Hoarding: Psychiatric Disorder or Normal Aging?

Astonishment!  That was the predominant sensation I walked away with after the recent Round Table Discussion.  The fact that someone could display such extremes, – hoarding, food, paper, animals, whatever — is to me astonishing.  Not to mention that some of the consequences, including bed bugs and scabies, is so disturbing as well as a public and individual health risk.  My admiration to those who continue to work with extreme hoarders.

Hoarding appears to be an intractable situation calling for behavioral specialists who can devote time to establishing trusting relationships, provide frequent and on-going support and constant reinforcing of behavior change.  But still, they say, although small changes may occur, the behaviors continue to repeat.

As mentioned in the Koenig, et al journal article, interdisciplinary teams working arduously sometimes resort to bargaining or coercive strategies and threaten clients with ultimatums such as evictions, mandatory clean-outs or attendance at a hoarders support group.   Should these clients be considered involuntary?  They haven’t asked for help when someone comes knocking at their door.  Coercion, manipulation, and arm-twisting is an uncomfortable and problematic role for the social work profession whose mandate is to respect choice and autonomy.  We have learned to accept the involuntary status for those with late-stage dementia or someone who is at risk of harming oneself or others, but just keeping stuff in your house?  Is an involuntary status for a hoarder justified?

Someone in the group wisely asked, “What is the best solution?” And for those teams working in the public sector, quickly came the response that systemically there is a lack of money and a lack of support.  Assessments are often inadequate, suggesting “lazy” behavior or labeling the home as simply “cluttered.”  A DSM hoarding disorder diagnosis would be more accurate and might authorize more hours of home care services.   Private pay families and geriatric care managers face a different set of challenges and client resistance.  Ultimately, however, the older adult’s hoarding behavior must be managed with a trusting relationship that seeks to understand the underlying emotional relationship that the adult has to each of the long-held items.

While some hoarding behaviors may be attributed to past trauma or intrinsic psychiatric disorders, another type of hoarding – call it overwhelming cluttering— is more about the developmental changes that come along with normal aging.  This is nicely discussed in the Eckfield and Wallhagen article.  Slowing down, not having the stamina to see a project through, making multiple changes in residences and changes in mobility restrict an older adult from regular cleaning and tidying.   Financial insecurity is another important consideration that impacts an older adult’s ability to keep house.  For the generation that lived through the Depression era of the 1930s, it just seems to make common sense, and soothes any anxiety about potential loss, that one should save any scrap of food or blankets for the eventuality that an item may one day not be attainable.

In either instance, developmental or disorder, some cleanup is always required.  Koenig, et al speak about work with involuntary clients as a political process “resting on the use of the professional’s power due to the assumption that the nonvoluntary client and professional have conflicting interests…The professionals’ roles as enforcer, negotiator, mediator, advocate and coach are most appropriate in this conflict approach.”  Is a therapeutic role mutually exclusive from these political roles?  I don’t think so if the work is done honestly and able to work diligently over a long stretch of time establishing and maintaining the trusting relationship that is at the heart of a good therapeutic connection.

The Round Table Discussion Group meets monthly for an interdisciplinary conversation with experienced professionals in the field of aging.  Each conversation uses one or two journal articles as reference points.  The articles read for this discussion were:

• Multidisciplinary Teams’ Practice Strategies with Older Adult Clients Who Hoard, Koenig et al, Social Work in Mental Health, 12:1, 81-97, 2014.

• The Synergistic Effect of Growing Older with Hoarding Behaviors, Monika B. Eckfield and Margaret Wallhagen, Clinical Nursing Research 22(4) 457-491.