Hoarding Disorder:

A Brief Overview

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

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

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

Little evidence for history of material

deprivation

Hoarding may be precipitated by loss

Chronic or worsening course

Insight fluctuates

Severity range from mild to life-taking

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

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

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

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

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
DONT 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:

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 owners 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

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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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