Hoarding and Squalor

Effective Support Responses

A Catholic Community Services Training Package

Common Characteristics

The person typically:• Cannot stop bringing items into the home• Believes that the items are in some way part of themselves• Is unable to effectively categorise items• Is affected by indecision• Is unable to discard items without feeling distressed• Has lost control of their living environment• Feels shame about their situation• May or may not seek help depending on their level of insight

and feelings of shame

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Why do People Hoard or Live in Squalor?An Outsider’s View

• There are different causes and combinations of causes including:– Family influences and experiences– Response to significant life events (e.g. war, trauma)– Difficulty with executive functioning (e.g. processing

information, categorisation, decision making, memory)– Emotionally driven reinforcement patterns– Inability to form personal relationships– Cognitive impairment caused by dementia, alcohol related

brain damage– Mental health issues (e.g. schizophrenia, depression)

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Why do People Hoard or Live in Squalor?An Insider’s View

People give different reasons including:• Protects from and prevents other people getting too close• Creates feeling of security• Strong emotional attachment to items• A belief that the items are worth valuing and/or might be useful

someday• A strong desire not to be wasteful• An intention to sort through accumulated belongings• Situation reflects negative feelings about self (e.g. feeling like

rubbish, not valued, broken)

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About Animal Hoarders

• Accumulate a large number of animals, usually cats or dogs

• 76% are women, 46% over 60 years• Recidivism rate is 100%• Sub-groups of animal hoarders include:

– Incipient hoarders– Overwhelmed caregivers– Rescuers– Breeder hoarders– Exploiters

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Animal Hoarders – Key Characteristics

• Unable to provide minimum standards of space, nutrition, sanitation, veterinary care

• Cannot see detrimental effect on the animals, other people, the environment

• Continues obsessively to maintain or accumulate animals despite deteriorating environment

• Denies or downplays that there is a problem

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Problems with CategorisationUsual Method of Organisation

Decision to keep object

Object is categorised into one of several major categories

Object is placed with other similar objects (e.g. crockery) in suitable location (e.g. kitchen)

Hoarding Method of Organisation

Decision to keep object

Object is categorised into either one major category for all items or multiple categories

Object is placed in sight due to fears or in an existing pile in a living area to be decided later

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Key Purposes of Case Management

• To achieve an optimal outcome for the client from planned & coordinated support service intervention

• To maximise client involvement in decision making

• To empower the client to take maximum control of their situation and be as independent as possible

• To provide quality support in line with the agreed plan of care

• To ensure all stakeholders work in a collaborative and coordinated way to address client support issues. 8

How are Hoarding and Squalor Situations Uncovered?

• After the person has been hospitalised by emergency services, social workers or after discharge by engaged community care services

• After a fire hazard notification has been made by neighbours or the Council

• After a fire incident and attendance by the the Fire Brigade

• When there is risk of eviction by the landlord or housing provider

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Key Engagement Issues for Service Providers

The person:

• May not have chosen for, and may be resistant to, others getting involved

• May not see it as a problem or have insight into the situation

• May be ashamed about their behavior and living environment

• May be living in unsanitary conditions with severe health and safety issues that need to be addressed

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The 1st Step – Developing Trust• Remember that trust is based on acceptance

• Get as much background information as possible before the initial approach

• Accept the person for where they are ‘at’

• Give the person a sense that they are okay

• Understand the fears they may have about change

• Offer to help in resolving another area of life that may be related or unrelated to their hoarding

• Establish trust before targeting the hoarding behaviour11

Engagement Strategies• First and foremost, accept the person for where they are

at now and listen, listen, listen• Do not show or verbalise judgments you might make• Control your reactions to sights and smells• Be prepared to make multiple visits and talk through the

front door or windows before being invited in• Keep turning up at regular, scheduled times until that

occurs• Offer help and then follow through in getting landlords,

Council, Police off their immediate backs and getting room to breathe

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Using an Enabling/Empowering Approach

• Take the time to capture the client’s story and take a holistic view of the person and their situation

• Identify strengths, abilities & resources as well as challenges and needs

• Ensure the person plays an active role in setting their own goals and making intervention and support decisions

• Work with and not for the person• Avoid taking over aspects of the intervention plan that the

person can or could do for themselves• Maintain flexibility to recognise, adapt and respond to

fluctuating client circumstances13

Step 2: The Assessment ProcessReferral with info on client & WHS issues

Home visits to engage; get the person’s story, assess capacity, person, squalor level, risk; & gain consent for further intervention

If consent address immediate WHS issues

If consent, start support plan dev’t

If consent, convene case conference

If refusing assessment, consider options

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Hoarding and Squalor Assessment Tools I

Clutter Image Rating Tool • Self administered tool that can be done by assessor• A series of 9 photographs showing escalating clutter

in a bedroom, kitchen, living room• Asks to pick the picture closest to being accurate

Environmental Cleanliness and Clutter Scale

• Records demographic details• 0-3 point rating on accessibility, accumulation,

rooms, cleanliness, odour, vermin, effect on activities, need for repairs, WHS

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Step 3: Support Plan Development

Key Principles

1. This is a person centred, multi-disciplinary and collaborative process between the person, the case manager and involved support services

2. All parties need to have realistic expectation about what can be achieved and in what timeframes

3. The person at the centre must be treated with respect and consideration

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Key Support Plan Objectives

• To address health, safety and legal issues that are immediate threats to successful engagement or intervention

• To stop or limit further, uncontrolled acquiring behaviour

• To develop a process for discarding items• To develop skills in organising things• To maintain motivation to achieve small and large

goals17

Key Support Plan Strategies IAddress health and safety

issues• Install smoke alarms• Identify unstable floors and walls• Identify and address immediate fire risks• Clear all access and egress doorways• Widen internal passageways through home• Eradicate vermin infestations• Arrange removal of diseased and distressed animals• Negotiate legal threats (e.g. eviction, enforced clean-

ups) and buy time

Prevent further acquisitions • Refer for counseling or therapy• Practice going shopping without buying anything• Keep daily log of everything acquired• Set rules for and questions before acquiring

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Key Support Plan Strategies IIDevelop a process for

discarding items• Identify different levels of anxiety about discarding

items• Plan de-clutter sessions• Start in specified areas and spread from there (e.g.

around front door, on kitchen benches)• Sort out according to least valued to most valued• Sort out by clear categories (e.g. keep, discard, donate,

recycle)

Develop organising skills • Create categories for retained items and specific places to store them

• Set deadlines• Maintain cleared areas

Maintain motivation • Set small, achievable and measurable goals• Keep a photographic visual record of progress• Celebrate milestones

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Support Plan Implementation I

Do Don’t• Be patient and allow all the time

necessary• Encourage, motivate and applaud

progress and change• Start with small steps and focus on one

part of the home at a time• Screen and select all direct support staff

for their appropriateness before they go into the home

• Develop formal service level agreements• Adequately brief and debrief agency

partners and support staff

• Pass judgment• Argue with the person• Make decisions for the person• Touch or remove the person’s belongings

without asking permission• Consider or treat the support plan as a

clean-up service• Go for the quick fix, the big clean-up• Leave a skip at the property• Expect that hoarding behaviours will

miraculously stop or not re-appear

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Support Plan Monitoring and Review I

Coaching and Motivating– Meet as a team and move in the same direction– Use ‘we’ language– Provide empathetic support– Support the person to make their own decisions– Express belief in the person– Provide physical help if requested and acceptable– Accompany the person on non-acquiring excursions– Stay within your professional boundaries– Talk about and keep visual records of achievement– Talk through barriers and blockages

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Options if You Can’t Get in to Assess Capacity

• If mental illness possible, apply under Mental Health Act to Magistrate to conduct assessment, with Police presence if needed

• Use Local Government Act to get Council to order inspection, with Police presence if needed

• Use Residential Tenancy Act to get order for landlord to conduct assessment

• Contact NSW Trustee and Guardian for advice on appointing a substitute decision maker

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Getting the Balance Right

Dignity of Risk Duty of Care

Effect of the person’s lack of insight

The ability to restore function

The need for safety and freedom from distress

The person’s right to choose

The person’s right to freedom and

independence

The person’s right to take a calculated risk

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Tips for Controlling the Gag Reflex

• Spread Vick’s VapoRub under your nostrils and/or a thin strip on your upper lip

• Try drops of lavender, eucalyptus or peppermint oil, if preferred

• Suck on honey lemon cough drops

• Apply a heavy spray of cologne on one shoulder so you can turn your head and inhale it

• If you need to use a mask, offer one to the client to reduce feelings of separateness between client and worker 24

Specific Issues for Sub-Groups

• Frail, Older People– Limited energy and physical strength to tackle big sorting and

cleaning tasks– Higher risk of health problems (e.g. falling, respiratory illness)– Cognitive impairment affecting ability to concentrate, focus and

remember

• Animal Hoarders– Difficult to gain entry and fearful of legal consequences– May see animals as replacement for family– Workplace health and safety issues– Recidivism rate means long term supervision and monitoring

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Key Messages

• There are different causes and combinations of reasons for hoarding and living in squalor

• The support response depends on treating each person as an individual and each situation as unique

• The overall aim of interventions is to enable the person and equip them with strategies for exerting control over their hoarding behaviour and their living environment

• The case management response rests on effective engagement with the person and the development of a trusting partnership

• It is important to take all the time necessary to engage, assess, plan, implement and monitor a support intervention

• A team approach by all people and agencies involved in the support plan is essential to progress.

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Thank you

Mercy Splitt

Service Manager

Catholic Community Services

1800 225 474

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