Course:SOWK551/2021/Hoarding and the Impact on Housing
Short Summary
Literature review on hoarding as a disorder and how it relates to one’s ability to access and sustain housing.
Author: Madison Holowatuk
Date: December 9th, 2021
Introduction
Over the past few decades, the number of possessions owned by the average person has dramatically increased (Tolin et al., 2007a). Most people however do not have difficulty managing their possession, but for those who save and acquire too much, the consequences can be devastating (Tolin et al., 2007a). Hoarding is associated with serious health and safety risks for individuals, their families, and the community at large (Iervolino et al., 2009) and therefore understanding this syndrome is critical to providing effective services (Bratiotis et al., 2011). This literature review will briefly discuss what hoarding is, and while hoarding is a complex issue with several medical and psychiatric comorbities that accompany it (Iervolino et al., 2009), this review will primarily focus on hoarding disorder as it relates to one’s ability to access and sustain housing. Finally, current interventions for hoarding will be explored as will the role of social workers within those interventions.
What Is Hoarding?
Prior to 1993, studies of hoarding in the mental health literature were virtually non-existent (Frost et al., 2012). Originally thought to be a subtype of obsessive-compulsive disorder (OCD), it was not until the release of the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association-5th ed. (DSM-5) that hoarding disorder was recognized as a distinct diagnostic entity (Pertusa et al., 2019). The criteria for hoarding disorder are based on Frost & Hartl’s (1996) seminal work, with the primary feature of hoarding disorder being defined as “difficulty letting go of possessions that most people would not choose to keep and that the person does not need, use, and sometimes even want” (Steketee & Bratiotis, 2020, p.7).
There are several factors or vulnerabilities that can increase the likelihood that someone will develop a hoarding problem. Some of these factors include age, for example, with the average age at which hoarding behaviour begins being around 13 years old (Steketee & Bratiotis, 2020). There also appears to be a genetic component to hoarding as evidence from family studies demonstrates that hoarding is common among first-degree relatives of people who hoard (Steketee & Bratiotis, 2020). Additionally, individuals who hoard report experiencing more frequent traumatic experiences (Hartl et al., 2005), however Steketee and Bratiotis (2020) stress that hoarding is not caused by any single life experience. They further state that even the most challenging loss, such as the death of a loved one, is unlikely to constitute the sole reason that an individual would develop a hoarding problem (Steketee & Bratiotis, 2020). As well, unusual beliefs, strong emotional attachment, executive functioning deficits, behavioural avoidance, and early developmental factors are all thought to be elements that contribute to the development of hoarding behaviour (Mataix-Cols et al., 2010).
There is a difference between hoarding disorder and hoarding behaviour. Only a small number of people are diagnosed with hoarding disorder but there are many people who have the behaviours of hoarding (Steketee & Bratiotis, 2020). Studies conducted across the United States and Europe indicate that clinically significant hoarding behaviour occurs in 1% to 6% of the population (Steketee & Bratiotis, 2020). There are various mental health problems that might account for what appears to be hoarding disorder but is in fact due to another condition (Steketee & Bratiotis, 2020). Examples of other mental health problems that may cause hoarding behaviour include depression, psychosis, brain injury, and dementia (Steketee & Bratiotis, 2020).
Risks Related to Hoarding
Housing stability is greatly jeopardized by hoarding, which in some instances may even lead to loss of subsidized housing or homelessness (Bratiotis et al., 2011). A breach of lease violation may ensue even from mild to moderate hoarding as even this can lead to unsanitary or unsafe conditions (Bratiotis et al., 2011). These unsanitary and unsafe conditions are due to the accumulation of clutter caused from hoarding which can lead to an increased rate of falls, tripping, and injury from falling items (International OCD Foundation, n.d.) and can also lead to homes falling into disrepair and lacking basic utilities (Luu et al., 2018). An individual’s or family’s health can become compromised due to contamination by rotting and perishable foods (Frost et al., 2000) and there is even the potential for developing health problems from mold or pests that live amongst the clutter (International OCD Foundation, n.d.). It is due to this deteriorating state of the home and the associated health and safety risks that people who hoard may face eviction (Rodriguez et al., 2012).
Severe hoarding behaviour not only affects the individual, but it can also have dramatic effects on the community at large (Frost et al., 2000). Fire hazards are one of the most common safety risks associated with hoarding as they pose a great threat to individuals, their neighbours, and the community; unfortunately fire hazards are plentiful in hoarded homes (Steketee & Bratiotis, 2020). A fire hazard can be created from an accumulation of possessions if “means of egress are blocked, if flammable materials (e.g., newspapers, magazines) are piled near stoves and furnaces, or if the volume of possessions would make a fire harder to control” (Frost et al., 2000, p. 229). The high volume of combustible materials in hoarded homes provides fuel for fires allowing them to burn faster and hotter than non-hoarded homes would (Steketee & Bratiotis, 2020). Additionally, injury and death are more likely to occur in hoarded homes because of firefighters not being able to enter a home or control a fire (International OCD Foundation, n.d.). To highlight the dangers associated with fires in hoarded homes a fire study was conducted in Melbourne, Australia, which determined that “24% of preventable fire fatalities occurred in hoarded homes, even though fires in hoarded homes accounted for less than 1% of all fires within the city” (Steketee & Bratiotis, 2020, p. 66).
Due to the risks associated with living in a hoarded home, individuals often find themselves facing serious legal issues. Of particular concern are the legal proceedings that threaten an individual with a loss of stable housing (Cobb et al., 2007). As hoarding can pose a “complex social and environmental problem in which communities have a legitimate interest in public protection” (Bratiotis et al., 2019, p. 94), legal enforcement of public health and safety regulations will often ensue.
Housing providers such as landlords, property managers, or contracted housing agencies, are often the first to become aware of a hoarding situation and can provide a point of entry for a necessary hoarding intervention (Bratiotis & Woody, 2014). Often housing providers are required to provide reasonable accommodation for a tenant with hoarding behaviour on the basis of disability (Bratiotis & Woody, 2014). Examples of reasonable accommodation include “providing access to dumpsters or other services that would facilitate bringing the housing unit into compliance with the lease, allowing additional time to achieve compliance and delaying eviction proceedings” (Bratiotis & Woody, 2014, p. 319). It is important to note that a disability accommodation does not absolve the tenant from having to comply with housing and sanitation codes, nor does it mean that housing providers cannot impose sanctions if the tenant does not come into compliance with these codes (Bratiotis et al., 2011).
Current Interventions
One of the most recognized evidence-based approaches to helping people who hoard is to utilize a collaborative and multidisciplinary community hoarding task force (Whitfield et al., 2012). These task forces typically consist of “mental health, housing, social service, public health agencies and community enforcement organizations (fire, police, legal, animal control)” (Bratiotis, 2013a, p. 245). The first hoarding task force was created in Virginia in 1999 and since then approximately 85 tasks forces have been created throughout the United States, Canada, and Australia (Bratiotis, 2013a). The goal of these task forces is not to stop hoarding but to prevent eviction by making the home safer (American Psychological Association, 2020). Creating trust between the task force members and the client is a critical component of the intervention and can be accomplished by using an approach that focuses on harm reduction rather than simply symptom reduction (Whitfield et al., 2012). Singh and Jones (2013) suggest that when there is no task force involvement in a hoarding case almost half of those interventions show no signs of improvement and rather 15% of those cases result in worsening hoarding.
The aim of harm reduction for hoarding is to prevent the consequences associated with hoarding behaviour while allowing the person to continue engaging in those behaviours (Tompkins, 2015). Harm reduction is not a treatment, as the primary goal is to manage symptoms and decrease risk, whereas with treatment, the goal is to eliminate or substantially minimize the symptoms (Tompkins, 2015). A harm reduction plan works to identify what is needed to be done to the “living environment to bring it to a minimum level of safety; who will do the work and how they will go about doing this; how long the process will take; and who will monitor adherence with the plan and how” (Tompkins, 2015, p.59). Harm reduction works to minimize the risk posed by accumulated objects by utilizing strategies such as agreed-upon rules to limit acquisition, moving items to clear exit paths in the home, or moving flammable items away from heat sources (Tompkins & Hartl, 2009).
Another commonly used intervention is a clean out; oftentimes this extreme intervention is forced. Clean outs can elicit extreme responses in the individual who hoards and can also have adverse effects on the person’s mental health (Bratiotis et al., 2011). When a clean out is performed the immediate public health issues related to hoarding are dealt with, however there is nearly a 100% recidivism rate for the person who hoards if they do not also receive any type of behavioural treatment (Bratiotis et al., 2011). When this is the case, the cycle of acquiring and the failure to discard will appear again, rendering the expensive and time consuming clean out ineffective (Tolin et al., 2007a).
Tolin et al. (2007a) describe hoarding as being “a problem of emotional, mental, behavioural, and social well-being” (p. 29). When interventions focus on clearing out items from a person’s home, they miss the point, because hoarding is not just a house problem, it is also a person problem (Tolin et al., 2007a). Unless a person makes “fundamental, sustainable changes in how he or she thinks, feels, and acts - that is, alters the way he or she relates to possessions - the problem is likely to return” (Tolin et al., 2007a, p. 30). It is not until employing cognitive behavioural therapy, which works to “alter the thoughts, beliefs, and behavioral patterns presumed to maintain the hoarding problem” (Muroff et al., 2009, p. 407), that an individual can then truly begin to address their hoarding problem.
Presently, the most studied treatment for hoarding is cognitive behavioural therapy based on a conceptual model described by Steketee and Frost (Steketee & Frost, 2007). The cognitive-behavioural model of hoarding suggests that there are “deficits in information processing, maladaptive beliefs about and attachments to possessions that provoke distress and avoidance, and positive emotional responses to saving and acquiring that reinforce these behaviors” (Muroff, Steketee, Frost & Tolin, 2014, p. 964). Individual CBT for hoarding disorder requires 26 sessions of outpatient therapy delivered in office as well as every 4th session occurring in the client’s home (Muroff et al., 2009). The treatment includes aspects such as goal setting, motivational enhancement, problem solving, challenging beliefs about possessions, practice with sorting and discarding, and non-acquisition (Muroff, Underwood & Steketee, 2014). As well, group treatment for hoarding can be especially useful as it can also work towards decreasing social isolation, increasing motivation, and is also cost effective (Muroff et al., 2009; Davidson et al., 2019).
Tolin et al. published a study that presented preliminary data on the promising therapeutic effect and efficacy of CBT for hoarding disorder (2007b). The study found that of the 10 individuals who completed the program, 50% were rated as much or very much improved on a clinical global improvement scale (Tolin et al., 2007b). However, a more recent systematic review of CBT for hoarding disorder noted that across studies, full remission of symptoms was not achieved, and there was a high attrition rate and low motivation often experienced by participants (Williams & Viscusi, 2016). Individuals with hoarding disorder typically do not respond as well to traditional CBT methods in comparison with other groups (Williams & Viscusi, 2016), and this issue, among others, emphasizes the need for further improvements in hoarding related interventions as well as more thorough and methodological treatment trials (Davidson et al., 2019).
Link to Social Work
There is currently little evidence on the impact that social workers can have with clients who hoard even though social workers frequently encounter hoarding situations (Brown & Pain, 2014). Social workers are well positioned to work with clients who hoard as the profession holds a unique skill set that places emphasis on empowerment, client strengths, and commonly employs a person-centred approach (Brown & Pain, 2014). Social workers are adept at assessing and managing risk as well as recognizing that a certain degree of risk cannot be avoided at times, which is particularly relevant when working in hoarded homes (Brown & Pain, 2014). Bratiotis (2013b) further states that hoarding task forces rarely include social workers in leadership roles despite their skills in case consultation, advocacy, and brokering. It appears that there is a need for social workers to become more involved in roles that support individuals who hoard due to the professions unique skill set and values that they work to uphold. Additionally, many professionals in primary mental health roles report a lack of clinical training on hoarding disorder and site this as a significant barrier to service delivery (Davidson et al., 2019).
This literature review may be used by social workers to gain a better understanding of hoarding and the implications that this behaviour carries. It can allow for social workers to reflect on how they envision their role within hoarding interventions and may inspire some to seek out new opportunities to work with those who hoard, noting that the skills they hold are well suited for work with this population. It may also encourage social workers to approach clients who hoard in a gentler way, now knowing some of the causes behind the behaviour as well as the difficulty in treating it. The review can also help social workers better grasp how they can work with housing providers to ensure that reasonable accommodation is provided to their client and how they can work to involve a hoarding task force to help ensure the best possible outcome for their client.
Conclusion
Hoarding is a behaviour that is difficult to stop and several professionals, such as code enforcement officials and social service workers, struggle with how to address the issue (Bratiotis et al., 2011). Hoarding poses a great threat not only to the individual, but also to their family and the community at large, due to the health and safety risks associated with the behaviour. It is due to these health and safety risks that devastating consequences, such as eviction and homelessness, can often befall those who hoard. This literature review has examined the limited interventions that currently exist for those who hoard. Hoarding task forces, which are an evidence-based method that utilize a harm reduction approach, work to make homes safer to prevent eviction; they remain the most recognized approach. However, interventions also need to focus on the person. While there is evidence to support the use of CBT for treating hoarding, there is also evidence that suggests further improvements in this, and other hoarding related interventions are needed. Lastly, while social workers currently do not have a vast involvement with clients who hoard, they are well positioned for this type of work due to their profession’s unique skill set which makes them well suited for roles on hoarding task forces as well as in mental health roles.
References
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