As in the case of the in-home harm potential assessment (Chap. 6: Assessing Harm Potential), it is essential that clinicians and other team members prepare for every in-home visit before entering the residence (see Fig. 9.1). During the initial risk and harm potential assessments, it is likely that the clinician or another professional has established that the residence is safe to enter and identified the particular precautions necessary to protect visiting HR team members.

Prior to entering the residence, the clinician may wish to bring disposable gloves to wear under heavy gloves, respirators or masks, goggles or wrap around glasses of some kind. Of course, if an environment posed imminent health or safety risks, the client likely received a modified cleanout, and the residence now meets a minimum standard of safety for the client. However, often following cleanouts, life-threatening particulates and foul odors may circulate in the air. Furthermore, a cleanout may have exposed rotted floors, rusty nails, and a myriad of dangers once covered by items. Proceed with caution and do not hesitate to leave the residence if you discover an unsafe situation. Often, clinicians are concerned that they may offend the client when the clinician dons gloves, glasses, and a respirator while the client walks around the home unprotected. Typically, I offer the client the same protection I wear, although most decline the offer. A client has never asked me to leave because I chose to protect myself in this way although many seemed surprised that I would chose to do this. I believe that a clinician who is prudent and careful in this way sends a clear message to the client that the environment is not safe:

I hope you will excuse me for wearing gloves, goggles, and a respirator today. I have extra goggles, glasses, and masks in my car if you would like to wear them too. I know that this gear makes it more difficult for us to chat but my body doesn’t have the tolerance to the air and other things in your living environment that you may have so I want to protect myself. I’m here to help you but I can’t help you if I become ill or hurt myself in your home. I am sorry but I hope you understand.

In addition to safety, clinicians and other team members may wish to consider their comfort too. Because of the nature of severe hoarding, the environment is quite inhospitable. It may be cold or hot. The air may be stuffy and foul. The clinician may not find a comfortable and clean place to sit. I recommend the clinician bring supplies to make the in-home visit more comfortable. Bring a coat or sweater to wear if the weather is cold. Bring a lightweight and compact stool for sitting. Although the clinician is likely to spend most of her time standing and walking through the residence, it helps to have a place to sit and chat with the client, especially at the end of the visit. Team members may wish to bring along cleaning or sanitizing wipes and gels to use after exiting the home and eye drops or an eyewash kit, nose drops (to wash odors from the sinuses), Vick’s Vapor Rub™ (to dab under the nose to neutralize foul odors), and allergy pills. Bring several bottles of water, and pens or pencils and a clipboard to in-home visits. Do not ask the client for a pen or pencil, or anything else, because a simple request can become a 30-min search and an effective avoidance strategy.

Prior to in-home visits, the HR team may wish to rent a dumpster, particularly early in the HR process when the team is likely to remove large amounts of paper or material from the home. The team may wish to purchase cleaning supplies, buckets, and sponges. I recommend the team purchase colored masking or glow tape to mark environmental targets. Last, team members benefit from supplies to document the in-home visit and record progress on the HR targets and general adherence with the HR plan. The team may wish to purchase three-ring binders for team members and organize the binder into sections: Harm Reduction Agreements (for current and past revisions of the HR agreement), In-Home Monitoring Visits (for past In-Home Monitoring Visit Forms and blank forms), and Communication (for additional notes to other team members about the client, the in-home visit, or any matter relative to the client and his HR plan).

Prior to entering the residence, I recommend that the clinician take a view minutes to review the In-Home Visit Monitoring Form from the previous in-home visit. I will describe this form and its use in detail later in the chapter. This form is a snapshot of the previous in-home visit and of the progress, in particular, toward managing the HR targets. I recommend the team member note the HR targets that were cleared and progress on any new HR targets that the team member identified during the previous in-home visit. In particular, I recommend the team member review the comments in the Process Notes and Comments section of the form for information regarding the manner with which the client interacted with the team member during the previous visit and how the team member managed any bumps or disagreements. Pay particular attention to current difficulties or stressors the client may be experiencing and what, if anything, the team member did to help. Last, I recommend the clinician transfer the HR targets to a blank In-Home Visit Monitoring Form. The targets are marked T on the form. The clinician will use this new form to document the current in-home monitoring visit.

The philosophy of HR is that any positive change aimed at reducing risk counts. Perhaps the single most important ingredient in positive change is the willingness of the client to work with the team to clear and re-clear environmental HR targets. Nothing erodes motivation faster than focusing on areas that the client failed to clear or to keep clear (and there is always more cluttered than clear space) rather than praising what he has cleared. Although it is important that team member and client discuss the environmental HR targets that he failed to clear, it is essential to praise the client for any success and regardless of the magnitude of the success. Praise reinforces the gradual shaping of behavior in the right direction, as most clients will succeed partially between in-home visits but not completely.

I recommend that clinicians take some time to instruct other team members in the benefits of praise and the most effective ways to praise clients. First, effective praise does not give with one hand and take away with the other. In other words, effective praise is not qualified praise. At times, a team member may qualify the praise inadvertently with criticism. For example, “I’m so glad you cleared this area as we agreed you would. Why can’t you do that more often?” Similarly, “I see you managed to finally clear this area, like we agreed.” Second, effective praise targets a specific behavior rather than global efforts. If the goal of praise is to increase the frequency of a behavior, it is essential that the client explicitly know what she did that resulted in the praise in order to receive praise again. For example, “I like how you kept the newspapers off the stairs this week” identifies the particular behavior that the clinician desires and therefore praises. “You’re doing a great job” is global and may not provide the client with enough information to repeat the behavior in the future. Last, effective praise focuses on approximations to the desired behavior. For that reason, I recommend team members praise the client’s efforts to clear an area during the clearing process rather than waiting for the client to complete the task before praising her. Small and frequent praise helps to maintain motivation in the desired direction. For example, a team member might say, “It’s great that you’re willing to move these boxes out of the way of the sliding door so that you have another exit. This is a great start to clearing an entire pathway between your bed and the sliding door. Thank you.” Similarly, a client may benefit from hearing, “It may not look like much to you, but I can see that you’ve removed half a box of items from this area.”

As the HR process proceeds, the client may be more open and capable of working on HR targets independently between in-home visits. These targets may be environmental targets, acquisition targets, or capacity targets. Regardless of the nature of the target, however, I recommend the clinician carefully consider how she sets goals for independent work. First, I recommend the clinician set goals for independent work that are SMART goals (see Chap. 8: Creating a Harm Reduction Plan). In particular, it is essential that the clinician assist the client to set a goal that is not only specific, but is attainable too. What the client can attain with assistance is likely a bit more or perhaps a great deal more than what he can accomplish without it. Even highly motivated clients who hoard cannot work more than 30 min clearing environmental HR targets, at least at first. For this reason, clinicians may wish to schedule much shorter times to work on environmental HR targets and to increase the length of time as the client (and clinician) gains confidence that he can work effectively between in-home visits on his own. The clinician may wish to break down other tasks into steps, such as calling to schedule a medical appointment or to find out when and where a support group meets. The clinician might schedule a time for the client to call to make an appointment during an in-home visit and to meet with the physician at that scheduled time prior to the next visit. Furthermore, the client might benefit from very brief telephone calls to check progress between in-home visits, “How about if I call you next week to check whether you called to make the appointment and, if you haven’t, I’ll make it for you? How does that sound?”

Second, many clients with severe hoarding suffer with depression, anxiety disorders, and attention-deficit hyperactivity disorder (ADHD), which can contribute to the difficulty they have staying on task when working independently. The clinician may wish to discuss with the client the best time of day for independent work. Some clients have more energy in the morning and are better able to focus on difficult or tedious tasks when they are fresh. Other clients may work best during the afternoon or in the evenings when they feel less depressed. In addition, some clients with severe hoarding may forget to begin clearing a target, even when they are motivated to do it. These clients may benefit from a quick call from a team member at the agreed upon start time to prompt the client to begin the task. Alternatively, the clinician can work with the client to create prompts within his environment that alert him to begin the tasks he agreed to work. Alarm clocks, or a large sign on the wall on which the clinician writes the day and time the client is to start the work along with a brief description of the work the client agreed to do during that period can help initiate the easily distracted client. The clinician can encourage the client to cross off a task once he completes it to create a sense of accomplishment and mastery. At times, clients may procrastinate starting a task because they are anxious about doing it wrong or because they predict that they will feel too anxious once they begin. They may even procrastinate because they cannot decide the “best” time to begin a task and ruminate about this rather than getting down to work. Setting clear and realistic goals, as well as scheduling short periods to work at specific and optimal times of day, can help a client start and complete independent work.

Last, I recommend the clinician discuss with the client features of the environment itself that can increase the likelihood that he will complete independent work. Some clients stay on task better while they watch a favorite movie or television program while others are distracted by these activities. Other clients might prefer silence whereas others prefer music playing in the background. Furthermore, watching a movie is far more pleasurable than clearing a space on a table and it is not surprising that a client quickly veers off task once the movie begins. I recommend the clinician clarify with the client what helps him stay on track and encourage the client to implement these strategies when he works independently. Later in this chapter, I offer other strategies to help clients effectively manage time and make decisions.

The HR approach is a dynamic process. Team members come and go. Harm potential and therefore HR plans change. Appropriate documentation is essential to manage a dynamic process. I recommend each team member purchase a three-ring binder to organize and store important documents. Organize the binder into sections: Agreements (for current and past revisions of the HR agreement), In-Home Visits (for past In-Home Visit Monitoring Forms), and Communication (for notes to other team members beyond what is noted in the Process Notes and Comments section of the In-Home Visit Monitoring Forms, or for communications from representatives of the legal system or others who may not be team members but are stakeholders in the HR process).

I recommend that team members use the last 10 min or so to chat with the client on any topic other than the clutter. Use the time to catch up on family news or find out what the client has been up to since the last in-home visit. Do not forget to praise the client for his openness to help and his willingness to work with you during the visit. Even a 10-min conversation about anything but the severe hoarding problem can mean a great deal to someone who has lived years in social isolation. Furthermore, this social isolation contributes to a worsening of hoarding behavior over time as people detach more and more from people and attach more and more to their possesions.

The socialization time at the end of each in-home visit may be a powerful motivator for some clients. A team member might remind the client, “We have an hour for this home visit and there is much to do. Let’s spend 25 min clearing the targets so that I have 10 min at the end to chat with you. Would that be okay?” These ten minutes are a powerful reward for clients and I encourage team members to use them effectively, “We’re slowing down. If we don’t work a little faster, we may not have as much time to chat today as we did last visit.” In addition, at the end of in-home visits, I recommend team members mention that the more work the client does keeping environmental targets clear between in-home visits, the more time the team member and client will have to relax, to have a cup of tea, and to chat. This may motivate the client to work effectively on his own between in-home visits.

First, I recommend the clinician walk through the home and quickly check the status of each of the environmental HR targets noted on the In-Home Visit Monitoring Form (see Appendices 1, 2, 3, and 4) from the previous visit. Try to examine the HR targets in an organized way. Perhaps start with rooms to your left and check all rooms in a counter-clockwise direction or examine rooms from the front of the house to the back of the house. Make certain to examine all the high priority targets. As the clinician walks through the house, I recommend that she take photographs of the current HR targets and to document progress using the Clutter Image Rating Scale (Frost, Steketee, Tolin, & Renaud, 2008) described earlier (see Chap. 6: Assessing Harm Potential).

As the clinician walks through the residence, I recommend she review the specific environmental HR targets marked (T) on the In-Home Visit Monitoring Form. Are the targets recluttered? If recluttered, note the types of items in the target to generate ideas for new harm reduction strategies. For example, if the client has recluttered the environmental target with plastic bottles, the clinician may wish to set aside a box or a bag for this purpose. In addition, look for potential new environmental targets to include in the harm reduction plan. Rate each environmental target according to risk on a 1–10 scale (where 10 is “extreme risk” and “highest priority”). Record this value in the Risk and Priority column of the In-Home Visit Monitoring Form. Always begin with the highest priority target. Estimate the time to declutter the target (in minutes) and record this estimate in the Estimated Time to Clear column of this form. In the Actual Time to Clear column of this form, enter the actual time (in minutes) required to clear the target. On the (P) line of In-Home Visit Monitoring Form, describe the progress the client made clearing the environmental target or managing the acquisition and capacity targets. Describe any problems the client encountered here too. On the (W) line of the In-Home Visit Monitoring Form, the team mumber describes the work that team member and client completed on the target and note information that may help a team member during the next in-home monitoring visit. Use the Notes and Comments section at the end of this form to describe additional problems or issues encountered and worked through during the visit.

Clinicians can expect poor adherence to the HR plan, particularly early in the HR process when the client and team are not yet comfortable with each other and the process. The goal of the HR process is then to identify and to work through poor adherence. Remember. It is more important that the client remains willing to work with the team and participate in the HR process than it is that he adheres fully to the HR agreement itself. Therefore, the manner with which the clinician and other team members monitor adherence to the HR plan is essential to the effectiveness of the ongoing management of a severe hoarding problem.

During in-home visits, team members may notice that the client is having great difficulty keeping a particular environmental HR target clear. In these situations, I encourage team members to be flexible and to modify an existing environmental HR target to increase the likelihood that the client will be able to keep the target clear, when that makes sense. For example, if a client continues to struggle with keeping the entire staircase clear, the team member could modify the target so that the new SMART goal is to keep half of the staircase clear, the half of the staircase closest to the banister. Flexibility and a willingness to collaborate with the client are hallmarks of an effective HR process. Just as no two people with a severe hoarding problem are the same, no two HR plans are the same. The monitoring process benefits from team members who have open minds, can think quickly on their feet, and are ready to brainstorm and consider any strategy that will assist the client to meet his HR goals.

It is important that the clinician or other team member not overlook the nonenvironmental targets, such as the acquisition and functional capacity targets. Because harm potential is an interaction between environmental risk and functional capacity, the progress the client makes in following through with these targets is as important as keeping the environmental targets clear and, for some clients, even more important. Check with the client regarding his progress on the functional capacity targets. Did he call to set up an appointment with his physician? If not, the clinician can ask the client for permission to make the call for him, as part of the in-home monitoring visit. Did he take the bottles to the recycle center as he agreed to do? If not, the clinician can ask the client for permission to drop the recycle materials at the center for him or to call one of the client’s friends to help him with that. Make tasks the client did not complete a priority and reserve time in the in-home monitoring visit to help the client do them.

I recommend that clinician spend a few minutes working with the client to identify new HR targets that pose high risk. At times, the client creates new potential HR targets as she relocates possessions to declutter one of the designated HR targets. For example, a client may move boxes away from a heater but then place the boxes in front of the back door, thus blocking an exit. During the in-home visit, identify those areas of the home that pose new risks and note these on the blank In-Home Visit Monitoring Worksheet. Remember to record new nonenvironmental HR targets as well, such as a change in the physical capacity of the client. For example, the harm potential of a client increased quickly when he fell outside his home and required for a period of time a walker for support and stability. Although the walker was helpful outside his residence it added to his risk when he used it in his highly cluttered living environment.

Because motivation to accept help is influenced by the interpersonal context, the clinician will wish to pay close attention to the interactions between client and team member during the in-home visit. On what topics did the client become upset? Was the client anxious or angry and why? Did the client order the team member to leave or did he refuse to answer the door? Most important, how did the team member work through these problems with the client? Keep in mind that the HR process depends on collaborative helping. That is, the willingness of the client to accept help from team members to manage the severe hoarding problem over time. The clinician may wish to think through what improve the interpersonal process between she and the client if the clinician were visiting again. This will likely help the next team member who visits too. Record this information in the Process Notes and Comments section of the In-Home Visit Monitoring Form.

The most important goal of every in-home visit is to work well with the client so that he is open to meeting again. For this reason, it is more important that the clinician enhance the working relationship with the client than it is to clear all the HR targets. The clinician can always schedule another in-home visit to do a bit more work, if necessary. If the home visit ends on a bad note, however, the team member may not get back into the home again, or at least not without first repairing the working relationship. To that end, I recommend team members check in with the client about the visit itself, “How do you feel about our work together today? Was there anything I did or said that upset you that you would like to discuss before I leave?” Once the clinician is assured that the working relationship is in good shape, she schedules the next in-home visit. Scheduling the next in-home visit might be more complicated than expected but problem solve and negotiate with the client to find a day and time that works. Do not assume that the client is not doing anything with his time. Many people who hoard still work and have active social lives. Many others try to spend as much time out of the home as possible, just to get a break from the clutter. Furthermore, clients who hoard may wish to delay in-home visits for a variety of reasons and it is essential that the clinician get a visit on the calendar before she leaves. If the clinician is having trouble pinning down a day and time for the next in-home visit, assume that the client is ambivalent and move into motivational interviewing (see Chap. 5: Engaging the Client who Hoards in the Harm Reduction Approach). If multiple team members are taking turns with in-home visits, the team can set up a rotating schedule during one of the HR team meetings. At the end of the In-Home Visit Monitoring Form, enter the date and time of the next in-home visit and the name of the team member who will visit, if known.

Harm reduction is not treatment per se. The goals of HR primarily focus on managing hoarding behavior in the service of managing the risks of the behavior so long as the person continues to hoard. Treatment, on the other hand, focuses on treating the underlying psychological factors that maintain hoarding behavior in the service of minimizing distress and improving day-to-day functioning. If the clinician is focused on treating the hoarding problem, she might point to a possession and ask, “Why do you have this?” This then leads to an exploration of the client’s beliefs and assumptions about possessions that contribute to her hoarding behavior. If the client has sought help for her hoarding problem, this question can move the clinician and client to a variety of conversations focused on helping the client quickly and effectively make decisions about keeping or discarding, and then on to conversations about sorting, categorizing, and then on to other strategies the client will use to declutter and manage her hoarding problem. However, if the clinician asks that same question of someone who has not sought help because she doesn’t see that she has a significant hoarding problem, the conversation can quickly dissolve into debating the merits of keeping the item or not. Soon, the person becomes guarded and defensive, and the process of clearing the area stalls.

Although discarding items is certainly a goal of HR, it is not the primary goal. Instead, HR strives for managing possessions to minimize harm. When someone asks a client who hoards, “Why do you have this here?” he invites her to discuss the merits of keeping the possession in that location, rather than in some other place that might present less risk to her. In so doing, the clinician sets the stage for a different kind of conversation during the in-home visit, one focused on safety and comfort rather than on changing the psychological factors that maintain the hoarding behavior. Furthermore, the question, “Why do you have this here?” orients the client to solve the problem of high risk. Problem solving, negotiating, and empathic listening are the foundation of collaborative helping.

For example, Joy is a bright and curious woman who collects and saves information. She saves magazines, newspapers, and fliers she picks up in cafes or from public kiosks and bulletin boards. She records and saves information from her favorite radio and television shows too. At a recent in-home visit, the clinician decided to work with Joy to clear the small counter to the right of the stovetop, which was one of her environmental HR targets. Thirty or 40 cassette tapes rested on the counter and littered the floor around the stove. Several cassette tapes lay on the stovetop itself and one of the audiotapes was blistered and blackened.

Although the clinician will use motivational interviewing throughout the HR process, and in particular during in-home visits, other HR team members may not have received training in motivational interviewing or in fundamental counseling skills. I present a five-step model (L.E.A.R.N.) that nonclinicians can use to work collaboratively with clients who hoard. The simple model captures the essence of motivational interviewing—empathic listening—while at the same time focusing on the need to negotiate and problem solve to clear environmental HR targets.

The five steps of L.E.A.R.N. do not necessarily proceed in a strict order. It may help to think of these five steps as rungs on a ladder that the team member and the client move up and down, depending on whether the client becomes more or less ambivalent when working to clear an environmental target. With practice, team members will learn to move deftly and seamlessly among these five steps, working to keep the clearing process moving forward.