Why trust, time and small steps are key to working with people who hoard
When large amounts of stuff build up in a house or flat, and cause difficulties with everyday household maintenance, moving around the property, or even in getting into some rooms, this may mean that hoarding is occurring. Housing, adult social care, fire services and other agencies regularly encounter this situation. However, it is not always easy to know how best to respond. Hoarding can often have complex causes. Responding in the right way calls for key practice skills, legal and policy knowledge and ethical awareness.
Often in the past authorities have resorted to forced clear-outs, damaging existing relationships with the person and destroying trust. Because this approach does little to address underlying issues, it usually achieves no more than a short-term ‘fix’, and the situation recurs before long. Other times, the hoarding has too readily been judged a ‘lifestyle choice’ and the risks have been inadequately assessed (Bristol SAB 2015).
Growing awareness and the explicit inclusion of hoarding within the safeguarding category of self-neglect (DH 2016, para. 14.17) have placed hoarding firmly on the social care agenda. In response, creative solutions are emerging. These start with realising that people hoard for a variety of reasons, understanding of which can be key to engaging the person. Previous experience of having had things taken away against one’s will, a way of feeling connected to other people, and the desire to put the things to future good use are among the motivations for hoarding that have been found by research (Braye, Orr and Preston-Shoot, 2014).
Working with individuals to reduce their hoarding often requires trust to be built over time. Progress is often made in small steps and may need to focus more on reducing particular risks or harms caused by the hoarding than on trying to eliminate it altogether. Cognitive-behavioural techniques are widely used to develop skills in sorting, selecting and discarding, but this process should be based on prior mutual exploration of the person’s own goals, beliefs and values. It is important to identify and work with what motivation there may be for change. Many find support groups helpful (Williams and Viscusi, 2016).
Hoarding can lead to the involvement of many different agencies and practitioners, from fire services to environmental health, from specialist clearing firms to safeguarding networks. Coordinating the work of these different parties with the individual is an important task, so that there is an agreed approach which draws on the different perspectives, roles and expertise of each. As views of the issue and thresholds for concern may vary between individual practitioners and agencies, assessment tools such as the Clutter Rating Scale, an assessment based on photographs representing different levels of concern (Frost, Steketee, Tolin and Renaud, 2008), may be helpful in providing a standardised measure that all can refer to.
Hoarding is rarely, if ever, resolved overnight, but with patience and informed, relationship-based practice, steps can be made that make a valuable difference in the individual’s life. At the core of this undertaking is not to lose sight of the person, however many things may be in the way.
About the author
Dr David Orr is Senior Lecturer in Social Work at the University of Sussex. He has a background working in Community Mental Health Teams in Older Adult Mental Health and Adult Learning Disability, before moving into academia to focus on developing research to address the challenges of these fields. He joined the University of Sussex in 2011 where his work has focused on adult safeguarding, self-neglect, global mental health and dementia. He is the author of RiPfA's Working with people who hoard: Frontline Briefing and related webinar.
The NHS estimates that between two and five per cent of adults in the UK may have symptoms of a hoarding disorder. Social care practitioners may have a role to play in supporting people who hoard. This work can be complex, and may necessitate a multi-agency response. This briefing builds on the Working with people who self-neglect: Practice Tool to outline the evidence on hoarding, and how to best support people who are engaging in hoarding behaviours.
This Practice Tool, written by Professor Suzy Braye, Dr David Orr and Professor Michael Preston-Shoot, draws on their latest research, which was commissioned by the Department of Health and involved interviewing staff and people who self-neglect in order to find out ‘what works’. It provides guidance on understanding and engaging with the experience of self-neglect, as well as practice approaches that can support positive outcomes.