Hoarding Disorder:
A Brief Overview
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Definition
Compulsive hoarding:
• the acquisition of, and failure to discard, a large
number of possessions that appear to be useless or
of limited value
• living spaces are sufficiently cluttered so as to
preclude activities for which those spaces were
designed
• significant distress or impairment in functioning
caused by the hoarding
(Frost & Hartl, 1996)
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Hoarding, Squalor and
Animal Hoarding
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Hoarding and squalor are not the same
Squalor is defined as filthiness or degradation from neglect:
Two forms– domestic and personal
Hoarding is related to the volume of clutter in the home, not
the cleanliness
Animal hoarding: involves the failure to provide adequate
facilities for animals overcrowded or unsanitary living
conditions, inadequate veterinary care, poor nutrition, etc .
Contact the MSPCA or Tufts University Hoarding of Animals
Research Consortium for information about animal hoarding
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Demographics & Prevalence
• Saving begins in childhood ~ age 13
• Average age in treatment = 50
• Marital Status: tend to be single
– Low marriage rate, high divorce rate, tend to live alone
• Education: ranges widely
• Family history of hoarding is common
• Squalid conditions uncommon among treatment seekers
• Estimates 3-5% of US Population (15 million Americans)
• Occurs cross-culturally: Japan, UK, Australia, Germany
• Gender – undetermined/ contradictory findings
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More on Hoarding
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Hoarding is a mental health disorder not a decision
Hoarding is not a moral issue; It is not caused by
laziness, lack of standards, lack of responsibility
Clutter is only a symptom of the problem
It is often characterized by low insight: others are
often more aware of/bothered by the clutter than
the individual
92% of individuals with hoarding have 1 or more
other mental health (e.g., depression, generalized
anxiety, obsessive-compulsive disorder, social
phobia)
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Course of Hoarding Disorder
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Little evidence for history of material
deprivation
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Hoarding may be precipitated by loss
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Chronic or worsening course
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Insight fluctuates
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Severity range from mild to life-taking
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Hoarding Behaviors
• Saving: Sentimental, instrumental, intrinsic
• Acquisition: Buying, acquisition of free things
• Clutter/Disorganization: Random piles, churning
• Difficulty Discarding: Indecision, attachment
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Understanding the Challenges of
Working with People who Hoard
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Beliefs and Emotions associated with objects
Beliefs about self in relation to world
Vulnerabilities (Time, Family History, Loss, etc.)
Co-morbid Conditions (Mental and Physical Health)
Cognitive Distortions (Problematic Thinking)
Motivation
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Hoarding and Insight
• People with hoarding problems have varying
levels of insight about the extent of their problem
and the ways that it impacts them & those
around them
– Non-insightful
– Insightful but unmotivated
– Insightful, motivated, but noncompliant
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Assessing Hoarding
• HOMES Multi-disciplinary Hoarding Risk Assessment
Instructions for Use
HOMES Multi-disciplinary Hoarding Risk Assessment provides a structural measure through which the level
of risk in a hoarded environment can be conceptualized.
It is intended as an initial and brief assessment to aid in determining the nature and parameters of the
hoarding problem and organizing a plan from which further action may be taken-- including immediate
intervention, additional assessment or referral.
HOMES can be used in a variety of ways, depending on needs and resources. It is recommended that a
visual scan of the environment in combination with a conversation with the person(s) in the home be used
to determine the effect of clutter/hoarding on Health, Obstacles, Mental Health, Endangerment and
Structure in the setting.
The Family Composition, Imminent Risk, Capacity, Notes and Post-Assessment sections are intended for
additional information about the hoarded environment, the occupants and their capacity/strength to
address the problem.
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Ineffective Intervention Strategies
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Make decisions (about a plan of action) for a
tenant
Argue or Persuade
Pressure the tenant to discard
Tell the tenant how to feel
Give verbal and non-verbal cues that are
judgmental or negative in nature
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Effective Intervention Strategies
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Be clear about expectations and limitations
Ask open-ended questions
Reflectively listen
Use respectful, non-judgmental language
Mirror the language used by the tenant
“Work with” the tenant instead of “doing for”
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Focus on Internal Motivation:
The ‘Magic’ Bullet
What makes people motivated to change?
Confidence
Importance
Factors Influencing Motivation
How much social support?
Are there any home visitors?
Can anyone monitor homework?
How depressed is the tenant?
Can tenant tolerate discomfort?
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Enhancing Motivation
Questions to start dialogue:
• How has hoarding affected your family?
• How does the clutter fit with the things you value
in life?
• What successes have you had that make you
think you address your hoarding problem?
• Why would you want to change if it means giving
up part of yourself?
HOARDING:
THE LEGAL FRAMEWORK
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LEGAL QUESTIONS
WHEN DOES HOUSEKEEPING BECOME A LEGAL
PROBLEM?
WHEN DOES REASONABLE ACCOMMODATION
COME INTO PLAY?
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PART 1
WHEN DOES HOARDING BECOME
A LEGAL PROBLEM?
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HOARDING IS A LEGAL PROBLEM WHEN…
It violates applicable housing health and safety
standards, including those for animals
It endangers vulnerable people as defined by
state law
• Children
• Elders
• Persons with Disabilities
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HOARDING IS A HOUSING PROBLEM
When it violates or progresses toward violating:
• The Lease
• HUD/DHCD Standards
• Local or state health and safety codes
• Animal cruelty standards
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ESSENTIAL HOUSEKEEPING
LEASE REQUIREMENTS
• DON’T INTERFERE w/ neighbors, staff
• MAINTAIN UNIT, Common Areas
• NO SERIOUS CODE VIOLATIONS
• Follow REASONABLE HOUSE RULES
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HUD HOUSE RULES (1)
May include requirements for:
• Garbage disposal, including disposal of
– Grease
– Smoking materials
– Used syringes or other biohazards
• Keeping kitchen and bathroom fixtures in
operable and sanitary condition, including
– no scum or mold build-up
– clean drains
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HUD HOUSE RULES (2)
May prohibit
• Storage of hazardous materials
• Blocking of exits
• Blocking of heating vents
• Overloading circuits and hazardous use of
extension cords
• Garbage or clutter that attracts insects or
rodents or produces foul odors
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HUD HOUSE RULES (3)
May prescribe repair/maintenance standards
• Prompt reporting of repair needs
• Clear access to repair area
• Prompt reporting of infestation
• Cooperation with necessary extermination
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HUD SANITARY STANDARDS
CAT
• May require changing of cat litter, but no
more than twice/week
• May require removing waste from litter, but
no more than once/day
CATS & DOGS
• May prescribe disposal of litter and waste
• Require control of noise and odor
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HUD AND DHCD STANDARDS
HUD
• Section 8 Housing Quality Standards
(HQS) Ch 10
• Pet Policy
DHCD
• 24CFR 982 and HQS Ch 8 (Public Housing and
Certificates)
• State Sanitary Code 105 CMR 410 (all Housing)
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ANIMAL CRUELTY REQUIREMENTS
MGL chapter 272: Sec 77 forbids
• unnecessarily fail(ing) to provide (an animal) with
proper food, drink… (and) sanitary environment
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HOARDING IS A SERVICE PROVIDER
LEGAL PROBLEM
When it endangers:
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Children
Elders (over 65)
Persons with Disabilities (any age)
Animals
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WHAT KINDS OF DANGER
Health and Safety
• Physical hazards, especially with disability
• Health hazards
– Mold
– Infestation
– Excessive dust
• Fire and egress hazards
• Structural/systems hazards
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PART 2
WHEN DOES REASONABLE
ACCOMMODATION COME INTO
PLAY
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PERSON W/ A DISABILITY - CIVIL
RIGHTS DEFINITION
• A PHYSICAL or MENTAL IMPAIRMENT which
SIGNIFICANTLY INTEFERES with one or more
MAJOR LIFE ACTIVITIES
• In this case, the major life activity of
housekeeping (and possibly other activities)
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HOARDING AS A DISABILITY
• Civil Rights Definition is FUNCTIONAL, not
diagnostic (DSM)
• US Supreme Court: the person is “unable” or
“very restricted” in the ability to do some
“daily life activity” (housekeeping)
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REASONABLE ACCOMMODATON (1)
Applicable when:
• Resident has a disability
• Disability is cause of housekeeping problem
• Resident wants an accommodation
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REASONABLE ACCOMMODATON (2)
Applicable when:
• Disability is obvious or there is relevant
verification including ability and willingness of
resident to cooperate
• Accommodation does not
– pose undue burden or
– require a fundamental change in nature of
program
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UNDUE BURDEN
Financial burden
• No set formula
• Cost of accommodation vs. size & financial
condition of owner’s overall housing business
Administrative burden (staff time)
• How much time?
• Effect on ability to carry out other responsibilities
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FUNDAMENTAL CHANGE
IN THE NATURE OF THE PROGRAM
FUNDAMENTAL NATURE DETERMINED BY:
• Landlord-Tenant Laws
• Health, Safety and Animal Protection Codes
• Funding source regulations
• Lease & House Rules
• Industry Practice
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Accommodation Plan Includes
(1)
1. Specific standards in specific areas
2. The timeline for each step and the deadline
3. Who will do the clean up and trash removal
4. Who will check and how often
Continued
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Accommodation Plan Includes (2)
5. Services resident will accept
6. Relevant releases
7. Consequences for failure to follow plan
8. Ongoing monitoring
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SEEK COURT RA AGREEMENT IF…
 There is potential danger to others
 Resident is in denial about serious violation
 Necessary to involve service providers and/or
family (Tenancy Preservation Program)
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