Okay. Hello and welcome. I'm Shereen Khan, Vice President of Operations and Strategy at Thresholds, Illinois' oldest and largest provider of community mental health services, and I'm also a social work expert for SMI Advisor. I am pleased that you're joining us for today's SMI Advisor webinar, Managing Hoarding Disorder and Hoarding Behavior in People with SMI. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental health conditions. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patient. Next slide. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one continuing education credit for psychologists, one continuing education credit for social workers, and credit for participating in today's webinar will be available until September 26, 2023. Next slide. Slides from the presentation today are available to download in the webinar chat. You can select the link to view. And next slide. Captioning for today's presentation is available. You can click Show Captions at the bottom of your screen to enable. Click the arrow and select View Full Transcript to open captions in a side window. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We will reserve 10 to 15 minutes at the end of the presentation for Q&A. And next slide. Now, I'd like to introduce you to the faculty for today's webinar, Kaylee Mullins, who's an LCSW. She's a licensed clinical social worker in Chicago and has over eight years of experience working with adults with serious mental illnesses in the community. She serves as a program director at Threshold, the same place that I work, a Chicago-based community behavioral health organization. Kaylee, thank you so much for leading today's webinar, and I will turn it over to you and see you back for Q&A. Thank you so much, Shereen. Thank you all for having me. I have no disclosures to share with anyone today. And our learning objectives are as follows. It's my hope today that you will learn the clinical definition of hoarding disorder and how to identify hoarding behavior in populations with differential diagnoses, to recognize the psychological and emotional factors associated with hoarding behavior and hoarding disorder, and explore evidence-based assessment tools to evaluate and measure the severity of hoarding symptoms, as well as learn appropriate interventions to apply to your clinical practice. So I think it's important to start off with a history of hoarding disorder. Hoarding disorder and hoarding behavior was not a specific diagnosis as we know it now. In 1980, around the release of the DSM-III, hoarding behavior was considered a markedly peculiar behavior for diagnostic criteria associated with schizophrenic disorder. In 1994, selecting items is referred to as a positive symptom of schizophrenia, and extreme hoarding was associated with OCD, obsessive compulsive disorder. However, it wasn't directly stated in the diagnosis of obsessive compulsive disorder. It's referenced as part of the differential criteria for obsessive compulsive personality disorder. So if you look through the differential material, if someone had quote, extreme hoarding behavior, they were most likely qualified for a diagnosis of OCD. However, after much advocacy, hoarding disorder becomes its own diagnosis with the DSM-V, and it is housed under obsessive compulsive and related disorders. Hoarding behavior is still referenced as a feature of OCD when it's compulsive and tied to an obsession. However, hoarding behavior may also indicate a diagnosis of schizophrenia when it is rooted in delusion. So we'll talk a little bit more about those differential diagnoses in further slides. So what is hoarding disorder as we know it now? It is a persistent difficulty in discarding or parting with possessions, regardless of actual value. Difficulty due to perceived need to save and distress associated with discarding. And difficulty discarding results in the accumulation that congests active living spaces. And clinically significant distress and impairment is present, particularly when considering discarding items or parting with valued possessions. So how do we simplify that to make it a more actionable diagnosis? I want you to remember three things. Acquisition and saving. Is someone actively acquiring items and saving them, regardless of actual value? Is there distress involved with the thought of parting with a possession? And is there clutter present in a way that impairs someone from using their space for its intended purpose? So is the bedroom so full of belongings that the person can't sleep in their bed? Or is the kitchen so full of belongings that the person can't cook on their stovetop in a way that they would need to use the space to its fullest potential? I also like to think of hoarding as kind of an iceberg. When you are communicating with someone who is experiencing hoarding disorder or in someone's living space who lives with hoarding disorder or is engaging in hoarding behaviors, what you see is the clutter of the living space. You see the person's attempts to save items regardless of their actual value and acquiring. So maybe someone has a difficult time going to the store and not making a purchase. Or if someone is kind of going through alleys and looking for items, if they see something that kind of matches their criteria for something that they'd want to save, they'd have a hard time walking away from that item. But what you don't see when you see the person in front of you is other diagnoses of mental illness or mental health difficulties in general. Maybe a family history of hoarding disorder. There's a high correlation between family history of hoarding disorder and someone actually meeting criteria for hoarding disorder. Struggles with executive functioning. So someone might have difficulty with organization. They might have difficulty with prospective memory, which we'll talk about in a little bit. Difficulty with categorization. So skills that someone with a healthy brain might take for granted. If I'm looking at an object and I know it goes in the kitchen because it's a food item or maybe a q-tip goes in the bathroom, I can easily call to mind what room that belongs in. Someone with hoarding disorder and struggles with executive functioning might have a hard time telling you what room that goes in. Personality features. We'll talk a little bit about the personality features that are common amongst folks with hoarding disorder in a future slide, as well as health. Does someone have a serious physical condition that impairs their ability to clean their space or organize their space? Those are all things to take into consideration when you're intervening. Memory. Can someone remember where they've put something? Can they remember what room houses what particular object in a way that would keep a space organized? And trauma. There's a high correlation between an experience of a traumatic event and hoarding disorder, all of which, when you think of interventions, need to be considered for someone who's experiencing hoarding disorder or hoarding behavior. So about 95% of people with hoarding disorder have a comorbid mental illness. Most commonly, we see major depressive disorder, an attention deficit or hyperactivity disorder, generalized anxiety disorder, and social phobia. I hear often that hoarding disorder is an anxiety disorder and what folks typically mean by that when they say that is oftentimes when you talk to someone who has hoarding disorder and they want to, you know, acquire an item or they're holding an item and you're asking them to put it somewhere, somewhere to encourage organization in the living space. The anxiety is so high such that someone is worried about making the wrong decision or when you think about parting with an item, the person might think, well, what if I need this item? And it creates such a severe anxiety that it ultimately leads to paralysis. The item gets placed on the ground and that's kind of how items accumulate. As we talked about previously, folks with hoarding disorder often have co-occurring executive functioning challenges. So struggles with categorization, with perception, the ability to look at a space and see the clutter is often impaired with someone with hoarding disorder. Difficulty with decision making. So as I talked about with this kind of anxiety and decision paralysis, right? Something that I often take for granted is the ability to be very decisional in my day-to-day choices. I have an apple that I'm putting away. I know it goes into my produce bin in my fridge, right? Someone with hoarding disorder might have a difficult time making that decision and being decisive about where something goes. And then prospective memory. So if I were to ask someone who doesn't struggle with hoarding disorder or hoarding behavior, tell me about how you would decide how to organize your mail. Someone might say, okay, you know, if it says to your valued customer, probably going to recycle it. It's probably just an advert. If something says to a neighbor, right? Something really general, I know to pitch it because it could be recycled. It's trash. And then I know if something says a bill, right? It's a bill. It's ComEd or, you know, gas company, whatever that I pull aside and I want to pay my bills. And then if I see like a handwritten note from a loved one, I know to keep it. It's got sentimental value. Someone who struggles with prospective memory couldn't tell me the steps that they would use or the criteria that they would consider in order to organize something like mail. So all mail therefore has some sort of value if someone's hoarding pieces of mail or paper goods. And it's difficult to encourage that person to make a distinction between an ad and a letter from a family member or a loved one. Personality features amongst folks with hoarding disorder. Often folks who experience hoarding disorder have excessively high standards, which when I say that folks kind of balk at that and it almost seems counterintuitive, right? Like we're in someone's living space and it's hoarded. We often assume that the standard of living is quite low. That's often not the case for folks with hoarding disorder. Again, this kind of goes back to the anxiety that's present amongst someone with hoarding disorder. They want to make sure that they are making the absolute best decision that they can and therefore they hold on to items again regardless of actual value in order to ensure that they are making the right decision. They have something that they can grab in the event that they do need it again. We talked a little bit about indecisiveness, getting lost in the detail. So if someone is standing amongst their items and they experience hoarding disorder, what they're looking at is the very specific items that give them pleasure, right? They're looking at maybe a stuffed animal that reminds them of a happy time or a memory of childhood or they're looking at a paper good that they want to do something very specific with. They're not looking at their space and seeing the clutter and that is accumulated creating an unlivable space. And then emotion regulation challenges. Often the items that are collected are tied to emotion regulation. So say for example, someone is experiencing serious anxiety, they pick up an item, that item can soothe the person in some way and that kind of reinforces this idea that collecting items is good because it makes me feel better. And I also just want to say if anyone has any questions, please put them in the chat and we'll get to them at the end. So all this to say, why is learning about hoarding disorder and hoarding behavior amongst folks with SMI so important? I think most obviously the behavior has the potential to create serious harm. It can contribute to homelessness. It can cause accidents. So if someone has a hoard and the piles are really high and those piles are unstable and fall, it can injure someone. It can cause the removal of children from the home and can even result in death. But it's also treatable. So we'll get into the different interventions that are helpful for folks who experience hoarding disorder or who exhibit hoarding behavior. It's also important to just be aware of hoarding disorder and hoarding behavior because you can't always see it. If you are site-based and someone's coming to you for service, it is so important that you ask questions about someone's living situation. Has anyone ever expressed concern about the cleanliness of organization of a living space? Has anyone offered to help you? These are important things to know and we'll get into more clinical assessment strategies. But it's important to get a good idea of what someone's living space looks like so you can intervene accordingly. And again, it can occur alongside other serious mental illness. So while a person might not meet criteria for hoarding disorder per se, they may exhibit behaviors that warrant intervention. So understanding appropriate interventions can simply strengthen your clinical practice and patient outcomes. So some assessment tools that we'll talk about. The clinical interview, to me, this is the most important. The clutter image rating scale, the Holmes assessment, and then other assessment considerations, which we won't delve into more specifically, but just something for your awareness. Assessing someone's executive functioning and the ability to categorize. Because if someone struggles with categorization and you give them homework and you say, I would love for you to organize this bookshelf, right? Something manageable that can be done in a specific timeframe. And they struggle with categorization, you're essentially setting them up to fail. That's not a homework that they can complete without the appropriate interventions to address executive functioning challenges. Same with cognitive and physical abilities. If someone has a physical limitation and you're asking them to remove items from a room, we want to think about what's reasonable for that person to accomplish. So the clinical interview, the goal of the clinical interview is to learn why items are being saved and why are they important? This is so critical. Without understanding why items are being saved, we can't appropriately intervene. So you might say, tell me about X item. If you're in someone's living space with them, point something very specifically out and ask what it means to them. Where are the items being acquired? This is important because I think roughly 10% of folks with hoarding disorder also meet criteria for kleptomania. So understanding if someone is kind of dumpster diving and gathering items, or if they're going to restore and purchasing them, or if they're stealing them. It's important to make sure our clients are aware of the impacts of theft, the possible consequences of engaging in that behavior and intervening most appropriately. Also learning about client goals. What would you like to use your space for that you can't now? So does someone have children that have been removed from the home and they want their children to come back to the home? What a great goal. And we can really partner with that person and use interventions to help them achieve that goal, right? If we're going into someone's living space and saying, oh, this is a fire hazard, this is dangerous, all the reasons that make sense to us as the clinician. And the person saying, that's all fine and good, but I just want my children back. We can achieve our goals while prioritizing the client goals. So also learning about history. What's worked for this person in the past? We don't want to duplicate an effort that's been tried and tried and tried again and hasn't been successful. So has anyone ever told you that they're concerned about your living space? This is kind of an area where you can assess someone's level of insight. Have you agreed with this person who's expressed concern about your living space? Folks with hoarding disorder have various levels of insight, right? As most people do. So someone might look around and say, yeah, I agree, it's hard to live in this space, but I can't fathom the thought of partying with my possessions. Or someone might say they're so lost in the detail of their possessions that they might say, no, I'm fine, I'm happy, this is good for me. So knowing kind of what you're up against is pretty important when assessing. And then also just kind of learning about supports, right? If someone has a relative that has come in and expressed concern, is that a support system that we can tap and leverage as we intervene? Has anyone tried to help you for what worked, what didn't? Again, not wanting to duplicate efforts and just finding common ground. So you're learning about in the clinical interview why someone is saving items. Here's some common themes that you might observe when interviewing folks who are hoarding. Beauty, this item is so beautiful and therefore I have to have it. Memory, a particular item is tied to a specific memory. And the fear is that if you relinquish this item, you're no longer going to remember this particular moment. I don't know, I kind of think about like Disneyland, for example, or Disney World. Maybe someone has like Mickey Mouse ears and they say, you know, if I give up these Mickey Mouse ears, I won't remember about the great time that I had in Disneyland with my family. So I can't part with this item. Utility, sometimes you'll find folks who explain that, well, I have this because maybe I'll need it to store, maybe if you're holding cans, for example. Well, I need to hold on to it because if I have this, if I find something that's a very specific size, I need to be able to use this can to store items and there's a function to it. Uniqueness, so if someone says, well, you know, I've got all these different pens and each pen writes in a very specific way, it's very different from other pens that you see at someone's desk, for example. This idea that the item that they have is unique from other people can create value. And then sentimental, similarly tied to memory, but maybe someone gives them a handwritten note and that is of sentimental value. But so is something that reminds them of a relative, right? It's not quite a memory of a specific instance, but it is something that's sentimental to the person and that it reminds them of a relative or a friend or just a value of theirs. Comfort and safety. So I participated in a training years ago and one of the examples that I thought was really valuable in terms of comfort and safety was this one. There was a woman who was engaging in hoarding behavior and they asked about a lot of the items that she was storing and a lot of her items were kind of stacked up against a window. And she reported that it's to keep her safe and she had experienced a pretty significant trauma. Someone had broken into her home and assaulted her. And so her desire was to create a living space that was safe for her and by gathering all these different items, she kind of came to the idea that if I have too many things in my home, someone can't break in and hurt me again. So it kind of creates a physical barrier between me and a possible assailant or someone breaking in. Identity. So maybe someone has a strong value of environmentalism. They are an environmentalist at their core. That's a core value of theirs. And holding various canned goods or paper goods or things that could be recycled but are often thrown away is a way to continue to save the planet. Having control. Wanting to make sure, you often see this kind of criteria with pet hoarding. So if someone is hoarding a large amount of animals and wanting to have control over the outcomes, and it's often benevolent, right? Like if someone is hoarding animals, the fear is that if they relinquish control, they can't control how someone will care for this animal, and that can be really distressing. And then fear of making a mistake. We talk about this often, right? The anxiety and decision paralysis, and then avoiding waste, wanting to have responsibility for the planet, and validation of worth. Like, look at all my things. This means, they mean something to me that makes me meaningful. So these are some common themes, and of course this is not an exhaustive list, but this is something that you can find when assessing for hoarding disorder and doing a clinical interview to learn a little bit about what interventions might be most appropriate. Next is the clutter image rating scale. This tool I really like, because I think it helps clinicians to develop a common language when discussing the severity of someone's hoarding disorder. It's a clear visual representation of the severity and maybe of the disorder or behavior, and it's a visual application of the clutter. So I'm going to show you an example of what this looks like. So a researcher and his TAs kind of got together. They rented this apartment and kind of created various levels of hoarding in various different rooms. So this is the living room CIR. Just a quick Google search will take you to other rooms as well, where you can kind of use this language. So someone might meet criteria for hoarding disorder between like a four or five, maybe even five to six. So again, this doesn't tell you about someone's level of distress. It doesn't really tell you about someone's executive functioning challenges, but it allows you to have a clear idea of how severe the hoarding disorder is amongst colleagues so that you can intervene appropriately. It doesn't require everyone to be in the living space. You can say the person's living space was about an eight, right, and we kind of have a clear understanding of what that looks like. Just some tips for using this scale. So the first thing you want to do is take an average of the pile heights. Often, if you are in someone's home that is hoarded, you'll see varying different piles and maybe an egress path in the middle. You want to take an average and that's the number you use. Look for windows and kind of compare it to where the pile height falls and then look for key furniture pieces in a room. So is the bed usable? Can you even see the bed? The most correct number. Another really great assessment tool that I think is really helpful for folks, especially when folks are doing home visits, is the Homes Assessment. It can help you quickly identify safety concerns and more specific causes for intervention. It's pretty quick to complete. It's a checklist and I'll show it to you in a second. And it promotes specific and measurable goal setting. When you think about folks who are hoarding and have executive functioning challenges, we want to make sure that our goals are specific, measurable, and achievable. And it highlights key dates. So if you're doing a home visit and someone is about to be evicted, that's a pretty serious and pending deadline to address the clutter in a room. So like the acronym suggests, it goes through H-O-M-E-S, health obstacles, mental health, endangerment, right? Is there a child in the home that we have to be mindful of? Is there a senior in the home? Is the structure and safety of the building secure enough that it's not causing a potential health hazard or safety risk for neighbors? So all things important to consider. And then the backside of the assessment is just kind of a quick overview of who's in the home, any imminent risks, and then capacity measurements. So does the person have the psychological or physical availability, sorry, ability to participate in some of the interventions that you're going to provide. So what interventions might you provide? There's a lot of interventions that are helpful, the gold standard being CBT. So we'll kind of go through the different interventions that are helpful for folks who experience hoarding disorder and hoarding behavior. So CBT is the most commonly used. It focuses on changing thought patterns, emotions, and behaviors associated with hoarding. So we want to challenge this notion, right, that a physical object can bring some relief to a distress that someone's experiencing. It assists folks with identifying and challenging distorted beliefs related to acquiring and saving possessions and develop alternative coping skills. So if someone has, I keep going back to a teddy bear, so I'll just kind of keep going back to it, but a teddy bear, it soothes for some reason, right, which we've learned through the clinical interview why these items are being saved, but it soothes some anxiety. We want to teach people how to manage anxiety and self-soothe without having to use a particular item that was acquired or acquiring in the first place, maybe acquire the act of acquiring and provide some soothing measures. So a case conceptualization that I kind of model that I really appreciate is Stuckety and Frost case conceptualization model. You know, these items are positive reinforcements and in order to intervene in someone who is experiencing hoarding disorder or hoarding behavior, we have to kind of break the connection between the item being the positive reinforcer. And Stuckety and Frost are two folks who have done quite a bit of research on hoarding disorder. We still don't have much in the way of hoarding disorder research or hoarding behavior, but they're two folks that come up quite a bit. Exposure and response prevention. So involves gradually exposing individuals to anxiety-inducing situations relating to discarding possessions while preventing usual saving behaviors. So for example, taking someone on a shopping trip and encouraging them to shop around without engaging in acquisition, right? So can we walk through a Goodwill together, use coping skills that we've learned already together before we do this and practice those coping skills instead of purchasing something that's really important, purchasing the canned good or the teddy bear or whatever and use our distress tolerance skills that we've developed to manage that internal distress and walk out of the store and be okay and not have these items in front of us that we felt compelled to purchase. So again, this should be done with someone who can support the person and guide them through these coping skills in the moment. And the goal is that the anxiety will diminish over time. Peer support. There's quite a bit of research that supports peer support as a support for folks with hoarding disorder. Hoarding disorder and hoarding behavior is really isolating, right? People are in their homes often struggling with this disorder without a clear picture of others who experienced something similar. So peer led interventions that have been specifically designed to address hoarding behaviors can be helpful often in combination with other treatments. It's not typically the only mode of treatment but there are various workshops like the Buried in Treasure Workshops which combines skill building and peer support. So sometimes what you'll find in these Buried in Treasure Workshops is folks will have kind of like a bookshelf. And when you come into a group, you have to bring something there to provide to the group. And you can also take something back too but the goal is to kind of promote this idea that I can part with my possessions and be okay and be surrounded by peer support. Medication. This is often not the primary treatment, very often not the primary treatment but SSRIs have shown to provide some benefit in reducing hoarding symptoms. But again, it's most effective in conjunction with other treatment modalities like CBT. Skills training. So again, as I kind of touched on earlier on in my assessment portion, if someone is struggling with executive functioning or prospective memory, we have to teach these very important skills to folks who are struggling with hoarding disorders so that our interventions are more productive. So how can we teach someone organizational skills? How do we teach decision-making? Something that I've used before in my clinical practice is kind of those big Post-it signs that you can just kind of peel off and hang on someone's wall. And I've made decision trees. If someone is struggling with decision-making and we're trying to encourage someone to sort through various paper goods that they might be acquiring and saving and contributing to clutter, I'll write out a decision tree in collaboration with my client so that they can use it when I'm gone, right? The mail comes in every day. So if I'm sitting in front of my decision tree, I say, okay, does it say ComEd or People's Gas or some sort of utility? Yes. Okay. I'm gonna put that to the right. Does it say valued customer? Yes. Okay. I'm gonna put it to the left and it's definitely probably getting recycled. Is it something that's handwritten from someone that I know? Yes. Okay. I'm putting that to the right. Something that's really clear and can be referenced by the person that you're intervening with so that they can practice this problem solving and decision-making skills. Another example of this. So maybe you have a box of items, right? A Q-tip, a piece of thread, scissors, whatever. And you wanna practice categorizing various items with the client. So where does a Q-tip go? Someone, again, someone who struggles with learning disorder might say, well, if you go in the bathroom, it can go in the kitchen, or I might need it in my office if I'm cleaning out my keyboard. So I'm not sure. And often when that happens, the item just gets placed kind of right where it is because of the anxiety of making the wrong choice and it just doesn't move and the clutter kind of expands. Practicing decision-making and categorization is really important here. So coaching the person that, okay, we're gonna look at where do we use the Q-tip the most? I most often use it in the bathroom. Okay, therefore it's going into the bathroom. Another skills training tool that I really like is kind of taking pictures of where things go and putting it on a cabinet. So I've used this in the past with folks. I've gotten kind of clip art labels and just labeled pictures, particularly if someone has low literacy, pictures of what goes into each cabinet, making it super easy for the person to put items where they belong instead of kind of getting stuck in that decision-making paralysis. And the goal to be that we organize the clutter that we have discarding possessions when appropriate and preventing the accumulation of clutter in the future. Supported clean outs. You see this a lot on television. Supported clean outs have, they have the potential to be a really practical support, right? Like if someone's in their home, they're about to be evicted and there's a lot of items, right? Sometimes you just need to get the items out to save housing. However, it can also be really dangerous when not done appropriately. They're time and labor intensive and not what you see on television. They are often precipitated by a lot of CBT and skills training to support the person with managing the stress associated with a supported clean out. You must have a safety plan in place. I cannot stress this enough. There are people very honestly who have completed suicide after a, I mean, I would call it an unsupported clean out where items are a person's most valued possessions have been taken from them. And there was no backup plan, no coping skills taught. The person then feels isolated, worthless, without a connection to their most important values. So it's typically done, supported clean outs are typically done by a team which includes practitioners as well as kind of tapping some organizers who can support with the goal of organizing, discarding and donating items. Just note how I'm using the word discard instead of throw away, right? We wanna disconnect the idea that we view these items as trash. While some things very honestly might look like trash to us, again, one of the indicators that someone is struggling with hoarding disorder is that they're collecting an item regardless of their actual value, like a paper good or an empty jar or something like that. What might be not important to me could be very, very important to someone else. So we wanna use language that reflects that value and be supportive of our clients. But again, this should only be done after coping skills are taught and are in place and someone is available to guide someone through the use of those coping skills during a clean out. Oftentimes this kind of coincides with the use of a decision tree. If we're making our way through a particular room and maybe it's filled with paper goods, we use the decision tree that I described before in order to decide what gets removed from the home versus recycled versus donated, et cetera. Something that I rely on often as a community-based social worker is some harm reduction strategies. So I rely often on visual cues. So particularly if someone struggles with executive functioning and we're working on developing these skills, you might take a really bright duct tape or something and tape pathways through each room and tape pile heights on the walls. The goal is to reduce harm. The goal of kind of putting tape on the walls and on the floors isn't to reduce the clutter, it's to lessen the likelihood of the severity increasing. And it's helpful for people to see, okay, I have X amount of things that has to stay within this kind of bright green square. What do I need to move? What do I need to discard on my own as the client before my social worker comes back and says, oh, that's past the line, how can we intervene here? So where I work, we have teams of folks who go out and support our members, our clients. And so everyone on the team has to be on the same page. If Joe member, we're using kind of tape as a visual cue, every person who enters that home needs to be on the same page that if something is passing the tape line, then we're intervening. Using incentives to clean spaces. So an example of fellow clinician use that I really liked, right, is if someone is having a difficult time keeping a stovetop clear of paper goods, which is a fire hazard, we wanna incentivize when the stovetop is clear. So this particular clinician that I kind of observed would say, okay, if I'm coming into your home and the stovetop is clear, I'm gonna bring you flowers or I'm gonna bring you a food item or something like that. So the member or the client was highly incentivized to keep counter space, keep stovetops clear so that they can have something that makes them feel good, right? Flowers are beautiful and they bring people joy and it was a good enough incentive to keep the stovetops clear. Again, prioritizing the cleaning of high risk areas. So if you're walking into someone's home for the first time and you see that it's a hoarded space, it's important to use harm reduction strategies to clear the areas that have the potential to create the most harm. So we're focusing on paper goods on a heat source, we're focusing on electrical outlets staying clear, we're focusing on creating an egress path, right? While we're doing other interventions like CBT, coping skills, teaching coping skills and addressing someone's cognitive or intellectual difficulties so that they can be more participatory. We're doing all of that and we're also addressing the fire risk. And then set up systems to minimize the acquisition and maintain organization. So again, having flow charts up on the wall, something that's really visible, really big so the person can default to that instead of trying to think through something on their own. And the goal being that eventually it becomes second nature because you're teaching a skill. Maybe you're unsubscribing from paper goods. If someone's holding on to paper goods, you're working with that person to unsubscribe from a magazine that they don't really read, or switching to electronic subscriptions. So if someone is collecting mail and has a hard time discarding their things that come to them in the mail, you might say, okay you really like this magazine, can we get you the electronic version? Can you read it on a tablet or the library computer? Can we have it sent to your email as opposed to into your home? So these are kind of some harm reduction strategies that you can employ in order to intervene assertively, quickly, and address when someone's, when you walk into a home, and it's kind of, it's important. So service provision, what's the best way to provide service? I'm community-based, so you know that's kind of the model that I know and love. Being in someone's home that's hoarded is the best way to address it, right? If to do a supported clean out, to teach skills, you need to kind of see what you're working with in order to be most effective. But you can also do this by partnering with your local housing authorities. If you provide service site-based and you know that someone's struggling with hoarding and they're at risk of eviction, maybe they got received notice or something, creating partnership with your local housing authorities can be really effective. There are some really good models that are already in place. One that just comes to mind more immediately is in Canada. I can't quite recall where, but there are some instances where social workers will be tapped by the local housing authority to intervene very specifically in homes that are hoarded. And the goal is to keep people housed. That particular housing authority is really invested in maintaining housing for their folks. So if you know someone who's struggling with hoarding disorder, reach out to your local housing authority and learn what services that they might have available. Or create peer support groups. Again, hoarding disorder and hoarding behavior can feel incredibly isolating. So it's important that we create a peer network for folks to learn that they're not alone in this, to partner with people who are also invested and motivated to address their hoarding. And even if someone's not, like some peer support groups can really help with insight building. I think it comes, it feels really different, right? If a peer is telling you, hey, this is a problem, we can't, neither of us should live this way. That feels really different than kind of Susie social worker coming in and saying, hey, we've got to clean this pile. So I think, you know, finding more peer support groups and making them available to our folks is so important. And with that, I will open the floor to questions and turn it back over to Shereen. Thank you so much. Thank you, Kaylee. So we do have a ton of questions. So I'm glad you ended. I tried to text you halfway through and just let you know. So thank you for that. So let's see. Sorry, I'm on the wrong side. Okay. So thank you for such an interesting, informative presentation. And before we shift into Q and A, I just want to take a moment and let you know that SMI advisor is accessible from your mobile device. So you can use the SMI advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. So download the app now at smiadvisor.org slash app. Okay. So we'll go into the Q and A. We'll try to get as many questions answered as possible. And then we'll talk about after if your question was not answered, we do have a consultation service, but we'll try to get through many. So there was a very nice discussion. So I appreciate that there was, you know, people were talking with each other, but there was a lot around lack of insight, right? So you did mention it a couple times, but really people are wondering what do you do when somebody does not identify that their clutter or that their hoarding is getting in the way. They don't identify it as hoarding. They want to say, call it hoarding. And then, you know particularly when that, you know, either is leading to safety issues or leading to issues with like, if it's housing, you know, when we have a housing inspection that is going to be coming today. So that's a long question, but basically what do you do when people are unable to see that the hoarding disorder is an issue? How do you approach this? So one tip that I've learned, and I've used this tip very sparingly and with permission, is sometimes I'll take a picture of the space and show it to the person. And I'll, and you know, maybe I'll take a picture earlier on, and if I'm learning that I'm kind of struggling or rolling with resistance because someone doesn't identify hoarding as a struggle, I might show them the picture and say, what do you think of this living space? What does this look like to you? And sometimes the person will say, oh my God, how can anyone live that way? And then that's a good time to say, you know, I took this picture with your permission, of course, earlier on in our working relationship, this is your living space. Because again, folks who struggle with hoarding disorder might be so lost in the detail and the specific items in their clutter that they're not seeing the big picture. They're not seeing the ways in which their space has become unlivable. It's almost like tunnel vision. So I'd consider using that. I'd also consider tapping some peer supports, but also again, using the clinical interview to find out what the person's goals are, I think is so important because someone might not say, you know, well, I have this hoard at home and I'd like to address it. They might say, well, I want my kids to visit me from time to time. And the living space is a barrier to having my kids over because my kids say I have a problem. I might not believe that, but my kids say it's true. So, okay, let's learn from the kids what they would like to see before they'd be comfortable coming to visit mom or dad. Yeah. Thank you. So somebody to ask also about motivational interviewing, and it sounds like kind of describing that approach, right? To really figure out what is a value to them, what's important because then they might be more likely to change the behaviors, whether or not they don't have to call it hoarding ever, right? They also don't, they can call it whatever they want, but how is it getting in the way of them reaching their goals? Right. Oh, go ahead. Well, I was going to say, I think hoarding, the diagnosis of hoarding or hoarding behavior is so heavily stigmatized. Like you see on television and hoarding buried alive, these shows that are really dramatic and they pull you in, but that's not, there's so much more that goes into the creation of those shows than what they actually show you. So people feel ashamed. I wouldn't, no one wants to call what they're living in a hoard. It's their most prized possession. So using language that exemplifies that you understand the value is really important. So the second part to that question is what do you do when you're up against like a deadline, right? So for example, if it's supported housing and there's an inspection or something that you don't have the time to kind of lay the foundation and approach this in the full way that you laid out for us today, any suggestions on how to manage that? Definitely. So I have a couple of thoughts. My first being sometimes homelessness is not the motivator that we think it is. So sometimes folks will go into a home and say, you're about to be homeless. We need to solve this problem. And maybe someone's already experienced homelessness. So that's not really frightening. It's writing to us as someone who deeply cares about the people that we're working with, but it might not be so frightening to the person. So learning about what their actual motivation for change might be is really important. Secondly, harm reduction skills are really important here. Harm reduction interventions, I'm sorry, are really important. Taping off pile heights or egress paths to give a visual cue of what's acceptable to a housing authority for someone to pass inspection is just important. Great. Thank you. So a few questions around early warning signs or co-occurring, right? So are there typically disorders that are co-occurring with, or not even disorders, disorders or circumstances that correlate with hoarding disorder? So some from the list were trauma, grief or loss, personality disorders or homelessness. I think people are wondering about early intervention, right? Before things become to the level of full hoarding, is there early warning signs or early correlations? And then how would you approach at that point? I think if there's ever an instance where someone is having a hard time parting with a possession, again, regardless of value, that's an early warning sign. Or if someone, just kind of anecdotally in my experience, I've found that oftentimes if someone has a history of homelessness, very often they have difficulty deciding what to part with. And that makes sense, right? If you are someone who has experienced street homelessness and you haven't been able to hold on to any of your most valued possessions, everything that you had was kind of relegated to a suitcase, it might be really hard to move into a living space, have more space for belongings and then decide what to keep and what to part with when you've never had that opportunity before. So addressing any sort of executive functioning difficulties at the front end will make everyone's life easier kind of in the more medium to long-term. Yeah. And I tried to answer this question in the chat about improving executive functioning. There's cognitive remediation therapy. So for anyone who had that question, if you go actually to our knowledge based SMI advisor, there's an answer card that will point you towards resources on how to help improve people's executive functioning. So another question is if you're unable to access the person's home. So whether it is that they come in to see you or you just don't have access to their place, but there's signs that there's hoarding disorder, how can you approach that when you're not able to do that full assessment? Sure. Learn about what the person's support systems look like and get some ROIs, have some more communication with collaterals who might be able to provide you with more insight into what's going on in the home. Again, if someone is very independent, doesn't have a support system that you can ask about, or maybe someone's not letting people into their home, which often happens again because of guilt, shame, et cetera. I think just being super direct is really important or honestly show someone the clutter image rating scale and say, Hey, what does your space look like? Can you pick a number for me? A lot of our assessments, they're not, they're not secrets from our clients, right? You can show someone the home's assessment. You can show someone the clutter image rating scale and ask someone to describe for you what their space looks like. Yeah. So what I'm seeing in the chat is a little bit of, I would say, I would call it sounds, feels like hopelessness a little bit. I think people are feeling with some specific cases based on the lack of insight or based on just not being the barriers that they're really feeling, like hoarding is a really challenging disorder to help treat. I think a question that I see throughout that, and so I just want to acknowledge that, that it is challenging. I don't know, Kaylee, if you have an example that you could walk us through about how you have shown kind of the steps that we went through today actually have an impact. I think just to help tie that in, maybe an example of a person that you worked with, because I think that might help people see what this actually looks like. Sure. So I have, at Thresholds, we call our clients members. So I have a member who I've known for as long as I've been at Thresholds, so almost a decade, and he struggles with hoarding disorder. And the first few years, very honestly, were us moving him from one place to another because he would collect so many items. The landlord would kind of catch wind of that and ask him to leave. And while he had to stress parting with his items, he had a lot of it in storage. So the distress was maybe about medium, mild to moderate. And so he just kind of leave his belongings and kind of restart in the next place. So what we started doing is before he moved into any space, we'd take egress paths while simultaneously doing a lot of cognitive remediation to address the executive functioning, prospective memory, categorization, et cetera, the difficulties that he's been experiencing. We, again, used a lot of harm reduction skills. So in addition to taping pile heights and egress paths, we would also put pictures. His literacy was quite low, is quite low. So we would put pictures on cabinets of where things belong. We would help him find organizational tools with pictures on them. So he was someone who really liked to collect phones and sunglasses and still does. The sunglasses have a drawer. The cell phones have a drawer and they're labeled with an image. So he knows that when he goes into his living space, the sunglass goes here, the cell phone goes here. And we're also practicing in real time, non-acquiring shopping trips. So we'll go to Walgreens and this can be challenging, right? There was a time we went to, I think it must've been Best Buy together. And this sales associate was really trying to sell him a phone, really trying. And I was hot because he has a lot of phones. And so that required me kind of saying, tell me about why this particular phone feels so important. He'd kind of default to the sales associate. And ultimately it required us kind of stepping away, me calling the person over to me and saying, look, this person really is trying to make a sales pitch here. Let's have a conversation about whether or not this phone is actually useful. Or if you have a phone that does something similar and just kind of walk through the criteria that I might use to make a decision about whether this phone was an essential buy or if it was something that we could walk away from and practice some coping skills. And we did just that. Mind you, there were a lot of failed shopping trips prior to this point where maybe he got the phone anyway, or he got the sunglasses anyway. And we would debrief after the fact about why that felt so important. And that helped me adjust my approach because if there was something that I wasn't thinking about as the clinician walking with him and joining him on these shopping trips, that informed my approach later. So if I knew he was going to say X thing as a rationale, I'm going to get ahead of that the next time. So it takes practice. I absolutely understand that it can feel really defeating when someone has low insight. But again, I think the clinical interview, learning why someone's holding on to things and learning about what their goals are is essential. In this case, this particular member had a history of homelessness and it was incredibly traumatizing, like it often is. And he was terrified of becoming homeless again. And we were on the same page in that I didn't want him to become homeless either. So we talked about ways to avoid that. What had contributed to his homelessness in the past? Often it was the hoarding. And he's someone who does not identify as having a hoarding disorder, but he can say, the way I organized my things wasn't appealing to the landlord, something like that. And I'll just adopt that language. How do we organize better? Yeah, that's a great case example. Thank you. And I think some of the questions I'm seeing, we only have time for maybe one more quick one, are related to really that line between just clutter and hoarding disorder. And I think there's a blurred line there. So I think I just want to reinforce that we're not saying that every cluttered space or every messy space is hoarding disorder, right? It's really when it gets in the way of the room being able to function as it's intended. And that's really when we want to think about it being more. So collections are OK, right? People having things they value is OK. Mess is OK. It's just when it gets in the way of their functioning or them being able to do what it is that they want with their life because of the anxiety or other things associated with the hoarding disorder itself. Definitely. And I'll even add to that. There have been instances where I have walked into someone's home and I thought, gosh, this person has hoarding disorder just based off the look of the space. And in part doing the clinical interview, I learned pretty quickly that there's no distress or need to hold on to these items, right? The person is in a wheelchair and just physically or have mobility concerns, and they just physically can't get rid of the space. What they really need is a homemaker, someone who can come in and help them organize because they're not tied to these items in a way that it would be hard to remove them in terms of kind of getting pushback or resistance. It was purely function, like they're just the person could not move in the way that they needed to to keep the space organized. Great point. Thank you. And I see a resource in the chat I just want to call attention to. I did a quick Google search of it when I saw it in the question. It's called Buried in Treasures. And that's for people who for individuals to use themselves. So I saw a lot of people who don't have access to social workers or don't have the resources in the county or in the state that others do. And so I did a quick search and they do use evidence-based practices in order to work with the person. Obviously that is upon the person to take it. They have to be the ones to initiate that, right? So they have to be at the point where they're ready to make that change in terms of where they are in their stages. So, but I just wanted to call attention to that. And I think that's all we have time for in the Q&A right now. But I do want to remind you that we do have the consultation services available. So if there were, you know, if you didn't get your question answered or if you have additional topics covered in the webinar that you want to discuss with your colleagues in the mental health field, you can post a question or comment on SMA Advisors webinar roundtable topics discussion board. That's an easy way to network and share ideas with other clinicians who participate in this webinar. And if you have questions about this topic specifically or any other things related to evidence-based care for people with serious mental health conditions, you can get an answer within one business day from one of our SMI Advisors national experts. And the service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI. And if it's something that's outside of our area of expertise, we can link with Kaylee to make sure you get an answer specific to this topic today. So SMI Advisor offers more evidence-based guidance, such as the SMI 101 Resource Center. And this center provides an array of resources to help clinicians master foundational knowledge and skills around SMI. So you can access the Resource Center by clicking the link in the chat or by downloading the slides. And to claim credit for participating in today's webinar, you need to meet the requisite attendance threshold for your profession. And after the webinar ends, you please click Next to complete the program evaluation. The system then verifies your attendance for credit claim. And this can take up to one hour and can vary based on local, regional, and national web traffic and usage of the Zoom platform. And lastly, please join us next week on August 4th as Dr. Nev Jones presents Strategies for Improving Client Engagement in Psychosis Services Across the Lifespan. Again, this free webinar will be August 4th at 12 p.m. Eastern, and that's Friday. Thank you so much for joining us. And thank you so much to Kaylee for such an informative webinar. And until next time, take care. you

hoarding disorder

hoarding behavior

serious mental illnesses

clinical definition

evidence-based assessment tools

interventions for hoarding disorder

executive functioning

decision-making skills

peer support

harm reduction strategies