On Monday I enjoyed calling NASW members in Minnesota as part of the election phone bank. The calls focus on the importance of the upcoming elections and encourage members to support our NASW-PACE endorsed candidates and to get involved in their campaigns. On my first call, I happened to reach a member who has been on the county board for 14 years. This is a full-time position, although he also teaches. I was reminded of how social work skills and practice are excellent for full-time public service. This member is a political social worker.

The next member I reached worked at a community center that is very involved in getting clients registered, educated and to the polls. The member explained all of the activities planned, including voter registration drives, a candidates’ night for a legislative race, and vans to take senior citizens to the polls. This member reminded me of the ethical principles and tenets of our profession regarding our responsibility to society.

On October 7, I will be one of the presenters for the Lunchtime Series Teleconference “The Political Power of Social Work.” Some of us practice or extensively volunteer in political settings and all of us need to learn and utilize advocacy skills for effective everyday practice. The teleconference will highlight both political social work and practice-wide advocacy skills.

For seven years I served as an elected member of an urban school district. The school board position was unpaid service; however, I believe some of my most exemplary and challenging social work practice occurred during those seven years, working with eight other members for the welfare of our children and, ultimately, our community.

To me, our advocacy skills and our ethical and philosophical understanding of our responsibility to society distinguish us as a profession. They are what allow us to not only address the immediate needs of our clients, but also to change rules, regulations and systems that adversely affect our clients on an ongoing basis. I hope you will join us for the teleconference to learn more about this important area of social work practice.

- Becky

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.

By Maurice Fisher, PhD, NASW Chair of ATOD Specialty Practice Section

June 23, 2008

Substance use disorders, in their many forms, have always been a more confounding social problem for people in minority groups than for others. Substance use/abuse treatment is complicated, owing to the many psychosocial, financial, health, mental health, and environmental challenges that clients face.

Several years ago, I was the clinical director of a large inner city residential substance abuse program where 98 percent of clients were racial and/or ethnic minorities. Seven out of ten of these patients happened to be men. There, I learned the complexities of substance abuse intervention through my lived work experience. No matter what I thought I had learned and what I thought I knew, my experience was taught by the clients themselves—through their stories and their experiences.

My minority clients taught me that there is an enormous difference between being “culturally aware” (i.e., recognizing that someone is different from you) and being “culturally sensitive” (i.e., actually using this awareness to intervene effectively).  Moreover, I quite quickly learned that though minority clients may well be evaluated and diagnosed as having a substance use disorder, either abuse (e.g., a judgment and/or decision-making problem) or dependency (e.g., a physiological or psychological addiction), the vast majority were de facto self-medicating for extremely painful emotional and situational issues. 

In 2006, the Central Registry of Drug Abuse noted that roughly 8 out of 10 people in minority groups diagnosed with a substance use disorder were men. This statistic speaks volumes about the needs for cultural competency and gender-specific interventions in social work practice with our clients. Let us begin the therapeutic process by first listening to what they are saying.