Is Hoarding a Big Deal?

As the percentage of the older population in the United States continues to grow over the next few decades, social workers will likely encounter the behavior of hoarding more often in their work. Yet, many of us do not have expertise in dealing with this issue.

Tell us what you think. Is hoarding a mental health issue, or just a harmless quirk? When does the collector’s impulse cross over into pathological hoarding? If you’ve had clients or personal acquaintances who struggle with hoarding, please let us know. How have you dealt with this issue? What would you do differently, if anything, in the future?

If you’d like to learn more about this issue, take a look at the following article from NASW’s previous Practice Update:

Excerpt from “Hoarding in Later Life: When Things Start to Pile Up” published in the Aging SPS Practice Update, January 2003

Introduction
Over the past few years, media coverage involving hoarding cases has resulted in increased attention to this issue by the public and by researchers and has raised several pervasive questions: What causes certain individuals to hoard possessions? What characteristics do they share? How can social workers and other professionals effectively intervene on their client’s behalf while considering the needs of the community at large?

With the aging of our population, the incidence of hoarding in older adults is bound to become more prevalent, yet hoarding is still something we still know very little about. Although some research does exist on the subject of hoarding in adults, less is known about problems of hoarding with older people. Consequently, social workers seeking information and guidance about this area of practice often must rely on nonclinical resources, such as existing state laws, local ordinances, or popular literature, when considering how to develop an appropriate plan of care.

Hoarding can manifest itself in the excessive collection of household trash, newspapers, magazines, clothing, and even animals. In some instances, not only have reams of useless items been accumulated, but also an entire household may be brimming with items from floor to ceiling. All available living space, including every surface, countertops, chairs, sofas, bathtubs, sinks, coffee tables, desks, and beds, may become jam-packed with broken televisions, radios, boxes, containers, bottles, magazines, newspapers, bills, photos, expired coupons, food, and old clothes, leaving barely enough room to maneuver throughout the home.

The mental health community attributes hoarding behavior to a variety of both physical and psychological factors. Because hoarding behavior is seen in a variety of illnesses, it has been difficult to place definitively in a diagnostic category. It may be considered a mechanism for coping; a symptom of depression, anxiety, or substance abuse; a result of cognitive impairment; an obsessive–compulsive disorder; or a number of other possible conditions.

The studies that characterize hoarding as an obsessive–compulsive behavior might not be sufficient to address some of the reasons for hoarding in later life. Many experts believe that age-related illnesses are not the primary cause of hoarding but that the problem typically begins in childhood or adolescence. However, there is research that suggests that hoarding is a common symptom in older clients who are diagnosed with dementia (Steketee, Frost, & Kim, 2001).

Hoarding is more likely to be a problem when a person ages because older people tend
to have more difficulties in managing their collections of items. This difficulty can result
in the attention of neighbors, family members, the public health department, housing
authorities, the fire department, and the legal system.

Practice Implications
Hoarding is a multifaceted problem that stems from several deficits or difficulties (Steketee et al., 2001). These can involve difficulty with information processing, emotional attachments to possessions, and distorted beliefs about possessions. Avoidance of each of these problems can lead to extreme clutter. Hoarding is recognized as both a mental health issue and a public health problem. It is typically not an immediate crisis. The hoarding behavior usually occurs over a long period, and hasty interventions are not always the best solution to this problem.

Hoarding exhibited in later life can have serious implications. As a first step, social workers need to understand the risks of hoarding behaviors as well as some of the possible causes. For many older people who exhibit hoarding behaviors, extreme clutter can represent physical threats, including fire hazards, risks of falling, and unsanitary living conditions.

In such instances, social workers must grapple with a host of issues related to ethics and aging. This is not an easy task, because it brings to light issues related to a client’s right to self-determination, how much older people have the right to make choices about how they live, and if involuntary intervention is justified when the choices clients make are considered to be harmful to themselves or others.

Hoarding can be extremely difficult to treat. Interventions can range from no action at all
to involuntary intervention (such as the mass disposal of the person’s belongings). Involuntary cleaning of a client’s home is merely a temporary solution to the problem, because without client involvement and their investment in the intervention process there is a strong possibility that the cleared areas will eventually become re-cluttered.

In addition, people who tend to hoard frequently identify their possessions as central to their identities, and losing or disposing of a possession may produce extreme anxiety or a sense of loss and grief. Although involuntary interventions are not encouraged, they may be necessary to ensure that the client is not in immediate danger.

One of the most promising approaches to intervention appears to be cognitive behavioral
therapy, which combines the systematic restructuring of thought processes with
practical exercises aimed at reducing clutter. Effective treatment is likely to require a
variety of interventions, such as the use of medication, modification of faulty beliefs,
assistance with organizing and decision-making, and examination of emotional
attachment and behaviors that promote hoarding (Steketee et al., 2001).

Although hoarding remains a challenge for both social workers and their clients, it is
likely to become a condition for which more interventions are developed. Public awareness has brought hoarding to the attention of the mental health professions. As more cases associated with hoarding reach mental health professionals, new approaches are being developed to help those who are most vulnerable as a result of this disabling condition.

Tips for Intervening in Hoarding Situations
• Respect the meaning of and attachment to the possessions of the older adult
• Avoid being critical or judgmental about the older adult’s living environment
• Assess for safety and risk
• Assess for mental capacity
• Refer for medical and mental health evaluation
• Go slowly and expect gradual change
• Collaborate actively with the older adult in seeking solutions
• Avoid talking about the older person as if he or she is not present
• Validate the older adult’s fears of forgetting or losing items
• Consult and collaborate with other service providers and agencies
• Do not force unnecessary interventions
• Treat the older adult with respect and dignity.

References
Steketee, G., Frost, R. O., & Kim, H. (2001). Hoarding by elderly people. Health & Social Work, 26, 176–184.

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7 Responses to “Is Hoarding a Big Deal?”

  1. lavonn guthals Says:
    August 9th, 2008 at 3:10 pm

    good article. I wrk in a nursing home and do have several residents who hoard. It is a problem.

  2. greg mcgann, lcsw Says:
    August 29th, 2008 at 11:41 am

    Interesting article on a difficult problem. For ten years I was an Adult Protective Investigator for the state of Florida. In that time I encountered many hoarders, most of them elderly. For all their commonalities many had characteristics that made each situation unique onto itself.
    Our state allows elders to live as they choose provided they demonstrate capacity, but that determination was often difficult to make, especially in the context of multiple ongoing cases with equally pressing problems and strict agency guidelines that mandated rapid closure of cases, safety be dammed. Frequently I tried to tease out a specific mental health diagnosis and ended up with a range including OCD, depression, dementia and schizophrenia.
    Depending on the specifics my interventions ranged from “hands off,” to seeking court ordered protective services.
    I did arrange and the state paid for a “deep cleanings,’ only to find the situation back to square one within a few months. This need is deeply entrenched in some.
    Ultimately I learned to base the decision on making an intervention on the current or potential risk to the health and safety of the individual although on some occasions the health and safety of other family members or neighbors had to also be considered.
    One aspect this article ignored was the ofen intense pressure brought on the Social Worker by relatives, public agencies including law enforcement and neighbors to “do something about the mess.”

  3. Kim Flowers Says:
    August 29th, 2008 at 6:15 pm

    Compulsive hoarding among the elder is a significant personal mental health issue and a public health issue. As an outreach clinician at an Area Agency on Aging, I have been working exclusively with this population for the past year, and have been trained and supervised by the Boston University School of Social Work (BUSSW), the CBT program developed by Dr. Steketee. It can be very difficult to engage elders in CBT, but many components of the protocol can be applied with some success. A key seems to be building a strong and trusting relationshipVery few very elder adults self-identify as hoarders, some will agree that they are “packrats”, collectors or savers. The intervention can be effective, and is necessary if the older adult faces eviction or the home is being condemned. This should definitely be treated as a mental health problem, and we need to understand the individual’s reasons for hoarding, the role it serves in their lives, and “least intrusive” intervention for alleviating the public health and safety issues while we maintain the dignity, self-determination and control of the individual. I love this work, but there’s no doubt it’s difficult, time-intensive and very individualized. It’s also very important to have this capability available to keep these elders in their communiities and in the homes that they have owned for years. I am working with BUSSW to publish the findings of the program within the next couple of months.

  4. Amy Knight Says:
    August 31st, 2008 at 8:47 pm

    I work in long term care and have encountered hoarding. Currently, I am learning more about frontal temporal lobe dementias like Pick’s disease. The frontal lobe is the storehouse for social and emotional skills. If the hoarding is coupled with strange unexplainable behaviors, consider dementia. This might not change your intervention, but it will give you something to share with families who often feel a lot of embarassment and guilt related to unexplained things like shoplifting, hypersexuality, extreme lethargy, hoarding, and OCD.

  5. Cindi Vietmeier, LCSW Says:
    August 31st, 2008 at 11:15 pm

    I have several clients who hoard - all in NF’s and all in their 60’s. Also have an Aunt in her 80’s who would not allow anyone in her home - her behavior and dress seemed odd - I gained access to her home a year ago by “needing to use the bathroom”. The whole house was unsanitary including garbage piled in the kitchen and feces and urine in pans in the living room - the toilet was almost overflowing, bugs crawling all over. Besides this there was beer stocked (she never drank beer before), gatorade piled, tissues, loads of rotton tomatoes, bananas, etc.,. I gave her doctor a heads up and he admitted her for UTI -then she went to a NF. Because she was so private before I knew she would not allow help in the home now. To me, her symptoms fit Picks disease. Her long term and even short term memory is pretty good but she is obsessed with food - particularly candy and is unable to manage money (had 1 year of social security checks stacked in her home) or drive a car anymore (gets lost). In addition, she gets very angry at staff, cusses, and hits them at times if she does not get what she wants when she wants it. She is manipulative and lying. She hides fruit, candy, and other food throughout her room. All this from what used to be a sweet old aunt - she really still is at times. My issue is on testing. The doctors do not want to test saying nothing will change because of testing. Because I’m not her DPOA I have no say and the DPOA just does what the doctor says. The seroquel sure isn’t working or the Buspar. Seems to me testing might help and wouldn’t hurt. Besides - it gives the family an understanding of family medical history. In my opinion hoarding is a symptom of an underlying problem. I also think therapy with the elderly for hoarding is very difficult due to reduced ability to concentrate, lack of insight (which is huge), developed habits/routine, independence, memory deficits, reduced executive functions– To get that person to recognize change is necessary - huge endeavor! Any thoughts?

  6. Robin Dilg Says:
    September 2nd, 2008 at 11:56 am

    Over the last 20 years I have dealt with many hoarders. This is more than just a quirk or eccentricity. It is an inability to throw things away. Ironically, I am married to a hoarder! After 45 years of marriage I have found that he does not care if I dispose of his unneeded belongings just as long as he isn’t around and he doesn’t have to do it. I thought it was laziness or lack of organization but it is really an inability to part with things. So I do my annual dumpster each spring while he is at a conference and it works out just fine. I have had patients whose homes were a total fire hazard with newspapers stacked to the ceiling in every room with only an aisle to get to the bed and the refrigerator - frightening! I even had a lady who saved her own bowel movement - now that was an easy guardianship petition. When it becomes a health and safety issue it is causing self harm and clearly needs an intervention by adult protective services and the court. Some of my cases have been driven by the fire marshall who was going to have the person moved out or shut the apartment complex down. I was very thankful when this became a DSM IV category. It clearly was a mental illness related to the OCD types of illness. This illness clearly drives friends and family away and destroys the relationships that people so clearly need. The very fear of loss of belongings causes the greater loss of relationships which is probably how this all started, how ironic.

  7. Beth Koon Says:
    October 17th, 2008 at 7:59 am

    Thank you SO much for the article and everyone’s input. I, too, agree hoarding is a significant mental disorder which endangers the people who suffer from it. I first learned about it when I was asked to help my adoptive grandmother.

    Your blogs are not only validating, they are educational and helpful. NASW is terrific for allowing us to conduct professional dialogue regarding these issues.

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