motivation.
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14. Thoughts: Decision Making
 Perfectionism  All-Or-Nothing
 Fear of making  Cluttered Space
mistakes  Spartan Room
 Missed opportunities  Decisions are
 Being caught complicated by fears
unprepared
 Distorted perception of
 Avoidance of regrets,
others’ spaces pain, or mistakes
 Focus on benefit of  “But what if…”
saving and risk of
letting go

15. Emotional Attachment
 Possessions as  Reaction to losses
extension of self  Grief-like reactions
 Attach greater  Ruminations
sentiment  Emotional discomfort
 Comforted by
possessions
 Fear of losing part of
oneself or one’s
identity

16. Evaluation Process:
Assessment of Individual
 Appearance
 Cognitive status
 Executive functioning ability
 Medical and mental health symptoms
 Insight into hoarding behaviors
 Motivation to address hoarding behaviors
 Relations with others
 Family history - mental health and hoarding behaviors
 Ability to consent to and participate in treatment
interventions (Capacity-Risk Model; Soniat & Micklos,
2010)

17. Who should be involved?
 Housing Management (inspectors, managers)
 Federal Programs
 Resident Services
 County’s Health & Human Services (e.g., CPS,
APS, case management)
 County’s Code Enforcement and Fire Department
 Community mental health providers
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18. Housing Management
Housing Management Mission Description
 The Housing Management Division is responsible for managing the
affordable properties in HOC's housing portfolio that receive State, Federal
and local subsidies.
Through both in-house management and contractual arrangements, the
division:
 Ensures occupancy by qualified households under numerous Federal, State
and local affordable housing programs.
 Ensures that all dwelling units are maintained at or above community norms,
and in compliance with Federal housing programs.
 Enforces the terms and conditions of residents' leases.
 Performs preventive maintenance on all units and building systems in order
to extend their useful life.
 Conducts frequent resident surveys.
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19. Roles I: Housing Management
1. Conduct annual inspection.
2. Respond to complaint from neighbors.
3. In known cases of previous violations, inspections are done,
when possible, together with on-site RS staff.
4. Managers have a relationship with residents and express
concerns directly to resident
5. Follow up with a letter and request an office conference,
usually within two weeks.
6. Time frame for re-inspection will be decided, usually within 30
days.
7. A service agreement will be used to define the necessary steps
to resolve situation.
8. If service agreement is not effective, a referral is made to FP
for a supervisory conference.
9. Close collaboration between Housing Management and
Resident Services is KEY to success.
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20. Roles II: Inspectors for HCV
1. Conduct an annual inspection. Residents with a history of late
inspection get 180-day notice.
2. Respond to landlords, community or HOC staff’s complaints.
3. Determines the degree of violation.
4. Verbally explains to resident the nature of the violations and follows
up with a letter copied to landlord.
5. Notifies RS, usually via email.
6. Do not refer to Disability Services directly. This will be decided by
RS staff.
7. Give 30 days to remedy violations, then follows up with another
inspection.
8. If situation not resolved, refer to Federal Programs
9. If resident can provide documentation for inability to follow up with
inspection process, inspector may grant extension.
10.Communicate with RS and FP staff to ensure follow up and positive
outcome. Collaboration is KEY. RS will update inspector on status
of progress.
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21. Resident Services
Resident Services links HOC clients to a wide
range of services intended to allow individuals
and families to achieve self-sufficiency, gain
independence, assimilate into the broader
community and to successfully retain their
housing .
Resident Services also provides counseling
support and service linkage to assist elderly
and disabled residents to live independently in
comfort and with dignity.
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22. Role IV: Site-Based Counselors
1. Conduct a home visit (routine visit or in response to a complaint/referral). A
complaint home visit is often conducted with onsite Housing Management.
2. Perform an assessment of the severity of condition and mental status of the
resident, using a hoarding scale when applicable.
3. Identify available resources for resident.
4. Determine which referrals need to be made and which agencies need to be
involved (e.g. Adult and child Protective Services).
5. Participate in an Office Conference with Housing Management and resident.
6. Assist in establishing a plan of action (e.g. Service Agreement) and follow up
on plan in collaboration with other HOC staff and outside entities.
7. Send a formal letter to resident to address issues subsequent to the Office
Conference.
8. Monitor weekly/bi-weekly/monthly to ensure progress is made toward goals.
9. If progress is not made, collaborate with Housing Management. Referral to
FP.
10. Prepare a Social Summary & Chronology for the FP Supervisory Conference.
11. If notice to vacate is recommended, the counselor will continue to work with
resident in an attempt to resolve the issue and to avoid eviction.
12. If termination is enforced, the counselor will seek to engage resources and
services toward a safe alternative housing plan.
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23. Roles V: Federal Programs
For HCV Residents:
1. Becomes involved after 2nd failed inspection.
2. Assigns an investigator to begin termination process.
3. Send termination letter to resident. Copy RS manager/supervisor.
Resident has 10 days to request an informal hearing.
4. Resident Services will attempt to contact resident to offer supportive
services.
5. If appeal is not received FP notifies HRD to terminate.
6. If resident requests a hearing, investigator will schedule and notify
resident and RS staff.
7. Hearing Officer will render decision within 30 days.
8. If hearing officer upholds termination resident has the right to request
a hearing board.
9. Hearing board will render decision.
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24. Roles V: Federal Programs cont.
For Public Housing:
1. Becomes involved if resident does not follow through with
recommendations from case conference .
2. Supervisory conference scheduled. RS, HM and resident invited.
It is held with or without the resident.
3. Staff in supervisory conference attempts to reach a consensus
decision.
4. Recommendations range between a service agreement, consent
judgment or Lease Enforcement Panel (LEP).
5. LEP may decide to send case back to FP with recommendation or
may agree to issue a notice to vacate.
6. If a notice to vacate is issued resident can request a hearing
board.
7. Hearing board will render decision.
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25. Role VI: County Fire, Inspection & Police:
 Respond to calls from neighbors and Housing Management.
 If entry is permitted by the occupant, by administrative search
warrant or due to an emergency incident where chain of custody
is maintained, enter the premises and inspect for compliance of
all fire and life safety codes. This would include proper smoke
detection, access to and operation of “Escape” windows, as well
as the “safe” operation of all water, heating and cooking
appliances.
 Inspect all the common areas and act on a concern found there.
 Can condemn a unit if conditions are deemed unsafe. Work with
property management to address issue.
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26. Role VII: Health & Human Services
 The role of Adult and Child Protective Services:
APS and CPS only intervene in extreme cases of
abuse or neglect and/or when loss of home is
imminent for a vulnerable adult. Resident
Counselors are mandatory reporters, but anyone
can make a referral. HHS has resources for services
in the face of imminent eviction and offers
emergency shelter.
 County Social Services to adults may also be
involved. They provide case management and
assistance in accessing resources. They are limited
in capacities and have a wait list.
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27. HOC goals for working with chronic
cases:
1. Prevent repeated crises.
2. Improve collaboration internally.
3. Collect data on prevalence and severity.
4. Foster a long term plan for stability.
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28. Now, let’s look at some case
studies..
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29. How to de-clutter
1. Select target area
2. Assess possessions
3. Create categories
4. Select a starting spot
5. Start sorting and de-cluttering
6. Continue until target area is cleared
7. Use space appropriately
8. Prevent new clutter
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30. Do
 Be safe (gloves, wash hands, look where you touch)
 Be positive
 Make supportive comments
 Foster self determination
 Be creative
 Let the person lead the process
 Come ready for hand on experience
 Believe in the client’s ability
 Highlight strengths
 Stay calm
 Take care of yourself
 Stay in touch with other staff and work as a team
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31. Do not
 Touch items without the person’s explicit permission
 Be judgmental
 Give negative comments
 Let the amount of stuff overwhelm you
 De-clutter behind the client’s back
 Minimize the challenges faced
 Make decisions
 Equate the clutter with the person
 Argue or try to persuade
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32. Challenging, not Confronting
 How many do you already have? Is that enough?
 Do you have enough time to use, review, or read it?
 Have you used this during the past year?
 Do you have a specific plan for this item? By when?
 Does this fit with your values and needs?
 Is it important because you’re looking at it now?
 Is it current, of good quality, accurate, reliable?
 Would you buy it again if you didn’t already own it?
 Do you really need it?
 Could you get it again if you really needed it?
 Do you have enough space for this?