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Hoarding Behavior Discussed at National Conference

Reprinted with permission. From the National Center on Elder Abuse Newsletter, Volume 2, Issue 3. October, 1999.

Two workshops at the National Association of Adult Protective Services Administrators' conference in Nashville, Tennessee in late September, 1999 focused on a type of APS case that workers typically find very difficult to resolve: elders who hoard items and/or animals.

Henriette Kellum, Coordinator of the Senior Adult Mental Health Program in Arlington County, Virginia, and Dr. Robert M. Licata, a psychiatrist in private practice in Virginia, focused on generalized hoarding.

Dr. Licata said hoarding may be defined as the collection of useless objects to the point where the collection encroaches on living spaces. Hoarders typically have a compulsion to hoard, which stems from having a great deal of anxiety over decisions.

By not deciding whether something should be thrown out or not, hoarders avoid the anxiety of choosing. The behavior is thus positively self-rein-forcing.

Typically hoarders find absolutely nothing wrong with their behavior. Confronted with the results of the hoarding, they minimize the problem, deny it's a problem, or give excuses and promises to clean up. They see no reason they need treatment or help.

Dr. Licata believes that even though mental evaluations of hoarders typically find them competent, there is probably some underlying brain problem. Hoarding is often associated with apathy, memory impairment, lack of goal direction, and, especially, indecisiveness. It may be the final common result of a number of psychiatric disorders, including obsessive-compulsive disorder, psychotic disorders, and dementia. (Hoarding behaviors typically increase as the degree of dementia increases.) Between one in four and one in five persons with dementia are also hoarders, and 20% of schizophrenics become hoarders.

In assessing hoarders, Dr. Licata says typical tests fail to ask the right questions, because hoarders know what the answers should be. The proper types of questions to ask are ones that require the hoarder to make actual decisions and show what they would actually do faced with directives or questions like, "please go get your food." He strongly recommends a medication review, as some common medications such as Benadryl and Tagament can cause confusion. Thorough histories are critical, as they may pinpoint when a serious behavior change began.

Both Dr. Licata and Ms. Kellum strongly recommend that those intervening in cases of hoarding take pictures and/or videos to help others understand the magnitude of the problem and to provide a literal picture to contrast with possible clinical findings that the hoarder has no measurable cognitive impairment. Arlington County has also developed a number of tools to help it with interventions. One such tool is a hoarding task force that is convened as needed to develop multi-agency intervention plans. Another tool is a pre-guardianship panel that includes seven citizen and agency representatives to provide consultation to APS workers thinking of seeking guardianship for a client. APS staff also have the luxury of weekly meetings with a professional like Dr. Licata to consult with on difficult cases. The County has also undertaken a campaign to educate decisionmakers on difficult cases like hoarders, working on developing such educational measures as workshops, in-home evaluations (crucial in hoarding cases, to avoid evaluators seeing only the competent side of the hoarder), pictures and videos, expert witnesses, and articles.

Arlington County also uses a capacity-risk model developed by Dr. Barbara Soniat. This model looks at three areas of functioning: physical (ability to feed self, dress, bathe, etc.); psychological; and social (availability of supports, finances, etc.). The model then plots these "capacity" findings on one axis, with the level of risk on the other axis. When capacity is high, the worker should respect the client's right to self-determination, without regard to risk. When capacity is low and risk is high, the worker should intervene, even to the extent of involuntary interventions such as guardianship. When the individual's capacity is moderate and the risk is moderate, the "worker should pursue psychosocial interventions that are geared toward encouraging the client to accept services. The goal of services should be to increase capacity while reducing or eliminating risks."

A second workshop, led by Phillip Snyder, Director of the Central States Regional Office of the Humane Society of the United States, focused on the connections between animal and human abuse, and on animal collectors or hoarders. He noted that about 2/3 of animal hoarders are female, 2/3 are unmarried, and most began collecting animals in their 30s. Collectors are generally well-educated and come in all income levels. A study he distributed noted that "although most of the multiple owners were somewhat removed from mainstream society, their isolation was a result of their accumulation of animals and not a cause."

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