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Working with people who hoard: research messages webinar

Presenter Dr David Orr Date 24th January 2017

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Webinar objectives› To outline the key challenges in addressing hoarding› To explore the research evidence on engagement,

assessment and intervention with people who hoard› To identify the policy and legal context for social care

with people who hoard› To identify the roles of agencies and

practitioners who might become involved with people who hoard

› To consider your own practice and what you will start, keep or stop doing when working with people who hoard

Questions: assessment in hoarding

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› What is the difference between collecting and hoarding? And between cluttering and hoarding?

› Who decides in an individual situation?

Shadwwulf at English Wikipedia, licensed under a Creative Commons Atribution 3.0

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Recent developments

› Hoarding disorder: included within the 5th Edition of DSM

› Included in forms of abuse and neglect in Care and Support Statutory Guidance: “Self-neglect covers a wide range of behaviour ... and includes hoarding”

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Collecting and Hoarding

Collecting Hoarding

Limited impact on life in general Interference with daily life (work, home management, leisure, family relationships)

Organised storage Clutter that impedes use of roomsLess likely to have a mental health diagnosis

More likely to have a mental diagnosis

Selection: boundaries on what is collected and each item chosen for its unique properties

Less selective: may accumulate multiple identical items; less boundaried types

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Safeguarding and Hoarding

› Section 9: Local Authority duty to assess care and support needs where it appears an individual may have needs for care and support

› Section 42: Local Authority duty to make enquiries where (a) an adult has care and support needs, (b) is experiencing or at risk of abuse or neglect and (c) as a result of their care and support needs is unable to protect themselves

CARE ACT

EmpowermentSupport to make own

decisions

PreventionTaking action before

harm occurs

ProportionalityLeast restrictive matched to risk

ProtectionFrom abuse and

neglectPartnership Working together

AccountabilityClarity of role and

purpose

Safeguarding Principles

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Hoarding and its dilemmas: finding the right balance

Prioritising self-determination: ‘hoarding as

lifestyle choice’?

Duty of care to protect from harm:‘hoarding as risk’?

Questions: finding the balance

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In your experience: › What problems arise when hoarding is

seen as a ‘lifestyle choice’ and practitioners do not inquire further?

› What problems arise when hoarding is seen as a source of risk that automatically requires immediate intervention?

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Why do people hoard? A cognitive-behavioural model

› INFORMATION

› - memory› - categorising› - attention

EMOTIONS

- reaction to loss

- positive emotions from new possessions

BELIEFS

- anticipated loss

- risks - loss of

control

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What reasons do people give for hoarding?› Sense of achievement and worth bound up in

possessions› Early life experiences› Environmental principles about waste› Concern with needing things in future› Not enough space› Having different standards to others› Things stand for or facilitate relationships › ...

Example› What are your thoughts on viewing this

video? › How might you try to engage with this

person in your practitioner role?

https://vimeo.com/603058(either 10:17 – 14:36 or 14:45 – 20:30)

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What people who hoard say about getting engagement …

“It does not work forcing things on

people. It made me worse.”

“The social worker said, ‘I can’t see your toilet,your bed’. […] That’s further down the line. But he was doing things by the book, which was quite unnecessary - had I been a different person, I would be in terror.”

“… they weren’t helping, they were just leaving it for me to do.”

“people like me, we’re not proud of the state and he came in and said, ‘you’ve got a lot of stuff’ and of course there was a lot of, the stress levels were very high.”

“She’s putting a lot of pressure on me, she knows I’ve got a mental illness and the root cause of hoardism is anxiety and … she just makes mine worse.”

Questions: getting engagement

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› What words and actions might I use to build trust and find out about people’s reasons for hoarding?

› What sorts of strengths might I be able to acknowledge and work with?

› How do I address questions of risk with the person?

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Clutter Image Rating Scale

› Images from International OCD Foundation, at http://hoardingdisordersuk.org/wp-content/uploads/2014/01/clutter-image-ratings.pdf

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Helpful approaches to intervention

› Relationship-based working› Harm reduction› Cognitive-behavioural therapy for

hoarding› Motivational interviewing

techniques› Signposting to support groups and

self-help resources› Keeping the door open

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Which agencies have you worked with in cases of hoarding?1. Local authority adult social care

services2. Health: primary care3. Health: secondary care (incl.

mental health)4. Fire services5. Police6. Specialist clearance/cleaning

firms

7. Animal welfare8. Voluntary sector

organisations9. Professional de-clutterers10. Environmental health11. Housing associations /

landlords12. Safeguarding networks

What worked well? What challenges were there?

Examples› Hammersmith & Fulham identified

challenges of coordinating a personalised response between multiple agencies

› Management support and direction to give SWers time for effective work

› Cases of hoarding to be referred to ACSW:− Clutter Scale 4-6: joint visit from SW + Fire

Service, EH and/or Housing Officer− Clutter Scale 7-9: urgent multi-agency case

conference to develop action plan› Local hoarding panel to advise on

challenging cases18

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Mental Capacity

› What common mistakes in capacity assessments in hoarding have you come across, or do you know about?

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Hoarding and Mental Capacity

Does the individual have an impairment of, or disturbance in the functioning of, the mind or brain

as a result of which they are unable to make the specific decision at the specific time, i.e. are unable to understand, retain, or use and weigh relevant information or to communicate a decision (s.3)?

Housing

Housing Acts 1985, 1988 (amended 1996)

Building Act 1984 Housing Act 2004

Environmental health

Public Health Acts 1936, 1961, 1984; Prevention of Damage by Pests Act 1949

Environmental Protection Act 1990

Public Health Act 1984,

amended by HSCA 2008

Mental Health Act 1983

- s. 2, s.3 admission - s. 7 guardianship

PACE 1984 police powers of

entryAnimal Welfare

Act 2006

Other Relevant Legislation

Summary › Effective work with hoarding requires:

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causes of hoarding, recognising risk, interventions, legal options and their limits

Knowledge

balancing autonomy with care, working with the person, respectful curiosity

Values

building a relationship, identifying person’s goals, mediating, coordinating multi-agency response

Practice skills

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Planning aheadIn my practice with hoarding, I will:

› Start doing:

› Stop doing:

› Keep doing:

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Working with people who hoard Frontline Briefing:available on the RiPfA website now.

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Further reading› Orr D, Braye S & Preston-Shoot M

(2017) Research Briefing: Hoarding. Dartington: RiPfA

› Holmes, S. (2015) A psychological perspective on hoarding: DCP good practice guidelines. Leicester: BPS. http://www.bps.org.uk/system/files/Public%20files/a_psychological_perspective_on_hoarding.pdf

› Steketee G and Frost R (2013) Treatment for Hoarding Disorder. Oxford: Oxford University Press

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