Hoarding and Homelessness - PowerPoint Presentation

Hoarding and Homelessness Randy O. Frost, Ph.D.Harold and Elsa Siipola Israel Professor of PsychologySmith CollegeJonathan Kessler, LCSWTeam Leader/CoordinatorHUD/VASH Housing First ACT TeamNY Harbor Healthcare System, Manhattan Campus

Presenters Randy O. Frost is the Israel Professor of Psychology at Smith College. He has published numerous articles and books, including Stuff: Compulsive hoarding and the meaning of things, a New York Times Bestseller and a finalist for the 2010 Books for a Better Life Award. His latest book, The Oxford Handbook of Hoarding and Acquiring was published in 2014. He has received a Lifetime Achievement Award by the Mental Health Association of San Francisco, and a Career Achievement Award from the International OCD Foundation.Jonathan Kessler, LCSW, is the team leader and coordinator of the HUD/VASH Housing First ACT Team for NY Harbor Healthcare System. He has worked at the VA since 2010. He received his MSW from Hunter College School of Social Work, and trained in couples and family therapy at the Ackerman Institute for the Family in NYC.

Road map What is hoarding? – DSM-5Why do people hoard?Treatment Considerations

A. Persistent difficulty discarding or parting with possessions, regardless of their actual value.  B. This difficulty is due to a perceived need to save the items and distress associated with discarding them. Hoarding Disorder: DSM-5 Criteria American Psychiatric Association, 2013

C. The symptoms result in the accumulation of possessions that congest and clutter active living areas and substantially compromise their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities). American Psychiatric Association, 2013

D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). American Psychiatric Association, 2013

E. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi Syndrome).F. The hoarding is not better accounted for by the symptoms of another DSM-5 disorder (e.g., hoarding due to obsessions in Obsessive-Compulsive Disorder, decreased energy in Major Depressive Disorder, delusions in Schizophrenia or another Psychotic Disorder, cognitive deficits in Dementia, restricted interests in Autism Spectrum Disorder). American Psychiatric Association, 2013

Specify if: Good or fair insight: Recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.Poor insight: Absent insight: American Psychiatric Association, 2013

Specify if: Good or fair insight:Poor insight: Mostly convinced that hoarding-related beliefs and behaviors are not problematic despite evidence to the contrary.Absent insight: American Psychiatric Association, 2013

Specify if: Good or fair insight:Poor insight: Absent insight (Delusional beliefs about hoarding): Completely convinced that hoarding-related beliefs and behaviors are not problematic despite evidence to the contrary. American Psychiatric Association, 2013

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.” American Psychiatric Association, 2013

Hazards of Hoarding Poor SanitationMobility HazardBlocked ExitsCommunity CostFire HazardHomelessness

COMORBID DISORDERS IN HD

Why do people hoard? The Cognitive Behavioral Model

Vulnerabilities Information Processing DeficitsMeaning of Possessions Learned Patterns of Collecting, Saving, & Storing

Vulnerabilities BiologicalEmotional DysregulationPoor HealthHistory of Loss/TraumaDistorted BeliefsE.g., perfectionism

Information Processing Deficits AttentionCategorizationMemoryPerceptionAssociationComplex Thinking Decision-making Difficulties

The Meaning of Possessions SentimentalIdentityConnection & OpportunitySafety & Comfort Instrumental Utility Responsibility IntrinsicAesthetic sensitivity

Learning Processes Positive reinforcement (positive emotions)Negative reinforcement (negative emotions)No opportunity to test beliefs & appraisals (avoidance)No opportunity to develop alternative beliefs (avoidance)

Treatment Considerations

Insight? Lack of awareness of illnessClutter BlindnessDefensiveness Overvalued beliefs about possessions

Social Context LanguageTVFamily

Specialized Treatment for Hoarding Assessment and case formulationMotivational enhancement throughoutRestricting acquiring Skills training Challenging maladaptive beliefs & attachmentsSteketee & Frost, 2013

Restricting Acquiring Inserting context into acquiring decisionsTeaching tolerance for the urge to acquire

Skills Training Organizing Problem solving Decision making

Challenging Maladaptive Beliefs & Attachments Identify problematic beliefs/attachmentsCreate hypotheses about themChallenge beliefs & attachmentscognitive strategiesbehavioral experiments/exposures Discuss beliefs during discarding exposures

Behavioral Experiment: Consider Discarding Identify hypothesis to be testedRate initial distress & predict durationConduct the experiment (not acquire, discard)List thoughts Evaluate thoughtsRe-rate distress Discuss outcome of experiment

Behavioral Test of Hoarding Predictions(top of lost board game box) Prediction 1: “If I throw this away, it will feel like death.”Prediction 2: “If I throw it away, I will feel this way (like death) forever.”

Outcome of Predictions One minute after discardingSUDS rating at 100, but “It does not feel like death.”24-hours after discardingSUDS rating at 10. “It doesn’t bother me much at all.”

Conclusions and New Hypotheses Conclusion - Neither prediction came true.New HypothesesThe thought of throwing things away is worse than the doing of it.If I throw something away that I am deathly afraid of discarding, the bad feeling won’t last as long as I think.

Outcomes: Treatment Responders (%) Steketee et al., 2010; Muroff et al., 2011

Conclusion Hoarding is a chronic and complex disorderGiftRecognition of potential & opportunityAppreciation of physical world & sense of responsibilityCurseLiving in a landfillCollecting life without living itAesthetics gone AwryCure?

Homelessness and Hoarding: Case studyJonathan Kessler, LCSWTeam Leader/CoordinatorHUD/VASH Housing First ACT TeamNY Harbor Healthcare System, Manhattan Campus

Housing First ACT Team Higher level of care within HUD/VASH Multidisciplinary approach: NP, RN, SW, Veteran Peer Specialist Informed by evidence-based practice modelsFocus on chronic homelessness, severe and persistent psychiatric and medical conditions, and co-occurring substance abuseWeekly visits, clinical crisis support, advocacy, skills buildingMaintains care continuum between VA and communityGoals: increase housing sustainability, prevent/reduce hospitalization, and improve overall well-being

Case Overview 58 year old single divorced, Caucasian female Army vet, ‘77-’80, and ‘92-’96 navy reservistPost military employment history as EMTCurrently disabled, receiving SSD Diagnosed with Schizoaffective D/O, Anxiety, Depression, obesity, COPD, leg edemaAccepted into HUD/VASH program after x1 year homelessness resulting from death of both parents, with whom she lived, and loss of family homeHistory of multiple hospitalizations, long use of PRRTP day programSignificant losses of family, home, possessions, identityTransferred to HUD/VASH Housing First ACT Team 2015

What We Encountered in the Veteran’s Apartment Clutter rating of 5-6, based on presentation imagesStacks of unopened boxes from regular Amazon Prime and QVC purchases, sometimes in duplicate, of household appliances, exercise equipment, diet supplements, etcA 2-3 foot high barricade of food wrappers and containers, surrounding the reclining chair where she sits most of dayPiles of garbage next to bags of garbage and overflowing binOverflowing cat litterbox, urine soaked carpet, a dead decomposing mouse in the hall Roach, fly and mouse infestationsA waist-height wall of belongings, boxes, papers, etc., around the perimeter of the apartmentA stagnant oppressive odor – “feels like you’ve stepped into a tropical climate”

Countertransference and Other Barriers to Engagement Difficulty staying in the apartment for any sustained period of timeStrong emotional and physical reactions, including: resistance, revulsion, and physical nausea, headaches during visitsEthical dilemma of exposing team to health/respiratory concerns during visitsDiscouragement and hopelessness of staff in the onslaught of accumulating objects and refuse

Relational Obstacles to Clinical Interventions by Team Vet finds team visits intrusive/disruptiveFeels judged or criticized, embarrassed, defensiveConflicting definitions of problem, experience of apartmentVarying levels of willingness among team around extent of involvementStruggle to summon motivation, emotional buy-in for treatment plan and goalsSense of failure at not completing agreed tasks

Case Conceptualization: Contributing Factors to Veteran’s Hoarding Behavior Loss of parents in close successionShame of losing family home and lifetime of belongings after parents’ passingTrauma of illness onset Loss of sense of self and identity as a working personHealth issues: Limited mobility secondary to COPD and leg edemaMental health issues: Generalized Anxiety Disorder (GAD), Depression, Schizoaffective D/O

Team’s Clinical Interventions Alternating staff for visits – benefits and drawbacksEthics committee consult RE veteran/staff safetyProcessed visits and strategized next steps in supervisionTeam building exercises to develop frustration tolerance around handling setbacksReadjustment of team agenda and goals towards a more veteran-centered and collaborative re-definition of problem to consider benefits and drawbacks of behavior

Team’s Clinical Interventions, Cont’d Exploration of historical/aspirational connection and symbolic meaning of objects and accumulating behaviorIdentifying varying values of possessions, what must stay, what can goLimited collaborative cleaning to practice discarding, and partialized cleaning assignments between visits, based on vet’s preference

Current Status of Case Hoarding behaviors continue to persist, though less intenseAdult Protective Services subsidized bi-annual cleaningsEngagement with local church collaboration for cleaning and shopping assistanceEscorts to medical psychiatric appointments to refer vet for home health careEstablishment of a pool trust for HHC, secondary benefit of limiting funds and restricting acquiringHome attendant provides witness and may curtail acquiring behaviorImproved appointment attendance and capacity to leave apartment with HHC assistanceNo current threat of eviction

Summary of Team Interventions to Address HoardingVeteran-centered approach to problem definition and goalsPsychoeducation Addressing safety issuesGuided exploration of emotional, cognitive and behavioral aspects Collaborative cleaning practicePartialize cleaning assignments Enlist family, community, and faith-based supportsReferrals to adult advocacy agenciesRep payee/guardianship/pool trust