(1)
San Francisco Bay Area Center for Cognitive Therapy and University of California, Oakland, CA, USA
Although few people with severe hoarding have received treatment or a cleanout intervention for the problem, many if not most have experienced years of pressure from family members, friends, clinicians, and other professionals to discard possessions and accept help. This, along with the limited insight they may have about the problem, makes engagement, even in the service of harm reduction (HR), a difficult task.
In this chapter, I describe the features of engagement and include guidelines for engaging the client with severe hoarding. The engagement approach described in here and in later chapters draws heavily on motivational interviewing (MI) (Miller & Rollnick, 2012). In this chapter, I describe the stages of change model and the principles and basics of motivational interviewing (MI) as applied to the problem of severe hoarding. In later chapters, I apply these MI strategies to engage and re-engage the client and team members in the HR process.
I conclude the chapter with a discussion of the use of appropriate pressure to increase willingness to accept the HR approach. Unfortunately, some people with severe hoarding are so resistant to help and at such significant risk, clinicians must seek assistance through the legal system to secure adherence with the HR approach. I view the use of appropriate pressure as an option of last resort. Unfortunately, in many cases of severe hoarding, the client visits this last resort too often and too soon.
5.1 Role of Motivation in Managing Severe Hoarding
Motivation is a state of readiness or eagerness to change influenced by the interpersonal context of the problem behavior (Miller & Rollnick, 2012). Motivation is therefore, in many ways, an interpersonal process, the product of an interaction between people. The interpersonal context of severe hoarding presents several challenges to clinicians wishing to enhance the client’s motivation to accept help. People who hoard often have suffered years of criticism, arguments, threats, and broken promises with family members, friends, and neighbors such that the interpersonal context of the hoarding problem is colored by hurt, mistrust, and anger (Tolin, Frost, Steketee, & Fitch, 2008). Professionals, such as social service workers, code enforcement officers, or fire or police personnel may engage in relentless and fruitless battles with the person who hoards, further aggravating this volatile interpersonal context.
The court sometimes mandates clients with severe hoarding to enter treatment or to accept cleanout interventions. Some clients with severe hoarding view a court order as an infringement upon their rights and either steadfastly refuse to comply or engage in more hoarding behavior in an attempt to assert their freedom. Others simply “jump through the hoops” and show little personal investment in the process. They are passive participants in the cleanout or do just enough to get the authorities to go away. Professionals are keen to tell clients what to do to fix the hoarding problem, and although these professionals are often correct, instruction rather than collaboration creates a power dynamic that moves clients further away from accepting help. Once this power dynamic is in play, it is far more difficult to build the rapport and collaboration with the client that is necessary to manage his severe hoarding problem. Furthermore, persausion rather than collaboration may increase the likelihood of relapse because the client is less willing to seek help again when the hoarding problem worsens.
As the courts, professionals, and other stakeholders exert pressure on clients with severe hoarding problem to change, it is perhaps not surprising that they push back, reflexively and with little thought, against any hint that other people are attempting to control them or constrain their freedom. They react strongly to directives from clinicians, family members, or professionals who become involved in the severe hoarding problem. They argue, they rationalize, they minimize the problem, and when that does not work, they close the door.
It is possible to change a client’s behavior through fear and intimidation. However, behavior change obtained in this manner is not true behavior change. It is compliance. People will comply even when they are not motivated to change their behaviors to avert an eviction or cleanout. However, once the fear or pressure lessens, the individual with a severe hoarding problem is likely to slide back quickly into old patterns of acquiring and saving and with less motivation to accept help to manage the hoarding problem in the future.
Client motivation is a critical component to the behavior change process, whether behavior change occurs through treatment or harm reduction. In the case of harm reduction, I define motivation broadly as readiness to engage and participate in the harm reduction plan and more narrowly as readiness to manage hoarding behaviors. The theory of self-determination (Ryan & Deci, 2000) may help us understand the apparently low or absent motivation inherent in severe hoarding, particularly when those with a severe hoarding problem come to the attention of community officials, the court, or others who may resort to coercive control to force the client to accept help.
5.2 Self-determination Theory and Motivation
Self-determination theory (SDT) postulates that motivation lies along a continuum (Ryan & Deci, 2000). At one end of the continuum lies amotivation, the absence of motivation to engage in new behaviors. In the case of severe hoarding, amotivation is the norm. People with severe hoarding show little interest in changing their hoarding behaviors. Often, they do not even wish to discuss trying new behaviors or to accept help with benign tasks such as organizing the living space or relocating items from a high risk to a lower risk setting.
At the other end of the continuum lies intrinsic motivation, a willingness to engage in behavior change in response to the self-determined reasons and desires of the individual. Extrinsic motivation lies between these extremes and is a willingness to engage in some behavior change in response to specific environmental contingencies. At times, people with severe hoarding will accept help from a trusted friend or family member to relocate or discard some possessions in the residence but may not agree to more than that.
According to SDT, change agents can create environments that support intrinsic motivation to change by addressing three basic psychological needs. The first psychological need is the need for personal autonomy or experiencing one’s behavior as determined by oneself and under one’s own control rather than under the control of external forces. In the interpersonal context of hoarding, many clients experience real threats to their autonomy, either by family members, by the court, or by well meaning professionals. This is particularly true for older clients who experience age-related physical and financial challenges to personal autonomy.
The second psychological need is the need for relatedness or the belief that others value and respect one’s thoughts, beliefs, and feelings as part of a supportive and caring group. The highly volatile, critical, aversive interpersonal context thwarts the wish for relatedness of the client who hoards. Shifting this interpersonal context in order to enhance the willingness of the client who hoards to accept help for the problem has been the focus of family-focused interventions (Tompkins, 2011, 2014; Tompkins & Hartl, 2009, 2014). However, in some cases, people with severe hoarding may lack any true interest in relating to others, which undermines efforts on the part of clinicians to enhance their motivation to accept even harm reduction.
The final psychological need is the need for competence or to believe that one has the skills and knowledge to produce desired outcomes. This is termed self-efficacy (Bandura, 1982). This psychological need underscores the importance of assisting the client to set realistic goals that enhance self-efficacy. The harm reduction approach strives to set realistic goals that with assistance the client can meet.
Based on an understanding of SDT, clinicians can understand the pushback from people with severe hoarding, particularly when the court or professionals mandate they accept help for the severe hoarding problem, often with considerable pressure to accept it immediately and fully.
5.3 Stages of Change Model and Motivation
The idea that intentional human behavior change is a process that occurs in increments is the heart of the transtheoretical stages of change model (TTM) (DiClemente & Prochaska, 1985, 1998; Prochaska & DiClemente, 1983, 1984). The TTM appreciates the role of self-determination in the change process and invites clinicians and other professionals to consider client resistance as a state that they can influence. I briefly describe the stages of the transtheoretical model but with special emphasis on the precontemplation stage, where researchers and clinicians assume many if not most clients who hoard reside (Frost, Tolin, & Maltby, 2010).
5.3.1 Transtheoretical Model of Change
The transtheoretical stages-of-change model (TTM) consists of four constructs that guide our understanding of the process of intentional behavior change (Prochaska & Velicer, 1997). The stage construct assumes behavior change is a process, rather than an event, that proceeds through a series of stages over time. The processes construct assumes that there are certain processes or covert or overt activities that people use to progress through the stages of behavior change. Researchers have identified ten processes (Prochaska, Velicer, DiClemente, & Fava, 1988) people use to change their behavior, such as consciousness raising (increasing awareness about the causes, consequences, and cures for a particular problem), stimulus control (removing cues for unhealthy behaviors and adding prompts for healthier alternatives), or helping relationships (seeking support of healthier alternatives from others). The decisional balance construct assumes that the thoughtful weighing of the pros and cons of changing influences behavior change. The self–efficacy construct assumes that the confidence people have regarding their ability to change influences their willingness to change.
All four constructs guide our understanding of behavior change put the idea that change is a process that clinicians influence is particularly helpful when working with people with severe hoarding. Rather than the clinician feeling discouraged when she encounters resistance, the stage model enables the clinician to see a clear roadmap to enhance the motivation necessary to move the harm reduction process ahead.
5.3.2 Stages of Change
The TTM assumes change proceeds through a series of stages, from an initial precontemplation stage, where the individual is not currently considering change; to contemplation, where the individual seriously evaluates the reasons for and against change; and then to preparation, where the individual plans a course of action and commits to moving the plan ahead. Once the individual successfully proceeds through these initial stages, he makes specific changes in his behavior. If these actions are successful, the individual then moves into the final and fifth stage of change, maintenance, in which he works to sustain the change over the long term (DiClemente & Prochaska, 1998; Prochaska, DiClemente, & Norcross, 1992). In addition, the TTM includes relapse or recycling, which is not a stage in itself but rather the return from the action or maintenance stages to an earlier stage of the change process (Prochaska & Velicer, 1997).
The TTM appears to apply to a range of health risk and health protective behaviors and although the behavior change targets differ, the structure of the change process appears to be the same. These stages appear to be applicable to the larger process of behavior change, whether that change occurs with or without the help of a therapist, an intervention, or a treatment program (Miller & Rollnick, 2002). For these reasons, TTM is a useful model for understanding the low motivation and high help-refusal behavior exhibited by people who hoard.
5.3.2.1 Precontemplation Stage
The precontemplation stage is the earliest stage of change. People in this stage are unaware of their problem behaviors. They engage in little activity that would shift their view of the problem behavior, such as reading about hoarding, or attending a hoarding support group. People in the precontemplation stage can be defensive about the behavior and are not convinced that the costs of changing the hoarding behaviors outweigh the benefits of continuing these behaviors.
It is useful to think of precontemplation as the absence of ambivalence. Therefore, the first step in helping people with severe hoarding is to increase their ambivalence about the hoarding problem and their role in maintaining it. Ambivalence then is the recognition that one’s behavior is in conflict with one’s deeply held values. For example, a man who hoards books because he values lifelong learning cannot honor that personal value if he cannot access these books to read because of the level of clutter in his home. Similarly, a woman who values art and creativity and therefore keeps all manner of colored paper, art supplies, and interesting postcards to use one day in her art projects cannot honor that personal value if she does not have room to do her art projects. As this discrepancy between hoarding behavior and personal values widens, ambivalence grows. Therefore, ambivalence is not an obstacle to change but rather the beginning of change.
Although there are many reasons for individuals to be in the precontemplation stage, precontemplators may exhibit four particular patterns of thinking, feeling, and reasoning (DiClemente & Velasquez, 2002): reluctance, rebellion, rationalization, and resignation. Although most precontemplators are likely a combination of these four patterns or types, I have adapted these four basic types of precontemplators for people with severe hoarding.
5.3.2.1.1 Reluctant Precontemplator
Bess was not angry when a clinician knocked on the door of her home accompanied by the fire marshal of the small local volunteer fire brigade. Instead, Bess was bewildered and embarrassed by the state of her home. The clinician explained that the fire department, on a routine examination of homes in the area, had noticed through an open window that clutter, piles of paper, and other flammable materials filled her home. Bess admitted that her home was messy but she did not understand why the fire marshal was concerned. The clinician and fire marshal gently asked Bess what it was like to live in her home. Was it easy to wash her clothes? Was she warm enough? How did she cook her meals? The clinician invited Bess to consider whether over the last few years these routine activities had become more difficult for her. When the clinician asked whether she would like some help cleaning her home, Bess declined but did agree to a follow–up meeting. Over the course of several meetings, during which the clinician continued to explore with Bess the influence of her living situation on her comfort and day–to–day functioning, Bess began to share with the clinician other difficulties she was having, such as feeling lonely because she could no longer invite friends to her home for crocheting parties as she once did. After several months, Bess greeted the clinician by stating, “You know, I think I could use a little help with some things. Do you have some time?”
Reluctant precontemplators do not consider change because they lack knowledge or perhaps inertia to ask for help. For reluctant precontemplators, the effect of the hoarding behavior is not fully conscious. They do not actively resist change but rather they are passively reluctant to change. Perhaps they fear change or they are not yet so uncomfortable with the status quo that the idea of change makes sense or is worth the effort or discomfort of change. Reluctant precontemplators benefit from clinicians who listen carefully and provide feedback in a sensitive and empathic manner.
Although at times, the reluctant precontemplator moves quickly into the contemplation stage once she verbalizes reluctance, this is not typically the case with severe hoarding. However, the reluctant precontemplator who feels listened to and understood may begin to feel the tension between her reluctance to change and the possibility of a different future. At times, the reluctant precontemplator may benefit from multiple meetings over many months with the clinician who listens and validates that the client, at this time, retains the freedom to make her own decisions. Furthermore, these early and careful conversations with a reluctant precontemplator may prevent the individual with severe hoarding from pulling back and withdrawing into a pattern of active rebellion.
5.3.2.1.2 Rebellious Precontemplator
Tom is a retired marine who is proud that at 67 years old, he can still climb the three flights up to his apartment. One day he exited the stairwell to find the property manager and a woman he did not know standing outside the door of his apartment. The property manager introduced the clinician to Tom and he understood immediately why they were there, “Look, it’s my apartment and my stuff, and you can’t tell me what to do. Get lost!” The clinician responded, “You’re right! No one can force you to do what you don’t want to do and I wouldn’t dream of trying.” This stopped Tom in his tracks for a moment but he quickly recovered and began to list his rights as a tenant, the reasons his apartment was safe, and concluded with an angry declaration that he had risked his life fighting to protect their freedom and that no one was going to take away his right to live the way he wished. The clinician responded, “Thank you for what you did for me, Tom. My freedom is very special to me too. Tell me why you think I would even try to take away the freedom you fought to protect for you, for me and for us all.”
The rebellious precontemplator often has a great deal of information about hoarding and they do not like others telling them what to do. They are sometimes hostile and often argue with the clinician. They are eager to tell the clinician the reasons that they are not going to change, that they will not accept help, and flatly state that there is not a problem. They are willing to invest a great deal of energy to maintain the status quo and are not reluctant to use that energy. The rebellious precontemplator often pulls for an argument but a clinician who is calm, open, and welcomes the client to express his strong feelings about change is likely to be more effective. A menu of options is a good strategy for working with the rebellious precontemplator, including the option of small incremental changes instead of complete and immediate changes. Harm reduction, with its focus on managing rather than stopping hoarding behavior, is a natural approach for the rebellious precontemplator. Furthermore, the rebellious precontemplator may find the collaborative nature of the HR process as well as benefits of a modified versus a full cleanout more palatable. At times, once the rebellious precontemplator has accepted help for the severe hoarding problem, he may focus that same energy on proving to the clinician that he can succeed with the HR plan.
5.3.2.1.3 Rationalizing Precontemplator
Gus is 72 years old and lives alone in a small house nestled in a grove of eucalyptus trees. A neighbor called the local fire marshal to alert him of the situation and the fire marshal then asked an Adult Protective Service worker to accompany him. Gus permitted the fire marshal to enter but told the Adult Protective Service worker that she could not enter and insisted that she stand at the door and watch the inspection. The fire marshal entered the house and stopped in the tiny cluttered kitchen where he saw dry and soiled magazines and newspapers stacked chest high around the stove. Gus told the fire marshal that he leaned over the stacks to cook his meals. In addition, Gus told the fire marshal that because the house no longer had heat, Gus kept a single gas burner lighted all day and night for warmth. When the fire marshal pointed out to Gus that this was a very unsafe situation, Gus barked, “You people are totally paranoid about safety. I’m fine. I’m not worried about a fire because I’m careful. I don’t care what you say. This is not unsafe. There is no way that a fire is going to start here because I’m careful!” The fire marshal listened and then replied, “Gus, we have a word for homes that catch on fire even when the people who live in the home are careful. We call those accidents.”
The rationalizing precontemplator appears to have all the answers. He is not considering change because he believes that he has studied the situation thoroughly and believes that there is no reason to feel concerned because he is not at any risk. The rationalizing precontemplator might tell the clinician that, “It’s not that bad” or that he is safe because he is “careful.” The rationalizing precontemplator may explain that the hoarding situation is due to another factor, such as, “I save because I lived through the Great Depression” or that the situation is the result of another person, “I keep everything because my mother never let me have anything of my own.”
The rationalizing precontemplator is prone to debating, arguing, and presenting a stream of endless counterpoints to every point the clinician makes. Furthermore, the rationalizing precontemplator is happy to discuss the hoarding situation with the clinician but often these discussions only serve to strengthen his side of the argument and frustrate the clinician. Empathy and reflective listening work best with the rationalizing precontemplator. The rationalizing precontemplator may find the harm reduction rationale more palatable, particularly the idea that harm reduction strives to minimize discarding and typically begins with a modified rather than a full cleanout. Clinicians may wish to ask the rationalizing precontemplator first to describe the good things about the hoarding situation and then, after a time, to ask him to describe the “not so good” things about the hoarding situation. Most important, however, I recommend that the clinician avoid arguing with the rationalizing precontemplator. Argumentation pushes the rationalizing precontemplator farther into precontemplation because argumentation begins an intellectual contest at which the rationalizing precontemplator does not wish to lose.
5.3.2.1.4 Resigned Precontemplator
Nicole is 57 years old and lives alone in a suburban track home with her two dogs. Nicole is happy to speak to the clinician and appears desperate for social contact. Empty dog food cans and feces litter the home. The dogs appear to be well nourished and healthy but the clinician cannot say the same for Nicole. She is pale, smells of urine, and appears to be very depressed. She sleeps with her dogs in a three–foot nest she created in one of the small litter–filled bedrooms. When the clinician asks Nicole about the hoarding situation, she shrugs her shoulders and says, and tells the clinician that she has tried to clear and clean her home many times and has always failed. She does not believe that the clinician can help her if she has not been able to do it herself, “It’s nice that you want to help but it’s no use. It’s too late for me. Just go away.”
Unlike the rebellious precontemplator, the resigned precontemplator has surrendered to the hoarding situation. The resigned precontemplator is likely overwhelmed and feels hopeless that she can change or improve the hoarding situation. The resigned precontemplator may have tried to manage the hoarding problem on her own and believes that if she could not help herself then what chance is there that other people can help her. The resigned precontemplator is hopeless that any real and lasting change can occur. It is essential that the clinician instill hope that with the right plan and the right people, she can improve her living situation and manage the hoarding problem. The realistic expectations of harm reduction can help remoralize the resigned precontemplator. Exploring what did and did not work on previous attempts to manage the hoarding problem can also help and set the stage for discussions of the benefits of the HR approach.
By definition, people with severe hoarding are in the precontemplative stage of change. Researchers believe that many people who hoard, even when the hoarding situation is less extreme than in cases of severe hoarding, may reside in the precontemplation stage of change (Frost et al., 2010). Progression from initial precontemplation, where the client is not currently considering change, to contemplation, where the client undertakes a serious evaluation of the reasons for or against change, is the first important step in managing a severe hoarding situation. The goal then is for the clinician to work diligently to move the severe hoarding client from the precontemplation to contemplation stage.
5.3.2.2 Contemplation Stage
In the contemplation stage, the client who hoards is intending to accept help to manage the hoarding problem and this help may include accepting a modified cleanout as part of the HR process. In the contemplation stage of change, the client acknowledges that he has a problem and begins to think seriously about solving it. At the same time, the client may be far from accepting help for the hoarding problem and perhaps even farther away from working to manage the problem. The client with severe hoarding in the contemplation stage struggles to understand the problem, to see its causes, and to think of possible solutions. A client in the contemplation stage may listen to the clinician describe various resources, such as a support group, to help him manage the hoarding problem but the client never enrolls. The client understands the changes necessary to make his living situation safe, but he is not ready to commit to changing them.
In other words, once in the contemplation stage, the client with severe hoarding may be more aware of the pros of accepting help, but the cons of accepting help are about equal to the pros. This is ambivalence. Although the ongoing ambivalence of many people who hoard often frustrates clinicians, ambivalence is an excellent sign. Ambivalence is the clinician’s friend. Ambivalence indicates that the client is more open to help even though he may put off taking action. Therefore, the clinician’s goal when working with a client in the contemplation stage is to tip the balance in favor of change and thereby move him from contemplation to action. Although some clients with severe hoarding who are in the contemplation stage move onto the action stage in a matter of weeks, a client with severe hoarding may spend months or years in contemplation. Unfortunately, in many severe hoarding situations, the client does not have months and certainly not years to make this transition.
Furthermore, clients with severe hoarding may represent a subgroup of contemplators who are in “chronic contemplation” (DiClemente & Prochaska, 1998). These clients think about change, often to the point of rumination, but do not move beyond contemplation. The chronic contemplation may be a feature of the ruminative process associated with depression (Velasquez, Carbonari, & DiClemente, 1999), which commonly co-occurs for those with substance abuse conditions as well as those with hoarding disorder (Frost, Steketee, & Tolin, 2011), underscores the importance of treating those with severe hoarding for concurrent depression in order to move the client along in the change process.
When working with a severe hoarding client who is in the contemplation stage, I recommend the clinician assess how long the client has been considering change and whether he has made past attempts to change. The goal here is to remoralize the client and instill hope that change is possible. The clinician helps the client see that past failures are likely due to insufficient support or an unrealistic plan. This is one of the strengths of the HR approach for severe hoarding. It offers the client a path forward that is realistic and therefore achievable with appropriate support and guidance. In addition, the client with severe hoarding in the contemplation stage benefits from accurate information about what it takes to change behaviors that contribute to the hoarding problem. I recommend the clinician educate the client with severe hoarding about the consequences of hoarding behavior as well as inquiring about the particular consequences (e.g., lost work days, frequency of respiratory infections, illnesses, difficulty maintaining hygiene, amount of money spent replacing something client could not find) he currently experiences due to the hoarding problem and the consequences he has experienced in the past.
As you will learn later in this chapter, when working with the severe hoarding client in the contemplation stage, careful listening, summarizing, feedback, double-sided reflections, affirmations, and increasing self-efficacy are powerful facilitators of change. Ultimately, engaging the client in the HR process involves moving him to the action stage where he is willing to accept help and collaborate with the HR team to manage the hoarding behaviors over time.
5.3.2.3 Preparation Stage
The client with severe hoarding in the preparation stage is ready to start taking action, which means he is open to help with developing a plan that will work for him. In the HR process, this means the client is willing to accept a harm potential assessment and to participate in developing a HR plan. In the preparation stage, the client with severe hoarding is ready for and committed to action. The challenge for the clinician is to develop a change plan that is acceptable, accessible, and effective. The HR approach, as a change plan is often more acceptable to people with a severe hoarding problem because it is realistic and provides the client with some control over the process.
Commitment to change does not mean, however, that change is automatic, or that the change methods will be efficient or work the first time. Furthermore, being prepared for action does not mean that ambivalence is absent. In fact, the decision-making process continues throughout the preparation stage for the client with severe hoarding. The client who is committed to changing hoarding behavior and enters into the HR process may have certain ideas about how the process will proceed. Other clients are ready to move ahead but may not have thought through the HR process at all. For example, a 67-year-old woman with severe hoarding recited all the reasons she was ready to change but had not thought through how she would achieve the goal of decluttering her home and managing her hoarding behavior. In fact, her plan was to set aside three hours each day to work on the problem. This was a plan she had tried many times before and failed. She had not considered the magnitude of the task nor had she thought through where to begin and who might help her. The goal of the clinician in this case is to assist the client to consider the difficulties of the task, the problems she might encounter, and to develop a plan for each of these problems and a way to know when she might need additional help and how to get it. This is the harm reduction process itself. In this case, the clinician assisted the client to think creatively about how to develop the most effective plan and gently suggested strategies that have worked for other people with whom she had assisted in the past. The clinician offered a menu of possible options from which the client could choose (e.g., various people to consider as HR team members, where to start clearing, where to store possessions and how).
Although in the preparation stage, the client is thinking about moving ahead and the clinician is often thrilled to hear this, the preparation stage is fragile and often punctuated by periods during which the client becomes ambivalent once again and moves back into contemplation. However, the clinician who helps the client see that the path out of severe hoarding is through careful preparation and planning, can move the client forward once again and ultimately toward action.
5.3.2.4 Action Stage
The client with severe hoarding in the action stage has started to modify his behavior. He has permitted the clinician to enter his home and has participated in the harm potential assessment. He has worked with the clinician to build the HR team and is actively participating in the HR process, such as working with the clinician to clear HR targets and following through with other requirements of his HR plan, such as meeting with his primary care physician for a medical checkup or for a medication evaluation. The changes the client has made during the action stage are more visible to others than those he made during the other stages and therefore he receives the greatest recognition for the changes he has made. However, although the ball is rolling in the action stage, there is no guarantee that the ball will continue to roll without the diligence of the clinician. The focus of work in the action stage includes strengthening the client’s commitment to change and assisting the client to fight urges to slip back into old help-refusal behaviors.
Clients in the action stage may make a public commitment to change. They may call family members and invite them to join their HR team. They may seek additional support, such as asking for more help or asking for additional HR visits. People in this stage progress by being taught techniques for keeping up their commitments such as substituting acquiring activities with visits with friends or family members, or avoiding people and situations that may tempt them to acquire items.
Action is not equal to change, however, and the clinician and other professionals may overlook or minimize the critical changes the client has made in the prior stages. The successful accomplishment of these initial stages made it possible for the client to take action. Without successfully moving through these earlier stages, the client would not have made the specific behavioral changes necessary to manage the severe hoarding problem. In particular, without moving through these early stages the client would likely not have accepted the help that is necessary to manage a problem as serious and as significant as severe hoarding. With the successful transition through the action stage, the client with severe hoarding enters the final and fifth stage, maintenance, in which the client works to maintain and sustain long-term change (DiClemente & Prochaska, 1998; Prochaska et al., 1992).
5.3.2.5 Maintenance Stage
Few clients with severe hoarding are able to maintain the gains they have made without ongoing monitoring and assistance. The client with severe hoarding in the maintenance stage has been open to assistance and is more aware of the behaviors that contributed to and will contribute again to the hoarding problem if he is not vigilant and open to ongoing assistance. In this final stage, the client works to consolidate the gains attained during the action stage and accepts help to prevent relapse. Without a strong commitment to maintenance, which includes continued openness to help, relapse is inevitable. The primary goal of the maintenance stage is to strengthen and maintain a strong working alliance that keeps the door open and engages and re-engages the client in the HR process.
To summarize, the evaluations of the pros and cons of the problem behaviors associated with severe hoarding are more or less equal in the contemplation phase (Prochaska et al., 1994), whereas there are more cons of change in precontemplation. As the clinician moves the client further along the change process, the client becomes aware and accepts more of the pros of change. Equal pros and cons is the definition of ambivalence and the task of the clinician is to help the client with severe hoarding move from this balanced state to one tipped in favor of change.
5.4 Motivational Interviewing
The stages-of-change model has played a significant role in the development of motivational interviewing (DiClemente, 1999; Miller & Rollnick, 1991; Rollnick, Mason, & Butler, 1999). Motivational interviewing (MI) is a counseling approach that evolved from studies of the treatment of problem drinkers (Miller et al., 1995) and elaborated by Miller and Rollnick (2012) and applied to other problem behaviors. MI is a goal-oriented, client-centered counseling approach that strives to facilitate and engage the intrinsic motivation of an individual through careful exploration of the ambivalence they have about changing (Miller & Rollnick, 2002). In addition, nonclinical professionals from a variety of backgrounds can learn the fundamentals of motivational interviewing (Miller & Rollnick, 1991; Rollnick & Bell, 1991). Although I apply MI to the problem of severe hoarding, I do not expect the clinician who is new to MI to gain competency in this approach through only reading this chapter. I encourage clinicians, therefore, to gain specific training in motivational interviewing and to seek ongoing consultation in order to achieve competency in this evidence-based approach (Miller, Yahne, Moyers, Martinez, & Pirritano, 2004).
Motivational interviewing recognizes and accepts that people who may wish to change their behavior come to the process with different degrees of readiness. For example, some people who hoard have thought about the problem and may have taken steps to change it, such as attending hoarding support groups, hiring professional organizers, or asking friends and family members to help them declutter. Others may have thought about the problem very little, in part, because they do not yet see it as a problem. These people are at quite different stages of change and may benefit from different approaches based on where they are in the change process. Motivational interviewing is nonjudgmental, nonconfrontational, and nonadversarial and strives to increase the person’s awareness of the potential problems, risks, and consequences experienced because of his problem behaviors. MI is directive and departs from traditional Rogerian client-centered therapy (Rogers, 1951) in this way, but is still a client-centered approach whereby the clinician focuses reflective listening on selectively reinforcing certain client statements to examine and resolve ambivalence.
Clinicians sometimes believe that the more serious the situation, as in the case of severe hoarding, and the higher the stakes, the less helpful MI will be in resolving the problem. They believe that in critical situations, which many severe hoarding situations are, they need to do more to achieve change—more confrontation, more persuasion, and more lectures, even though doing more in this way often produces fewer changes for many problems (Heather, Rollnick, & Bell, 1993; Miller, Benefield, & Tonigan, 1993). This has certainly been my experience when working with clients who hoard, particularly those clients in the precontemplation stage where the client with severe hoarding typically resides. The harder I push the harder they push back. Even with a police officer standing at the door and knowing that authorities will remove him from his home and condemn it, I have observed the client with severe hoarding refuse help in spite of the risks he faces.
A large and growing body of empirical research demonstrates the efficacy of MI for a variety of problems ranging from substance use and other high-risk behaviors, to engaging clients in treatment of psychological problems (Lundahl & Burke, 2009). Furthermore, the changes achieved through MI appear durable up to one year and effective in a variety of formats, although it may work best as a precursor to treatment and is at least amenable to a group format (Lundahl & Burke, 2009). MI appears to work with clients regardless of their age, gender, and severity of the problem and professionals with different orientations and training can learn to use the approach effectively (Lundahl & Burke, 2009). At this time, however, there are no studies of the efficacy of MI applied to the problem of severe hoarding or hoarding disorder.
At the same time, MI appears to be well suited to people with severe hoarding. Clinicians have used MI successfully with clients who are angry (National Institute on Alcohol Abuse, 1995) and many clients with severe hoarding are angry and resentful. The client with severe hoarding may be angry because the court or because a professional has told him that he must work on the hoarding problem. The client with severe hoarding may be angry because the clinician has instructed him to attend a support group or to begin treatment. The client with severe hoarding may be angry because he is frightened and reluctant to relinquish control in a judgmental environment. In addition, because MI is a respectful, humanistic approach, it is useful for people who are victims of stigmatization or public condemnation. People with severe hoarding have heard others call them lazy and filthy. Neighbors have ridiculed them or refused to speak to them. It is perhaps not surprising that people who hoard push back against this stigmatization through denial, rationalization, and minimization of the problem. Last, many people with severe hoarding are overwhelmed by the situation. They do not believe anyone can help them and they have surrendered to the hoarding problem. Because MI strives to enhance the self-efficacy of the client with severe hoarding and views the client as an active and important member of the HR team, people with severe hoarding learn that with help, they can manage the hoarding problem over time.
5.4.1 Assumptions and Conditions Necessary for Change
MI rests on several assumptions. First, change is elicited rather than imposed on the client. For example, the clinician can elicit change talk by asking the client questions, such as “How might you like things to be different?” or “How does hoarding interfere with things that you would like to do?” Change may occur quickly or may take considerable time, and the pace of change will vary from client to client. Second, change occurs through a partnership between the clinician and the client, or between the client and the broader HR team. Change does not come through the clinician making decisions for the client nor taking responsibility for the change process. Rather, the clinician and client work side by side to understand the roadblocks to change and to devise a plan to move through these roadblocks. Third, the interpersonal interaction between clinician and client influences the readiness of the client to change. The client with severe hoarding has likely suffered many hurts at the hands of well-meaning family members and professionals. A trusting relationship may take longer to develop but it is essential to the change process. Fourth, the role of the clinician is to assist the client to express his ambivalence and then to explore both sides of this essential feature of the change process. By definition, the client with severe hoarding is ambivalent about accepting help for the problem. The client believes that he can solve the severe hoarding problem without assistance and may commit to clearing an area of his home. However, his motivation soon flags as he becomes overwhelmed by the magnitude of the task or by the many decisions that he must make to clear even a small area of his home. Last, persuasion is counterproductive, and direct, authoritative styles simply push the client further into ambivalence. Instead, a thoughtful and curious clinician is more likely to elicit the ambivalence that is the target of MI strategies than the direct and less curious clinician, even when both clinicians wish to help.
To summarize, the assumptions that underpin MI involve collaboration not confrontation, evocation not education, autonomy rather than authority, and exploration instead of explanation. Effective processes for positive change focus on goals that are small, important to the client, specific, realistic, and oriented to the present and/or to the future (DiClemente & Velasquez, 2002).
Certain conditions are necessary for behavior change and MI strives to create these conditions through four fundamental principles (Miller & Rollnick, 2002):
Express empathy. The clinician strives to convey respect, understanding, and genuine warmth. The clinician understands that ambivalence about change is a normal feature of the change process. The clinician invites the client to collaborate through reflective listening
Develop discrepancy. Motivation to change arises when the client becomes aware that the severe hoarding problem is incongruent with his personal goals and values. The client who finds great joy and meaning in being a mother and grandmother may become aware over time that she cannot honor this value if the hoarding environment prevents her children and grandchildren from visiting her. Clinicians strive to heighten awareness of this discrepancy through a careful, supportive, and nonthreatening examination of the pros and cons of change that encourages the client to take responsibility for his situation.
Roll with resistance. Instead of arguing with the client with severe hoarding or confronting his opposition to help, the clinician views resistance as the client’s desire to cope with the hoarding situation and the manner with which he copes reflects his personal beliefs and interpersonal history. Resistance, then, signals the clinician to respond differently. Resistance invites the clinician to offer new perspectives for the client to consider. Resistance alerts the clinician that the client wishes more control over the process and wishes greater voice in identifying solutions to the hoarding problem.
Support self–efficacy. Once the clinician assists the client to recognize that he has a severe hoarding problem, the clinician then works to help the client believe that he can do something to manage it. The strength of that belief is confidence and the clinician can enhance and assess the client’s increasing confidence that he can manage the severe hoarding problem over time. Harm reduction, particularly with its focus on realistic goals and practical solutions, can do much to enhance the self-efficacy of the client with severe hoarding.
5.4.2 Strategies to Enhance Motivation
Although clients with severe hoarding come to the attention of clinicians and other professionals when they are in any one of the stages of change, most severe hoarding clients appear to be in the precontemplative stage (Frost et al., 2010). This is particularly true when the legal system has “mandated” the client to accept help for the severe hoarding problem or when concerned family members, or in some cases, employers pressure the client to accept help. However, internal motivation not external pressure provides the impetus for the focus, effort, and energy required to move through the entire process of change (DiClemente, 1999; Rollnick et al., 1999; Simpson & Joe, 1993) and is essential to the long-term management of a severe hoarding problem.
Motivational interviewing is not necessarily a lengthy process. Sometimes a few carefully timed, incisive questions and some reflective listening is enough to create some motivation to change. Other times, motivational interviewing takes longer to create some motivation. However, in many cases of severe hoarding, time is short. At these times, the clinician thinks, “I don’t have time for this! If we don’t get moving, this lady will lose her house.” Sometimes, clinicians think that listening is something you do when you have lots of time; when time is short, they think that confrontation and persuasion is the key to change. The problem, however, is that people tend to react to confrontation and persuasion in the same way, whether time is short or not. They push back and resist. Perhaps the single most important point to remember at such moments is a central principle of harm reduction—first, do no harm. If time is of the essence, as many severe hoarding situations are, strive at least to protect the relationship with the person who hoards. Do not entrench resistance and discourage change by pushing too hard, or by pushing at all.
Motivational interviewing includes a variety of strategies (Miller & Rollnick, 2012) to assist the client to make statements that reflect readiness and later willingness to change. In the case of severe hoarding and harm reduction, these statements reflect that the client: recognizes that she has a hoarding problem; that she is concerned about her living situation and her safety; that she intends to accept help for the severe hoarding problem; and, that she believes that with help she can learn to manage the problem. In this section, I briefly describe several MI strategies focused on eliciting these statements and include transcripts to illustrate the strategies and approach. I open each transcript with typical statements from clients with severe hoarding, such as “It’s not that bad,” or “I can do it myself,” so that the clinician can see how MI might work with a severe hoarding client. Again, I encourage clinicians to gain specific training in motivational interviewing and to seek ongoing consultation in order to achieve competency in this evidence-based approach (Miller et al., 2004).
Motivational interviewing rests on a set of fundamental counseling skills that most clinicians already understand and use with clients (OARS): open-ended questions, affirmations, reflective listening, and summaries. The clinician uses these fundamental skills strategically and purposefully to explore some topics (e.g., change talk) and not other topics (e.g., no change or sustain talk). Of these skills, reflective listening is the primary skill that directs MI and for that reason, I devote more time to describing that skill. At the same time, open-ended questions, affirmations, and summaries are essential skills too because they encourage and continue the conversation. In a sense, the clinician is like a soccer player. He uses open-ended questions, affirmations, and summaries to get the ball rolling and reflective questions to direct the ball down the field.
5.4.2.1 Open-Ended Questions
The clinician gathers information in two ways when working with a client with severe hoarding: Closed questions and Open-ended questions. Closed questions prompt short replies from the client. The clinician uses closed questions to gather simple facts, “How long have you lived here? When did the collecting start?” Open-ended questions, on the other hand, prompt the client to give more than “yes” or “no” answers, and to offer more than simple statements to questions, such as, “I get things from the dumpster,” when the clinician asks the client from where he collects things. Open-ended questions focus on what, why, and how and are the backbone of the MI information gathering process. Open-ended questions invite the client to offer information that she feels is important to her and set a tone that is curious and nonjudgmental. Open-ended questions alert the client that the clinician is there to listen rather than to persuade. Instead of asking the client, “How often have you fallen in your home?” the clinician might ask instead, “What areas in your home do you think are unsafe?” At times, the client will find these questions too vague and will ask for clarification, and the clinician might respond, “What kind of concerns do you have living here alone?” A question such as this creates momentum, which the clinician then directs using reflective listening (see later in this section).
Open-ended questions are not the same as small talk. In fact, the clinician who uses small talk to put the severe hoarding client at ease may find that the client wishes only to engage in chitchat and therefore becomes a barrier to momentum. Furthermore, small talk can interfere with what makes the client feel truly comfortable—the experience that the clinician understands her situation and does not judge her for it. Many times, the clinician will use open-ended statements that are not exactly an open-ended question, but act as though they are. Open-ended statements are a hybrid of a question and a reflection. For that reason, open-ended statements encourage the client to respond with more information and are particularly useful in building initial rapport. Here are a several examples of client statements that the clinician follows with an open-ended statement to move the conversation forward:
Client: “Why are you here?”
Clinician: “So, you’re wondering why I am here since you did not call me and you don’t see a good reason for me to be here. I’d like to come back to that in a bit, but first I’d like to find out a little more about you. Tell me a little bit about who you are and what your life is like.”
Client: “So, you think I want your help.”
Clinician: “So, you’re thinking I’m here to help you with your house but you don’t see the point. It’s understandable you would think that and I want to come back to that in a bit, but first I’d like you to tell me what the last few years have been like for you.”
Questions, rather than statements, communicate to the client that the clinician is willing to listen rather than to persuade or lecture. Questions encourage the client to respond and engage in the conversation whereas statements often demand the client to prepare a retort. Effective questions create momentum and ineffective questions take the change process off course (see Fig. 5.1).
Fig. 5.1
Features of effective motivational interviewing questions
The key question is a special type of question the clinician uses during motivational interviewing with the severe hoarding client. It is helpful to think of MI in two phases (Miller & Rollnick, 2002). In the first phase, the clinician builds motivation to change. In the second phase, the clinician focuses on developing, implementing, and maintaining a plan for change. The key question focuses on the transition between these two phases. That is, as MI shifts from building motivation to asking for commitment to change, resistance lessens and the client is talking in favor of change even though ambivalence remains. At this critical juncture, the client may begin to talk in favor of change. The key question typically begins with a summary and then focuses on the theme, “What is the next step?” For example, the client with severe hoarding may share with the clinician that a modified cleanout sounds better than a full cleanout. The clinician may respond, “So, it sounds like you have decided that a modified cleanout works better for you. What do you think you will do now?” Similarly, the clinician can ask, “So, how will you proceed now that you’ve decided that a modified cleanout works better for you?” or “Now What do you think you could do today to move that decision a head?” that you’ve decided that a modified cleanout sounds better than a full cleanout.
5.4.2.2 Affirmations
For years, family members, friends, and professionals have tried to help the client with severe hoarding by pointing out her deficiencies and failings. As a result of these conversations, the client she has backed away from the belief that things can be different or that she can be different. She has given up and therefore given in to the hoarding problem. Affirmations serve to empower and enhance a “can do” attitude regarding change.
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