An effective HR target focuses on a specific area of improvement. In the case of severe hoarding, the desired improvement is to decrease the harm potential of the client. A specific HR target then describes in clear and unambiguous terms exactly what is expected (see Fig. 8.1). For example, a general HR target might read: “Keep back and front doors clear of clutter.” A specific HR target, on the other hand, might read: “Keep clutter out of swing areas of front and backdoors so that the doors swing fully open.”

The greatest challenge for the clinician is to craft specific HR targets from the chaos of a severe hoarding situation. At the same time, the effectiveness of the HR process and the efforts of the HR team depend on specific HR targets because specific targets focus the team on what to do and why it is important to do it. The clinician may benefit from keeping three W’s in mind when crafting specific HR targets: “What do I want to accomplish?” “Why do I want to accomplish this?” and, “Who or what is needed to accomplish this?” Most specific HR targets will include the answers to these three questions. For example, consider the issue of food safety for a 79-year-old woman who hoards food. The client has stuffed the pantry, closets, refrigerator, and freezer with foods of one sort or another. The clinician can smell the odors of rotting food in her apartment, but the client cannot, and for that reason, the client may eat food that is rotten or contaminated without knowing it. The clinician formulates the specific HR target as she examines the home. She asks herself the question, “What do I want to accomplish?” and answers that she wishes to decrease the likelihood that the client will eat bad food. She asks herself the next question, “Why do I wish to accomplish this?” and answers that she wishes to protect the client from food poisoning because she is unable to smell or taste spoiled food and therefore may eat tainted food, and a great deal of it. The final question she asks herself is, “Who or what is needed to accomplish this?” The clinician realizes that the client requires visual cues that the food may be tainted rather than the sensory cues (smell and taste) that other people use to avoid eating tainted food. The measurable HR target then depends on the use of expiration dates on foods and includes keeping and discarding rules for food. For example, when the client purchases new food, if it does not have an expiration label, she agrees to place tape on the food with an expiration date of 1 week from the date of purchase. Discard rules would include the client agreeing to discard food past the expiration date on the food, with the help of the clinician or other HR team member.

An effective HR target, in addition to being specific, is measurable in some way. In harm reduction, progress is literally measured in inches. A measurable target then specifies the number of inches the client must keep clutter away from the stovetop or the height of stacks of paper (in inches) the client must not exceed when he stacks paper against a wall or in front of a window. A measurable HR target includes criteria for measuring progress toward attainment of the goal. If a goal is not measurable, then neither the client nor the team will know whether they have achieved that goal. For example, a HR target that is specific and measurable might read: “Keep clutter out of taped swing areas of front and backdoors so that the doors swing fully open to the doorstop.” In this example, both the tape and the doorstop indicate whether the client achieved the goal of keeping the swing area clear of clutter. If there is clutter in the taped area, the client and clinician will quickly see it. If there is clutter in the front or back of the door, the client will not be able to open the door fully to the doorstop. The clinician can use tape or other visual cues to convert a situation into a measurable HR target. The clinician may place a strip of tape on food on which she has written the agreed upon expiration date. The clinician may use tape to identify the paths out of the residence to keep clear of clutter or to identify the distance from stoves, furnace registers, or other sources of heat to keep clear of clutter.

Measurable goals usually specify how much (How much space is needed on the stairwell to be clear?), how many (The client may keep only as many newspapers as fit in the box by the door?), and how the clinician knows that the client has achieved the goal (the only newspapers in the house are in the box by the door). Often, health and safety codes are a terrific place to gather measurable safety goals. Code enforcement officers, health and safety officers, and fire personnel can provide the clinician with specific guidelines for measurable HR targets.

An effective HR target is realistic or attainable. An attainable or realistic goal is neither out of reach nor beyond the capacity of the client and the team to accomplish. For example, most people with severe hoarding cannot work more than 20 or 30 min on clearing tasks, in part because of age-related limitations or because of co-occurring conditions, such as attention-deficit hyperactivity or major depressive disorder, that make it difficult for them to sustain effort on a task. Furthermore, a realistic or attainable HR goal may depend on whether the client is expected to work toward the goal independently or with a HR team member.

In crafting realistic and attainable HR targets, the clinician will consider what to add to or subtract from a task or target to increase the likelihood that the client and team will accomplish the HR goal (see Fig. 8.2). For example, a HR target to clear items away from the stove may be realistic if the client and team must move items only a few feet away from the stove. This same goal may become unrealistic if the goal is to clear the entire kitchen of all items. At the same time, for many clients, even moving items back a few feet from the stove may be unrealistic without assistance.

The HR goal to clear the sofa in the living room of all items by 11:00 a.m. may be specific, measurable, attainable, and time-bound, but is not relevant if the goal of the visit does not enhance the safety of the client in his home. Although clearing the sofa may make him a bit more comfortable, it does little to increase his safety and may, at times, decrease his safety if he moves the items from the sofa to the stair to the second floor. A relevant HR target focuses on minimizing risk first and, when possible, increasing the comfort of the client within the living environment. At times, the clinician who focuses on enhancing safety may improve the comfort level of the client too, but comfort is a result not the primary goal of harm reduction. For example, working with a client to move combustible materials off the furnace registers increases his safety and also may improve his comfort if he can now heat his home. At the same time, clearing the furnace registers may have no influence at all on the safety of the client if the furnace no longer works. At the same time, clearing the furnace registers of materials and repairing the furnace may be appropriate safety targets for older clients who live in cold climates.

However, the relevancy of HR targets is not limited to enhancing safety. HR targets are relevant when the HR team has agreed that they are relevant. Relevant goals motivate the team to move forward with the HR plan. A HR goal that supports or is in alignment with other goals is a relevant goal. Therefore, the job of the clinician is to assist the team to agree on specific, measurable, attainable, and time-bound HR targets that align with the overarching goals of the team. The relevancy of any HR target depends to some degree on agreement among HR team members that the target is relevant. The most relevant targets are those that the HR team agrees to enhance the safety of the client.

In addition, the HR team makes a HR target relevant when they agree that the target is worthwhile, that it is they agree that it is the right time to focus on the target, and that it is a good match for the skills and efforts of the HR team members. Usually, a worthwhile HR target focuses on getting the biggest bang for the buck. That is, a worthwhile HR target is the most cost-effective path to meeting the overarching goal of managing the harm potential of the client. Typically, this means that worthwhile targets focus on the two or three situations that significantly influence the client’s harm potential. At HR team meetings, this often comes down to an agreement on what is necessary to ensure that the client is “safe enough” given the limitations of the team, the resources, and the client.

A HR target is also relevant when the team agrees that it is the right time to focus on a target. This is particularly true in light of the changing functional capacity of older adults over time. For example, keeping the kitchen clear of clutter is relevant when the client cooks in the kitchen but is irrelevant when the client no longer has the energy or stamina to cook meals even if the kitchen was clear of clutter. Similarly, keeping the bedroom or bathroom clear and clean may become a relevant target when the health of a diabetic client deteriorates and self-care and a clean environment to manage her illness is the new priority. At times, a relevant target can quickly become irrelevant when a new professional enters the HR team or when a current team member must enforce a new health and safety code. These changes in team composition or in the codes and laws of the community can quickly alter the focus of the HR process. For example, a clinician working with a 72-year-old woman with severe hoarding scrambled to rework the HR plan of the client when the code enforcement officer informed her that the code that limited the amount of combustible material in a residence had changed. The client’s apartment moved from compliant to noncompliant when the code changed in the new year.

Last, a relevant HR target or goal matches well with the skills and knowledge of the HR team members. Although repairing a leaking roof may be an appropriate HR target, it may be irrelevant if the team does not include an individual with the skills to repair the leak or if the team cannot find the financial resources to hire someone to do it. Similarly, although connecting the client with a mental health specialist to treat her depression may be an appropriate HR target, it may be irrelevant if the client lives in a community where the nearest mental health professional is 50 miles away and the client does not drive. A more relevant HR target may be to facilitate her connection to a physician at a local health clinic and arrange for transport to and from the clinic.

An effective HR target has a specific target date. A clear target date organizes the team and can help the client and team to decide whether a goal is realistic or unrealistic. In addition, a HR target that is time-bound helps to focus the team on the primary goals of the HR plan and to generate and maintain a sense of urgency for the client. Typically, the clinician will use time between HR visits as the time frame: “The first four stairs are clear of clutter by our visit next week.” The clinician can use time between telephone check-ins too, if the clinician trusts the client to report accurately.

As the clinician goes through the Harm Reduction Planning Worksheet, she will ask the client many questions to identify and elaborate the details of potential environmental targets (see Fig. 8.3). For example, the reasons the client keeps an item in one place rather than another can help the clinician and team later generate strategies for keeping the target area clear. Similarly, how and why the client uses something can help the clinician better understand when a situation may be dangerous and when it may not. If the client tells the clinician that he sometimes prepares meals at home but the clinician notices that the stovetop is cluttered with paper and other items, the clinician may wish to ask him how he cooks. The client might then state that sometimes he uses an electric hotplate that he sits atop the clutter on the counter or, he cooks outside on a gas grill (except in the winter when he brings the grill inside). In addition, the manner with which a client answers a question can suggest his level of insight into the potential danger of a situation. The client, who is indifferent to questions regarding his safety, may be indifferent or unaware of the level of danger he faces.

I recommend that the clinician examines each room with standard HR targets in mind (see Fig. 8.4). Do not forget to assess other non-living areas (garage, attic, storage areas, yard) that may increase harm potential due to fire or earthquake (e.g., an overfilled attic increases risk in earthquake country). Furthermore, although external storage areas may not directly contribute to the environmental risk of the client, they may contribute to the financial risk she faces.

Remember that many factors can influence the harm potential of the client, therefore do not overlook targets that at first glance may seem like small problems. Rate the risk on a 0–10 scale in order to prioritize the risk (and therefore the priority) of targets. Sometimes, however, what at first appears to be a low-risk situation (e.g., gas grill on the porch) can become a high-risk situation (e.g., gas grill brought inside for heat or to prepare meals during the winter). Again, refer to the environmental measures (see Chap. 6: Assessing Harm Potential) used during the initial harm potential assessment to identify potential HR targets.

Not every client with a severe hoarding problem compulsively acquires things, but most do (Frost, Tolin, Steketee, Fitch, & Selbo-Bruns, 2009). A client with severe hoarding will report that he cannot resist purchasing items at certain stores, nor can he resist urges to bring home multiple copies of the free daily newspapers, pamphlets, and flyers. Some clients with severe hoarding may not admit that they buy things they do not need because they see it quite differently. For example, the client may believe she needs the 200 or so small stuffed animals she purchased as gifts and will tell you that it is always good to have extra gifts on hand for unexpected guests or celebrations. In this situation, the clinician may wish to ask family members or friends who are familiar with the shopping habits of the client for specific information on her acquisition patterns. Other clients with severe hoarding might eagerly endorse that they acquire too much. They are pleased with the “great bargains” they find and may encourage the clinician to visit the store to take advantage of the bargain before it is too late.

An effective harm reduction plan will identify the multiple pathways that items enter the home or apartment of the client and will include both active strategies (e.g., client brings an item into his residence) and passive strategies (e.g., client accepts items from others or accepts delivery of mail, newspapers, magazines). The greater the flow of items into the residence, the greater the harm potential of the client, if for no other reason than it is difficult for the HR team to keep up with this relentless inward flow of things. Use the worksheet below to determine what methods of acquisition are most common and problematic for the client (see Appendix 2).

As you see items, ask how they got there. When you see magazines, ask the client whether he has a subscription and if not, how he acquires them. Ask about multiple items (e.g., rolls of paper towels, cases of soda) and how he acquires them and why. Examine dates on items (ask permission first), to get an idea of the age of items. Examine the refrigerator and freezer and ask about other freezers and refrigerators on the premises. You may wish to take care when opening a freezer or refrigerator. It may no longer operate and now contains rotten and putrid food. Before opening the freezer or refrigerator door, I recommend that you ask the client whether the refrigerator is operating, whether it is plugged in, and whether there is food inside.