The primary objective of the initial phase of the HR process is straightforward—to assess whether the client can continue to live in his home without intervention and, if not, to decide on the degree and the timeline for that intervention. At times, the risk is high and imminent, such as when a police officer discovers on a wellness check a frail and ill older adult who lives alone in a dilapidated home without heat or running water. In this case, the clinician and other professionals may decide to remove the vulnerable adult from the home until they can make the home safe and sanitary. At other times, the risk may be high but not imminent. Different harm potentials benefit from different degrees of intervention and the goal of the initial phase is to assess the risk and develop an appropriate plan to handle it.

However, whether the risk is low or high and imminent, setting the stage for the HR process itself is the second objective of this initial phase as the clinician utilizes the initial phase to prepare the client for the ongoing phase. I have observed that the manner with which the clinician handles the initial phase of the HR process sets the tone for all that follows. For that reason, I recommend the clinician begin to discuss the HR approach with the client at the first meeting. Introducing HR early can improve the willingness of the client to participate in managing a cleanout, if it is necessary, rather than steadfastly refusing an intervention that is likely inevitable. In addition, a client who is open to HR may more willingly participate in other features of the approach, such as selecting and working with a HR team. In Chap. 5 (Engaging the Client Who Hoards in the HR Approach), I describe this process in detail. In a sense, the HR approach is an engagement strategy and, as such, the goal is to engage the client in an approach that yields a plan to help him now and in the future.

The third objective of the initial phase is to begin to develop the HR team. At times, the clinician may take the lead from the start and build the HR team. Typically, this is when a severe hoarding problem is still a private situation and unknown to authorities, such as code enforcement officers or environmental health workers. For a severe hoarding problem that is already a public situation, other professionals may invite the clinician to join a team that has already formed to assist the client. Clearly, the manner with which the clinician handles these two situations is quite different. In the first situation, the clinician will likely take the lead and build a HR team from scratch. In this case, the clinician has more influence over who may participate on the team and over the HR process itself. In the second situation, the clinician will likely strive to join the team effectively and define her role on the team and within the HR process. In a situation such as this, other professionals are eager to hear from the clinician on how best to manage the HR process given a client’s unique psychological strengths and weaknesses. In Chap. 7 (Building and Facilitating a HR Team), I describe in detail the process of building the HR team.

The final objective of the initial phase of the HR process is to decide on the level of cleanout required—if a cleanout is required—to achieve minimum standards of safety and comfort for the client and then to develop a plan to carry it out. At times, the hoarding situation is so severe and the client faces such extreme risk, the only effective course is to provide a full cleanout where the residence is cleared, cleaned, and—when possible—the client returned to the residence. Full cleanouts are extremely difficult for a client and, at times, a life-altering event for clients who are frail older adults. I favor modified cleanouts, if possible, but only as feature of an overarching HR approach. I describe the rationale of these two types of cleanouts later in this chapter as well as guidelines for carrying out each in the service of a HR process and plan.

As mentioned earlier, viewing the HR process in terms of initial and ongoing phases assists in setting clear and realistic legal benchmarks as well. Legal benchmarks for the initial phase might include: (1) a list of materials authorities are to remove from the home immediately (flammable materials, garbage, or animal waste), (2) specific areas to clear for safety (entryways, fire escapes, or stairwells), and (3) specific tasks to ensure the health of the client (sanitize counters and sinks, replace refrigerator, or repair toilet). In addition, the court will likely provide a timeline to complete these tasks and decide whether the client can continue to live in his home while the process proceeds (Volunteer Lawyers Project, 2008).

The goal of the ongoing phase of the HR process is to implement and manage a HR plan. A HR plan includes a number of components and I describe those in detail later in the book. However, the primary objectives of the ongoing phase are to assess risk or harm potential and identify HR goals or targets, to achieve and maintain a critical HR team mass, and to keep the door open for ongoing monitoring of the client’s harm potential and adherence with the HR plan.

The first objective of the ongoing phase of the HR process is to assess risk or harm potential. Both the initial and ongoing phases include a risk assessment. However, the assessment of risk in the ongoing phase continues so long as the HR process is in play. This means that the clinician assesses the client’s harm potential as part of the ongoing monitoring of the severe hoarding situation. The harm potential may go up and down over the course of months and years for a variety of reasons, and the HR plan will reflect these changes. For example, the harm potential may increase as the health of the client declines or after her spouse dies. The harm potential may decrease as the client becomes more open to the HR process itself and as her living conditions improve. Therefore, the ongoing phase is quite dynamic, shifting and changing as the functional capacity of the client improves or declines relative to the environment in which she lives. Identifying HR targets and goals is part of the ongoing risk assessment and I say more about this later in this chapter.

A second objective of the ongoing phase of the HR process is to achieve and maintain a critical mass of HR team members. In Chap. 7 (Building and Facilitating a HR Team), I describe in detail the process of developing a HR team and managing the HR team during the vicissitudes of the HR process. An effective HR team is essential to the success of an HR process and the clinician, among all the professionals at the table, likely has the best skills to manage the team process in the service of protecting the wellbeing of her client.

Access is critical to the effectiveness of the HR process and much of the focus of this phase—and the work of the clinician—is to keep the door open so that HR team members can assess and manage risk over time. People with severe hoarding, by definition, lack motivation to follow through on their own and it is necessary that HR team members monitor the client’s adherence with the HR plan and assist her to comply with it. Perhaps the most important function of the court during the ongoing phase is to order the client to keep the door open to the clinician and other professionals so that they can monitor his risk so long as he is at risk. In addition, the court is wise to order the minimum frequency of these monitoring visits, who may visit and for what purposes, under what circumstances the frequency of monitoring visits might increase or decrease, and, whether the visits are to be announced or unannounced. This last point—whether to order announced versus unannounced visits—is interesting. It is unlikely that a client with severe hoarding can do much to improve the safety of his home when given 2–3 h or even 2–3 days of notice prior to a monitoring visit. More likely, the clinician will arrive at the home of her client only to discover that he is not there. The absence of the client may suggest more ambivalence about the HR process or, as is often the case; the client is away because he avoids spending time in his dilapidated and uncomfortable home. I recommend, when possible, that the court specifically order the client to meet with the clinician in the home rather than to order the client to accept visits to the home. In this way, the court orders face-to-face meetings with the clinician or other HR team members not just access to the home itself. Additional legal benchmarks include meeting minimal health and safety standards for specific HR targets and a timeline for achieving these minimal standards initially.

Betty’s adult children called for a consultation after years of worrying about their mother. At the meeting were Jason, who lived in the same city as his mother, Jessica, who lived in Southern California, and, Donna, Betty’s oldest daughter, who lived on the East Coast. They told the clinician that their 62-year-old mother had always collected things, mostly newspaper clippings, magazines, and cookbooks. However, their mother had managed the problem until her husband (their father) had died and Donna and Jessica had moved out of town. Then the hoarding behavior spiraled out of control. Now, Betty totters from room to room on an uneven mass of damp and rotting newspapers and paper bags, and she cannot use her kitchen because she has covered the stove with newspapers and magazines. She eats all her meals out and brings leftovers home in plastic and Styrofoam containers that sit atop piles of newspaper. The home smells of rotting food and flies swarm around the mass of trash and debris that litter the floors. Although they had pleaded with their mother for years to accept help for the hoarding problem, Betty adamantly refused to meet with anyone.

Doreen is an adult protective service (APS) worker and a member of the Hoarding Task Force in her community. A week ago, a police officer contacted APS to report that he had discovered Bertie, a frail 78-year-old man, in a severely hoarded apartment. Doreen visited Bertie and found that he was living without a functioning toilet or shower and had not bathed in 6 months. Bertie suffers from Type I diabetes and has trouble walking because of neuropathy in his feet. Bertie has very poor vision but cannot afford to replace eyeglasses he lost in his apartment over a year ago. Bertie has never married and has always lived a solitary life. He does not have friends or even acquaintances. Doreen presented Bertie’s case to the Hoarding Task Force and reported that Bertie’s harm potential was very high, she recommended that the team devise an appropriate plan to ensure Bertie’s safety and welfare.

A severe hoarding situation comes to the attention of clinicians in a number of ways. However, as the two vignettes above illustrate, the clinician encounters a severe hoarding problem that is either a private or a public situation. Private severe hoarding situations are secrets. That is, authorities and other professionals are unaware of the hoarding problem. Sometimes family members are the only people aware that a loved one has a severe hoarding problem. Public severe hoarding situations are no longer secrets. Because clients with a severe hoarding seldom seek treatment, other professionals, such as professional organizers, visiting nurses, adult or child protective service workers, fire or police officers, code enforcement, animal control officers, or property managers often respond first to the problem and thereby bring the problem to public attention. In other words, the authorities are aware of the hoarding situation and may have initiated a response to the problem.

In a private situation, the clinician discovers a severe hoarding situation in a number of ways. First, in the course of her work with a client, she may discover a severe hoarding situation. This is not surprising, really, because so many other mental health conditions or disorders co-occur with hoarding. It is very likely a clinician treating clients with typical mental health problems—depression, anxiety, or inattention—may have a client or two who engages in some hoarding behavior. This is particularly true for clinicians who treat older adults where a hoarding situation, if present, has likely reached a severe and dangerous level. Many times, a hoarding situation remains private because clinicians who are treating a client do not know about the hoarding behavior, either because the clinician did not ask about it or because the client who hoards did not bring it up. However, even when the clinician discovers the problem and raises the topic of accepting treatment or help, she risks that her client will bolt from therapy or adamantly refuse to discuss the issue.

Second, the clinician may discover a private hoarding situation when collaborating with other professionals involved in the care of her client. During a collateral contact with another clinician, such as a psychiatrist or physician, she may learn that her client has a severe hoarding problem. The daughter of a client may call the psychotherapist treating her mother to tell him that in addition to her mother’s bipolar disorder, she has a severe hoarding problem. A professional organizer might call the clinician to report that her client is a little more than “disorganized” and alert her that the client is in peril.

Finally, clinicians enter a private severe hoarding situation when an adult child calls the clinician seeking a consultation for his mother or father with a severe hoarding problem. In this case, family members are shocked, embarrassed, and terrified for the parent and look to the clinician for help. Most times, they hope the clinician will help them find a way to encourage the family member to seek treatment or help. Other times, family members hope the clinician will help them decide whether it is time to contact the authorities, such as APS, to alert them that their loved one is in peril because of the severe hoarding situation.

A private hoarding situation is perhaps more complicated than a public situation for the clinician. For example, the clinician consulting with a family member regarding a family member who hoards may determine it is necessary to make an APS report to protect the client from imminent harm. Many well-meaning family members sought help from a clinician only to learn that a hoarding situation that was private has now become public. The family members then watch an already fragile relationship with the loved one quickly deteriorate while they scramble to sort out what will happen to her if authorities evict or relocate her. Later in this chapter, I describe the circumstances and guidelines to file a mandated report of a hoarding situation.

In a public situation, other professionals or authorities invite the clinician to participate in a HR process that may be underway or soon initiated. The role the clinician plays in public hoarding situations depends on the manner with which the community typically responds to the problem. For example, some communities have created a Hoarding Task Force or some other standing multidisciplinary team that responds to severe hoarding situations (see the section on Hoarding Task Forces later in this chapter). Typically, clinicians are included in these multidisciplinary teams and play an important and integral role in managing public hoarding situations. Alternatively, authorities—code enforcement officers, visiting nurses, or environmental health workers—contact the clinician to alert her to a severe hoarding situation. Typically, the clinician works for a community agency or department, such as APS. The clinician then evaluates the client and makes recommendations to the authorities regarding a thoughtful response to the hoarding situation. A final public scenario involves an invitation from a municipal authority to evaluate a client after the authorities have failed to achieve compliance with a plan to manage a hoarding problem. For example, a code enforcement officer contacts a clinician after several months of working with the client who has failed to comply with an order to correct health and safety code violations.

Perhaps the single most important component in the HR process is engaging the client and other potential HR team members in the approach itself. There are two reasons I believe it important to introduce HR to the client as soon as possible. First, I have observed that many times a client with a severe hoarding problem is a bit more open to an approach that de-emphasizes discarding and focuses on managing the problem so that he can remain in his home. In addition, although the idea of a team approach to the hoarding problem initially unsettles many people who hoard, many others are relieved that they no longer must try to manage the problem on their own. Furthermore, if a cleanout is necessary, the HR approach can lessen a client’s panic and resistance to the inevitable when he understands that the cleanout is part of a broader plan to help him stay in his home safely and more comfortably.

Second, a client with a severe hoarding problem is, by definition, not open to treatment. It is likely family members or friends who know about the hoarding problem have urged her to seek treatment or accept their help but she repeatedly declines. They may have even threatened to tell authorities about the hoarding problem if she did not accept some form of help. A therapist treating a client or a professional organizer working with a client with a severe hoarding problem may have repeatedly urged him to seek treatment too or if the hoarding problem is public, the court may have ordered him to accept treatment as a condition of living in his home. In other words, the client with a severe hoarding problem may have heard for many years from those beating the drum of treatment. Although some clients with a hoarding problem, who appear to have low insight, may accept treatment later, many others do not. Although I know of no research to guide clinicians in identifying early who and who is not a good candidate for treatment, I recommend clinicians consider every person who hoards to be a candidate for treatment until they tell the clinician otherwise, particularly if others have not informed the client of this option in the past. However, with a client who continues to balk at the mention of treatment, particularly if that client faces considerable harm potential, I recommend that clinicians set aside discussions of treatment in favor of HR. Too many times, I have observed the clinician lose the client to the HR approach because the clinician pressed the client to accept treatment too long and too hard. Furthermore, I do not recommend the clinician insist on treatment as a condition for harm reduction. Once the client has accepted the HR process, the clinician may find him more open to treatment later. In Chap. 5, I describe in detail strategies to engage the client who hoards in the HR process.

Of equal importance to the HR process is engaging other team members in the HR approach. Do not assume, however, that all team members are open to HR process. A property manager may not be interested in the HR process because he wants to remove the resident immediately to escape the constant complaints of other tenants. Family members may wish to deal with the hoarding problem quickly and move their mother to a supported-living environment, even if she can live independently, so that they worry less. Municipalities may balk at HR because they view the process as a more costly and time intensive approach than a full cleanout when this is not necessarily the case. Other professionals, such as code enforcement officers or environmental health workers may resist HR because they have their own way of working with people who hoard and wish to continue to operate the way they have. I do not necessarily view these as “wrong” reasons to exclude HR from the list of possible solutions to a severe hoarding problem. I only mention this to help clinicians understand that other people, not just the client, may resist the HR approach. In Chap. 7 (Building and Facilitating a Harm Reduction Team), I describe in detail how to work with potential HR team members who are ambivalent about the HR process.

The goal of the initial harm assessment in the HR process is twofold. First, the clinician assesses the level of risk a particular client faces living in a particular environment. More simply, the clinician determines whether the risk is so high that the client cannot stay another moment in his home. If the risk is imminent, then the clinician must develop a plan to remove the client from his home and relocate him to a safe living situation. Second, the clinician determines whether a cleanout is necessary. In most cases, a cleanout is necessary and the decision then is to determine whether a modified or full cleanout is required.

It is unlikely that an initial assessment is sufficient to develop a HR plan and, furthermore, I encourage clinicians to separate the process of an initial assessment from the process of assessing harm potential. I view these assessments as distinct processes with different goals and intentions. As mentioned, the goal of the initial risk assessment is to determine whether the risk is imminent or not and whether a cleanout, of some sort, is necessary or not. The goal of a harm potential assessment is broader and focuses on identifying harm reduction targets and monitoring those targets to manage the severe hoarding problem over time. Separating these assessments—initial versus ongoing—helps the clinician stay tightly focused on the goal of the particular assessment in order to efficiently complete what she must complete.

Separating these assessments can help the client as well. Clients with a severe hoarding problem may not have had anyone in their homes for years. They are understandably anxious and likely angry too that a stranger is in the home to assess the situation. In my experience, the clinician can achieve the goal of the initial assessment quickly, certainly more quickly than a comprehensive harm potential assessment and then leave; or, complete the initial assessment and remain and devote more time to building rapport with the client and to explaining the HR process. Either way, a tightly focused initial assessment means that the clinician spends less time in the home of the client, which the client will appreciate. Furthermore, limiting the amount of time required from the client will help him stay focused on the task and better tolerate a process he likely experiences as overwhelming and powerless to stop. In addition, the client may feel quite anxious about the HR process itself and have many questions about the process. Focusing on the goals of the initial assessment permits the clinician to answer questions relevant to the initial assessment and to defer other questions about the harm potential assessment to later in the process. Furthermore, separating the phases of the HR process and differentiating the initial risk assessment from the more comprehensive harm potential assessment slows the process a bit for the client and reassures him that the clinician has a plan and will proceed with that plan in a careful and methodical manner.

When conducting the initial risk assessment, I recommend the clinician explain to the client the rational for the initial assessment and the role of this assessment in the overall HR process. I suggest the clinician describe the situation and the goal of the initial assessment in concrete terms and in nonblaming language, “Ms. Williams, as you know, the health department has asked me to evaluate your living situation to see if you are safe and comfortable here. I know you have not asked for this and I am certain you are uncomfortable with my visit. I will try to do this as quickly as possible. At the end of the assessment I will tell you what I have observed and what the next steps in the process are for you. Would you like to accompany me as I walk through your home or would you prefer to wait here for me to complete the assessment?”

The client is likely to be angry and hostile during your visit, particularly if the court has ordered him to permit you into his home. Try not to defend yourself or to defend the court or agency that has instructed you to complete the assessment. Simply and politely state what you must do and why and that you will try to complete the initial assessment as quickly as possible with as little disruption for the client as possible. I strongly recommend the clinician look for any opportunity to explain the HR process and the role of the initial assessment in the overall plan, “Ms. Williams, this assessment is the first step in a harm reduction process that we hope will enable you to continue to live in your home. The harm reduction process focuses on helping you live safely and comfortably in your home. Safety is our primary goal. How successful we are with this approach depends a great deal on you and your willingness to work with us with that goal in mind. Do you have any questions?” In Chap. 6 (Assessing Harm Potential), I describe in detail guidelines for conducting the in-home harm potential assessment. Much of what I describe there also is useful to clinicians during the initial risk assessment.

I recommend the clinician strive to include the client in the process as much as possible, or at least to encourage the client to be in the home during the initial assessment. The initial risk assessment is the first step in the HR process and the manner with which the clinician conducts the assessment can do much to build trust and rapport with the client at a time when trust and rapport may be in short supply. In addition, having the client present during the assessment lessens the likelihood that the client may claim that the clinician stole or discarded possessions or is in some way responsible for the chaos and disrepair of the home. If the client is unwilling or unable to attend the initial assessment, I recommend the client ask a representative to attend the initial assessment, unless the court has ordered the client to be present for the assessment.

Cleanouts are interventions in which the community or municipality mandates that the individual who hoards remove the bulk of his possessions from the home to improve hygiene and safety. Cleanouts typically involve authorities removing the individual from his home, then clearing the residence of possessions, perhaps cleaning it, and then inviting the individual to return if the residence is safe and livable. At times, family members will conduct and pay for a cleanout to forestall eviction of their loved one or condemnation of the home in which she lives. Whether municipalities or families pay for cleanouts, they are expensive operations. A single cleanout intervention can cost the town or county tens of thousands of dollars in labor and special equipment or cleaning services. Typically, a cleanout is the last intervention in a series of failed interventions by officials and family members. Unfortunately, cleanout interventions appear to do little to change hoarding behavior and that is seldom the goal. The goal of cleanout interventions is to return the residence to a condition where it once again meets the minimum criteria set forth in the health and safety codes of the community.

Cleanouts can be full or modified. I favor modified cleanouts, when possible, and as part of a comprehensive HR plan to manage the hoarding problem over time. Modified cleanouts can be less traumatic for the client, particularly when he understands that authorities will stop the cleanout when the home meets minimal safety standards. In my experience, clients are more open to a modified cleanout and are more willing to participate in a process that includes this option rather than a full cleanout. Modified implies that at the end of the cleanout, the client will have some possessions, and likely many possessions. A full cleanout, on the other hand, implies that the client may lose everything. Furthermore, a modified cleanout can serve as a bargaining chip. Typically, I explain to the client that a modified cleanout is part of the HR process. If he does not accept a modified cleanout, the only option for him is a full cleanout. In accepting a modified cleanout, he accepts the harm reduction process. In other words, a modified cleanout sets the stage for harm reduction and reassures the client that the clinician honors the agreement to discard no more than is necessary to maintain his safety in the home. It is essential that the client understand that the HR process is not limited to a cleanout intervention but that a cleanout is the beginning of a process that will continue for as long as the client is at risk in his living environment.