There are three reasons a team approach makes good sense when tackling the problem of severe hoarding. First, every situation of hoarding is unique and therefore requires a variety of team members with different skills to manage the hoarding problem. For example, people with severe hoarding typically live in severely dilapidated conditions and benefit from team members who are handy (e.g., plumbers, carpenters, electricians) and have the skills to repair sinks, toilets, and sagging floors. Similarly, many older adults with severe hoarding have multiple medical conditions and may benefit from team members who are medical professionals or are at least available to the HR team for consultation. Similarly, people who hoard may have close friends who are eager to help or a long and trusting relationship with a psychotherapist. These individuals may offer support as well as guidance to the client who struggles with severe hoarding. Second, because severe hoarding is a chronic problem, a team is better able to provide assistance over time, often over many years. Visiting nurses, adult protective service (APS) workers, even family members may come in and out of the life of the client with severe hoarding. However, a team, in some form, can always be there. Third, a team approach can be a cost effective way to help the client with severe hoarding, particularly if the goal is to manage the problem over time. For example, a HR team with six members can alternate in-home visits and attendance at team meetings such that a particular team member participates directly in managing the severe hoarding problem only a few times per year, depending on the agreed upon frequency of in-home visits.

As described in Chap. 4 (Harm Reduction Process for Severe Hoarding), the role of the clinician in the HR approach is a bit different from the usual role of most clinicians who are providing psychotherapy or other mental health services. As we have argued, managing severe hoarding behavior over the long term is a team effort. As such, the approach is team-centered rather that clinician-centered or even client-centered. In this team-centered approach, the clinician takes care of the client by taking care of the team. The role of the clinician within a HR team is a challenging and sometimes perilous tightrope to walk. The clinician may feel pressured to side with the client over another team member or experience the frustrations of team members working at cross-purposes. The client may look to the clinician to go easy on her while another team member may plead with the clinician to push the client a little harder.

At the same time, although the role of clinicians on HR teams is difficult, clinicians have the best skills to do this job. Clinicians are experienced in facilitating clear and effective communication between people. They understand how to mediate difficult situations and how to help people manage the intense emotions that arise in these negotiations. They can identify process factors that derail conversations and are skilled in strategies to get the conversations back on track. Last, through their ability to empathize, clinicians can truly understand from where each team member is coming and, as importantly, clinicians have the skills to communicate to team members that they get it.

Many clinicians report that their first time as a team leader was difficult and that they “fumbled” through each of the meetings by simply responding to whatever came up. However, responding to whatever comes up can be important work when it keeps the HR team on track and the HR process moving forward. Responding to whatever comes up typically requires the ability to negotiate a common goal, to empathize with all members of the team, and, most importantly, to assist the team to solve the myriad of problems that do “come up” when managing a HR plan over time. This is not easy work but it is essential work. Furthermore, mental health clinicians are experts in understanding human behavior and motivation. Addressing the ebb and flow of motivation of all team members, not just the client, is an integral component of the HR process.

The first step in devising a HR plan is to create the team that will develop, carry out, and monitor that plan. Creating a HR team that can work well together for the long term is one of the most important steps of the HR process, as the team, not just the clinician, will make many of the decisions that follow. An effective HR team is collaborative, respectful, and committed to the HR process.

Members of a HR team include a clinician or mediator to facilitate the team, the client who hoards, family members, and professionals either who have regular contact with the client or who can provide useful services aimed at reducing harm. It is a challenge to build an effective HR team, even for experienced clinicians. The clinician must first identify individuals who would be effective members of the team. The clinician must then coordinate the schedules of all team members to make regular team meetings happen, and in general keep the team energized and moving forward in the face of the many challenges associated with a severe hoarding problem.

Identifying potential HR team members who are willing and available to help is not an easy process. For example, although family members can make excellent HR team members, not every family can be an effective HR team member. The relationships between people with a severe hoarding and family members are typically conflicted or distant. In some cases, family members may have never had a good relationship with the person who hoards, and the hoarding problem has only made things worse. At the same time, family members are often highly invested in helping the family member. However, just because a family member wishes to help does not necessarily mean that he would make an effective HR team member. Furthermore, it can take considerable effort on the part of the clinician to transform a family member who is a poor candidate into an acceptable one. In spite of the clinicians efforts, certain family members can become effective HR team members and others cannot. However, friends and family members who may be poor HR team members can help in other ways. For example, they can coordinate the master schedule or organize appointments for the client, such as meetings with her physician, meetings to clear HR targets, or attending a hoarding support group with the client. Family members can purchase storage boxes or shop for the client who may compulsively acquire. With permission of the client and other HR team members, family members can setup electronic bill pay systems or arrange for a safety deposit box in a bank to store valuable papers.

In addition to family members and friends of the client, potential HR team members can come from a variety of professional disciplines. For example, potential HR team members can include public housing managers, public health or environmental health workers, vector control or animal control officers, CPS or APS workers, members of the legal justice system, fire and police safety officers, physicians, visiting nurses, occupational therapists, professional organizers, professional cleaning companies, and in-home health aides. Furthermore, the range of professional disciplines involved in severe hoarding cases reflects the overlap of the environmental and functional capacity factors that influence harm potential (see Chap. 6: Assessing Harm Potential).

At the same time, professionals from such diverse disciplines may have conflicting goals and mandates. For example, a child protective service worker will wish to protect children in the home and may thereby insist that the HR team focus first on clearing and cleaning the bedrooms of the children. Family members may wish to improve the comfort of the client with severe hoarding whereas a code enforcement officer may insist that the HR team bring the home into compliance with health and safety codes that may or may not significantly improve the comfort of the client in her home. In addition, the HR team members likely have spoken or unspoken preferences and standards for how to live and perhaps how a home “should” look. However, personal standards are not legal standards and a home need not meet personal standards to be acceptable under the law. The clinician will have many conversations with team members on this topic, assisting them to stay focused on legal violations rather than the way they think the client “should” live.

Clinicians who work with clients who hoard may benefit from forging strong relationships with professionals who are knowledgeable about hoarding behaviors and about the principles of HR, if possible. In addition, HR team members will possess several key qualities. Among these are patience, a stake in the HR process, and a low-conflict relationship with the client who hoards.

People approach service on the HR team with different degrees of enthusiasm. As mentioned, some family members are reluctant to join the HR team because they have a caustic relationship with the person who hoards. Other family members are remarkably eager to participate and believe that the HR team is the solution to years of worry about the safety and health of their loved one. Still other professionals wish to help but are reluctant to commit themselves to an endeavor that likely will demand time and energy for many years to come. One of the first steps in building a HR team is to clarify for each potential member the advantages and disadvantages of participating on the team.

To begin this process the clinician can describe to a potential team member the HR approach, the frequency and duration of team meetings, and typical responsibilities of HR team members. The roles and responsibilities vary according to the relationship the potential team member has with the client, as well as the skills that he possesses. For example, a family member who is quite handy may be best suited to repair things in and around the client’s home.

In addition to clarifying the roles and responsibilities of potential HR team members, the clinician underscores that participation is voluntary and the team member can end participation at any time. An individual may be reluctant to join the team if she believes that she must participate for as long as needed. More than once, a HR team has splintered and a HR plan faltered because a team member began to resent his participation. While this may seem obvious to clinicians, it is wise to clearly and to carefully cover this at the very beginning and with every potential team member. In addition, the clinician may wish to cover this territory explicitly in a consent form (see Appendix).

In building a HR team, it is important that the clinician include, when possible, an individual that the client values and with whom he is interpersonally invested (Longabaugh, Beattie, Noel, Stout, & Malloy, 1993). This is particularly true when considering family members as HR team members. Furthermore, it is better to not include family members than to include one that has high potential for undermining the HR process. Sometimes, the client does not welcome individuals who would be useful additions to the HR team. Either because the person who hoards already has formed a contentious relationship with a potentially useful team member, or because he fears that having that person on the team will make things more difficult for him.

For example, a client had lived in the same apartment for 11 years and the property manager, after many attempts to reason with the client and after many offers to help, finally began the eviction process. The client strongly objected to the property manager participating on the HR team because he feared that he would evict the client the first time he failed to honor the HR agreement. However, the property manager stated that his intent was to help the client comply with the minimal safety standards and would like to avoid eviction if he could. After the clinician facilitated much discussion, the client agreed to allow the property manager on the team for a trial basis. Over time, the property manager demonstrated that he was indeed interested in keeping the client in his apartment, so long as he made progress clearing the apartment. This reassured the client and he no longer protested when the property manager arrived for a team meeting.

Once the clinician identifies a potential candidate for the HR team, the clinician asks the client for permission to include the individual on the team. The clinician then uses motivational interviewing to address any concerns the client may have about the potential team member. Open-ended questions followed by reflective listening, as well as decisional balancing (e.g., what’s the worst and best thing that could happen if this individual participates on the HR team) are particularly helpful strategies to assist the client to explore his ambivalence regarding the potential HR team member. If the client remains ambivalent about the potential team member, encourage the client to accept the individual on the team for a trial period and then to reevaluate after a limited period of time (e.g., 2 or 3 months). Alternatively, the clinician can use motivational interviewing with the client to help him accept certain individuals on the team but not others and then as the HR process continues, use motivational interviewing to help the client accept others on the team.

Some professionals will insist on joining the HR team if they have a big enough stake in the outcome. This may dismay the client and even other HR team members. For example, the daughter of a client with severe hoarding insisted that she participate on the HR team. However, the daughter lived in a distant city, was the sole parent of four young children, and did not have the financial resources to travel back and forth between her home and her mother’s home. Neither the client nor the other HR team members thought that the daughter could fully participate on the HR team but the daughter insisted that she could. The clinician spoke with the daughter several times, using motivational interviewing, and gradually the daughter agreed to serve as a consultant to the HR team, which she, the client, and the other team members viewed as a more realistic option.

At times, a client will object to a potential team member because there is a history of critical or hostile interactions between the client and the potential team member. Such was the case with a client who objected to the participation of his youngest daughter on the HR team. The client explained that this daughter had berated him for years about the hoarding problem and still at times called him “a pig” and “a slob.” In addition, he reported that he had tried to mend the relationship with his daughter but she showed no interest in improving things between them. Understandably, when his daughter volunteered to participate as a HR team member, he was suspicious and assumed that she wanted to unearth his valuable coin collection, for which she had asked several times. The clinician met several times with the client and his daughter and observed firsthand the daughter ridicule the client while the client looked to the clinician for help. The clinician recommended that the HR team deny the daughter’s request to participate on the HR team. In addition, the team devised a plan to protect the client from possible emotional and financial abuse.

The client is not the only HR team member that may at times deny a potential team member a place on the team. For example, an APS worker who had a longstanding relationship with an older adult with severe hoarding opposed the addition of a code enforcement officer on the team. Prior to a team meeting, the clinician explored with Marcia, the APS worker, her reasons for wishing to deny team membership to Mike, the code enforcement officer, who was young and eager to help the client. The clinician moved into motivational interviewing with Marcia during a telephone call with her:

While earlier chapters describe in detail the fluctuations in, or lack of, motivation of clients who hoard, clients are in no way the only members of the HR team who are likely to feel ambivalent about the HR process. In the majority of cases, there will be at least one reluctant team member sitting around the table at a HR meeting. Whether it is the client, a family member, or a professional, not everyone comes willingly and cheerfully to these meetings.

As described in earlier chapters, the clinician expects the client with severe hoarding to resist engaging in the HR process, or other forms of assistance. However, the clinician may not expect and may be quite surprised when other members of the HR team resist the HR process too. Resistance among HR team members can take many forms. A HR team member may resist collaborating with other team members, that is he may refuse to negotiate with other team members to craft a mutually acceptable set of goals and an HR plan. A HR team member may resist listening. He may resist doing what he has agreed to do or to attend team meetings. Some team members may resent something that was said by another team member at a past meeting and wish to withdraw from the team. A team member may feel frustrated with the slow progress while another team member feels pressured to work faster than she thinks is wise. Still another team member may question whether his particular goal has been fully addressed. Some team members may simply resent giving their time to help manage a problem they do not view as their responsibility. Furthermore, the HR process can foster a “them against us” attitude that can quickly undermine the willingness of team members to work together. Therefore, when facilitating a HR team, the clinician is wise to keep a steady eye on the level of engagement of team members. Enhancing and maintaining motivation is as important in harm reduction as it is in the treatment of hoarding disorder, and perhaps more important, because some people with hoarding disorder seek treatment for the condition and therefore may have greater motivation than those with severe hoarding, who by definition, adamantly refuse help for the problem.

This section describes the application of the same motivational interviewing (MI) approach described earlier (Chap. 5: Engaging the Client who Hoards in the Harm Reduction Approach) to engage and re-engage other members of the HR team. Applying motivational interviewing within a group differs from applying the approach with just a single client, which is more untested and is far more complicated. Because of the complexity of interactions in a group, there is greater potential for discrepancy diffusion, nonparticipation, resistance, and collective argumentation. For example, during team meetings, one team member may be filled with “action” talk while the client or another team member remains ambivalent about a goal or a proposal. This mismatch of change stages can create a potentially volatile dynamic that can create much resistance on both the part of the client and other team members. In such instances, the clinician can soften the feedback to prevent the meeting from proceeding into the action stage before the client or another team member is ready, “George is ready to discuss the modified cleanout and Joan wishes a bit more time to discuss how to support the client during the process.”

Another challenge of MI within a group is the reactive nature of resistance. For example, a clinician may discover that as she rolls with the resistance with one team member another team member amplifies the resistance. Typically, this occurs because one team member is alarmed that the clinician has rolled with the resistance rather than “confronting” the resisitance of the client or another team member. At other times, a team member may misread rolling with the resistance to mean that the clinician agrees with a point. The other team member then steps in to defend the side of the argument the clinician first raised. At other times, the clinician moves in to promote discrepancy for the client or team member only to observe another team member minimize the discrepancy in an effort to help. For example, the clinician who wishes to promote discrepancy by highlighting what is happening now versus how the client or another team member would like things to be, might say, “Your grandchildren refuse to visit you because they’re upset to see you living in your home the way it is. At the same time, you would like to spend more time with your grandchildren.” Just as the clinician finishes, she hears another team member say, “I’m certain we can find a way for Roy to see his grandchildren outside his home.”