Hoarding & Squalor

Hoarding & Squalor expert David O’Leary chats with Cassie Gillespie & Pete Cudney from CWTP about hoarding disorder and engagement & assessment strategies.


Cassie Gillespie (00:04):
Welcome to the field, a podcast of targeted trainings for child welfare professionals. Over the next few episodes, my colleagues and I will be interviewing various local experts about topics that are pertinent to child welfare workers in Vermont. I’m Cassie Gillespie and I’m Pete Cudney and today we’ll be talking with David O’Leary. Dave, do you want to introduce yourself and let folks know where you’re coming from and what your area of expertise is?

Dave O’Leary (00:28):
Absolutely. Thanks for having me. My name is David O’Leary and I’m a rostered psychotherapist in private practice in Shelburne, Vermont. I currently see a wide variety of patients issues, uh, including everything from anxiety and depression to mood disorders. And I also work with couples. I’m their relationships and families and my area of specialty is hoarding disorder and squalor like conditions.

Cassie Gillespie (00:56):
Thanks. We’re so excited to have you here today. So we wanted to ask you a couple of questions about hoarding and squalor, in particular hoarding and squalor as they pertain to child welfare because that is the folks who are listening to our podcast. So to start off, would you mind giving us just the brief overview on the difference between hoarding and squalor?

Dave O’Leary (01:17):
Absolutely. Hoarding disorder is a condition in which a person has difficulty discarding possessions regardless of what their actual value is. Squalor is a state of being that occurs when people do not clean up after themselves, do not take care of their own bodies or the environment that they live in and then find themselves living amidst, um, filth, uh, through, uh, neglect essentially. And how do you respond to those? Do you, do you treat them the same? Do you treat those situations differently? There’s read it very differently and a lot of it has to do with the acuity of the situation at hand. A lot of times what squalor because of the degradating, um, factors involved, it means that you can have, uh, issues like animal feces or even up to human waste that might be involved. That means that you’re probably going to have to lead with more proactive, practical, uh, methods such as getting a team and to do a very deep clean to mitigate the serious health and safety concerns that are there. The same may not be said necessarily have hoarding disorder where it may be a relatively clean environment, but it is cluttered. Something like that will take a longer approach and is going to involve more of a therapeutic approach initially with practical help likely later on in the process.

Cassie Gillespie (02:39):
So I know in your role now you’re working predominantly in private practice, but would you tell us a little bit about how you came to have this area of expertise and focus and what some of your work has been with people experiencing hoarding and squalor?

Dave O’Leary (02:52):
Absolutely. My, my academic interests are in, psychology and I have a master’s in clinical psychology from St. Michael’s college in Colchester, Vermont. I also got into the world of housing advocacy back in the day when I left undergraduate and I began to work with Women Helping Battered Women now known as Steps to End Domestic Violence. So I found myself in the, in that perfect spot between housing advocacy and, the actual counseling profession where I was trying to help people through that very difficult process of leaving after an abusive relationship and trying to get housing stabilized. After a few years doing that, I wanted to delve a little bit deeper into both housing and psychology. And when the opportunity presented itself with an opening of a housing retention specialists concentrating and hoarding disorder at Burlington Housing Authority in 2015, I jumped at the chance to get involved in that because it was a perfect combination of both of my interests.

Pete Cudney (03:55):
Dave in child welfare, often family service workers are facing pretty strict timelines. I think you, you know, this, you, you interface with them from time to time. And my understanding of hoarding, especially hoarding disorder, is that quick interventions aren’t always the most effective or beneficial. If you’re thinking from the perspective of a child welfare worker and they need to have some kind of resolution as quickly as possible, um, what, what advice would you be giving them in terms of how they’re engaging with clients? What’s the fastest they can expect without some kind of rebound? Yeah. Could you speak to that all?

Dave O’Leary (04:37):
Well, there are some statistical analysis that has been done. It says that 26 clinical sessions is about pretty much the, the average amount of sessions that you would have with somebody with hoarding disorder where they would display changing behaviors that are likely to have a lasting effect throughout their lifetime. And that’s really only the tip of the iceberg because by the time you’ve completed a 26 sessions, you may have a structure, a structured environment for the person to be able to work in. But that doesn’t necessarily mean that you’re going to be clipping along as a very fast pace at that point. The reality is that, um, with a specific type of motivational interviewing, cognitive behavioral techniques, a lot of understanding and patience and, uh, some something of a mandate that homework is done outside of sessions. Um, you’re really just setting the foundation for what likely will be something of a struggle that the person will have throughout their life. But by changing some of these behaviors and learning new patterns of behavior and developing new skills for sorting techniques and making decisions over time, the speed can increase.

Pete Cudney (05:49):
So if there are more imminent safety concerns and then there’s also hoarding, is it, is it, am I understanding it correctly that there may be quicker interventions to resolve the safety issues, but then the underlying pattern of hoarding is going to be months, if not years to address.

Dave O’Leary (06:10):
I think that’s a fair assessment and I think that my advice to anyone who’s in that process who is unsure of how to proceed and what would be the best thing that they could do for a family would be to get as much information initially as possible. And that might mean getting an inspection report from a code enforcement official, a fire Marshall, which is maybe seen as intrusive into the person’s life. But what it does do is it gives quantifiable measurements of exactly what the issues are so that the DCF worker and the clients can have a good conversation that’s based around the quantifiable measures rather than qualifying measures that might be seen as more judgemental or might be too nebulous, in the sense that they’re not very direction focused.

Cassie Gillespie (07:01):
I think what I’m hearing you say is that it’s really important to be as specific, as objective as possible. I think there are some tools out there. Are there any recommendations you have for family service workers about what they could be using when these cases come up?

Dave O’Leary (07:15):
Absolutely. And the good news is that unlike other tools for a psychological assessment of some kind, these are all free. They’re available on the internet and they are applicable for clinicians in the field. So therapists, social workers, or home visitors or anybody who might be working with somebody who has a hoarding disorder. The first one that I would point to, which is easily searched through Google and is also now an app that you can get on most smartphones, is the Clutter Image Rating index, which is a series of pictures between one and nine that depict, various rooms at varying degrees of clutter. And those of us in the fields who work with hoarding disorder will often use this as a frontline strategy to be able to do two things. The first thing that it does is it allows for uniform language when describing the situation that you’re trying to tackle as you speak with your peers that manages to keep it away from qualifying terms such as there’s too much stuff, there’s too much clutter, there’s too much here that can be quite confusing for everybody. And one person’s clutter is another person’s neat house.

Cassie Gillespie (08:23):

Dave O’Leary (08:24):
So that’s the first thing that it does. The second thing that it is beneficial for is trying to get a gauge on where your client’s interpretation and their current understanding of their clutter is. So for example, and anyone who’s listening to this might be taking out their phones right now and downloading the app. If you say that, Oh, I think that my house is, is a three or four out of nine in terms of clutter. And then you have a team who was working in there and they can all see that it’s seven or eight, well then you know, you have a cognitive dissonance going on of some kinds. There may be an executive functioning issue. So these kinds of information that you can glean from using this very simple free tool you can learn quite a bit in the evaluation process.

Dave O’Leary (09:07):
The second tool that I would encourage people to use is the Homes Assessment. Again, a simple Google search, H O M E S assessment. There’s a PDF form that will pop up. When you enter that into Google, it’s a two page sheet. And it has, a list of precinct issues that might be a play for somebody with hoarding disorder and but also so that would be some things like psychological readiness or, or is the person, uh, you know, actively keeping them their own bodies clean. But also it can measure the amount of rooms and it, and it can go some way towards documenting your intentions for helping. And it’s something of a roadmap that allows you to at the very least see what the situation is in the home, the person’s level of readiness and awareness of the situation.

Dave O’Leary (09:58):
And then in turn, as you work with community members, you can give that piece of paper so that everyone is quite literally on the same page because confusion, confusion amongst workers in hoarding scenarios is very common. And it can be often something that leads to a lot of trouble down the road. But these tools help to mitigate that.

Pete Cudney (10:19):
That’s great. So you’re describing these tools, if I’m hearing you right, that they help to create more objective language, they may be open dialogue between you and a client. They help to assess severity and the client’s perspective. And so I’m guessing these are all parts of a larger, larger kind of approach that you have or methodology. Yeah. Would you talk a little bit about how you approach these cases?

Dave O’Leary (10:43):
Ideally, first of all, you’re going to have a team structure of some kind and the team, um, I think can, has to be carefully considered. Whoever is the lead case manager or whoever is the person doing the greatest amount of organization really has to think about who is involved in a hoarding scenario. For example, if you have a family member who wants to help out, that’s a consideration. On the one hand there’s help that’s available and ready. There’s a familiarity with the, with the clients which may be helpful trying to get more work done, but if the relationship is actually strained or if there is a history of not working well together. Well, having that family member involved, maybe the worst thing you could do in that situation. Having in home health workers, VNA workers. If there’s any housekeepers that have that would be willing to come in and help out, um, inspectors for if it’s a section 8 environment. The section eight staff themselves, who them, who would be the ones perhaps, keeping track of how compliant the person is with section eight rules.

Dave O’Leary (11:49):
Fire marshals, code enforcement officials, the social workers who work at doctor’s offices. All of these people can be considered a part of the team. But I wouldn’t recommend that people are very careful in how they choose those people, especially if if you get the sense that one of those people or more maybe has some preconceived notions about hoarding, maybe coming in with something of a judgmental attitude or is not willing to give the process the time that it deserves.

Cassie Gillespie (12:18):
What happens when you do rush the process?

Dave O’Leary (12:20):
Rushing the process for people who are trying to help and intervene can be a very frustrating and ultimately results in the person not getting help for the person who has the hoarding disorder or is living in squalor. It can be downright traumatic in certain cases, especially if it’s rushed in such a way that they, they end up losing control of the situation and of the process and often the delivery to leads to something of a reaction formation in which if the person feels, especially that the things have been taken away from them, there may be a further efforts to gain some of that stuff back to fill whatever void that and sense of betrayal that they will have felt in that situation subsequently. It means that other efforts to intervene may be jeopardized as a result of the trauma associated with the first attempt to help. And that’s something that I’ve come across in more than one occasion is a fearfulness of what happened the first time happening again and all of my words and assurances that it wouldn’t happen. Don’t necessarily cut it. Hmm.

Pete Cudney (13:29):
So, so you’re moving more slowly when you have the time to do that. And I imagine, that each case may be slightly unique based on who the person is. Is there a process of trying to assess what for this individual, what’s underlying the, the patterns of hoarding or squalor? And if so, are there common underlying drivers?

Dave O’Leary (13:56):
I think there are common underlying drivers such as social anxiety disorder, generalized anxiety disorder, certain mood disorders. Certainly people who’ve experienced trauma can manifest in very different ways. But I think that, there’s no central underlying factor, for anybody. I think that where clinicians such as myself have an advantage is that we have the ability to be able to do certain assessments and, and to be able to ascertain what some of the underlying mental health, um, issues might be. Not everybody who’s involved in a hoarding case, who’s taking the lead on it wouldn’t necessarily have that capacity or training to be able to do it. An example would be a case manager for um, an agency such as age well who may have tons of experience in the field, but when it comes to the assessment process, it might be difficult to do that. Um, again, we come back to the team factor. If there is a way in which they can connect the person to a therapist or they can connect to a psychologist who might be willing to do some, some work on trying to find out what the underlying issues are. Well then you have more information at the end of that. Hopefully that can lead you to a specific type of intervention. And I’ll give you an example of this. If I find out that somebody is actively undergoing psychosis or is prone to psychosis. Then I have another person who, um, has a history of trauma, and has a very sentimental attachment to the same items. I’m going to go about that in two very different ways. The fact that one person is going to be questioning their very reality. I’m hesitant at that moment to even try an intervention until that’s been addressed. However, the person who is firmly entrenched in reality but nevertheless has a traumatic response, that’s someone that I’m, going to be able to do work with more readily in that moment as long as they’re ready to commit to the process. But knowing the underlying issue is a very important thing.

Cassie Gillespie (16:07):
So for our listeners who are predominantly workers in the field, and will not have the clinical background or even the time, you know, to do that type of assessment and yet they’ve been out in the field and they’ve recognized that someone has a hoarding issue or squalor issue, what do you recommend in terms of who should they contact? Who can they reach out to to build that team?

Dave O’Leary (16:29):
I would say that for people who fall under the, very low income category of and who are also potentially, housing insecure. Especially if there were in the section eight program public housing system, I would say that the housing retention team at Burlington Housing Authority, is a good place to start going on their website. I also think that, you know, I’m always available to take a call. I frequently take several calls a week and have for the last four years from all over new England at this point, from people who have these issues. And sometimes it’s a family member who’s calling. Sometimes it’s a social services worker or DCF worker who’s looking for advice. Sometimes it’s the person themselves. And, I’d like to tell you that there’s a team of, uh, clinicians out there in our community who is just trained and ready to go in this, that’s not reality.

Dave O’Leary (17:25):
Um, I, I’ve not been able to find dedicated clinicians. There are a few people out there who, uh, who have done this. I’m a little hesitant to say who they are because they don’t openly advertise necessarily that they’re, that they’re doing this and I don’t want to overburden them with anything. But we do need more services in our state in general, and certainly in Chittenden County. But I think that BHAs housing retention team, myself and, I think that’s it right now that I can really think of. But we have, we have a pretty large problem but we don’t have the amount of personnel required to meet the need.

Pete Cudney (18:06):
And is that the same as the hoarding task force? Is, is that the same group and the name has changed or?

Dave O’Leary (18:11):
I’m glad you brought that up. I forgot my own task force, but, it’s been a long, it’s been a long day so far. The hoarding task force in Chittenden County is the largest of its kind. It’s been around for more than a decade at this point. And there, there is a somewhat limited ability for us as a team, which is made up of various members of our community representatives from agencies. Both of you have attended in the past. Yes. And we are able to do some limited case work. We’re able to do some coordination of services simply because we have so many representatives of agencies at the table that if nothing else, we can often get people hooked up with a service that they might not have had in the past, which is very good in trying to do the case management. However, for an individual through the task force, it’s, it’s quite difficult to do that. Um, often we look for a central key figure in that person’s life already and try to make that person comfortable with taking on something of the role of coordinating the efforts so to speak.

Dave O’Leary (19:15):
That person doesn’t have to have all of the expertise in the world, but with some guidance from myself or you know, just a step in the right direction. Um, you can, you can do some good with people if they’re willing to receive the help.

Pete Cudney (19:28):
And how would people get in touch with hoarding task force, say on line or?

Dave O’Leary (19:34):
We have a Facebook page, Chittenden County hoarding task force. You can drop a message, you can call me directly at my office. Um, and, um, my website is O’Leary therapy.net. So you can catch me on there and, and, uh, you can always reach out. I’ll always take a phone call. I have a big passion for this and you know, I know that there are upwards of 35,000 people and the state of Vermont who need the help. So if there’s anyone out there who is willing to help a person out as best they can, I’m happy to give that person my time and hopefully a little bit of advice about how to do that.

Cassie Gillespie (20:12):
And I think I know the answer to this, but I just want to check in because we have 12 districts statewide and only one of them is Chittenden County. So for those folks in those other districts and other counties who don’t have local task force or local clinicians that they’re aware of, can they reach out to you just to touch base, pick your brain and see if you know of any local folks?

Dave O’Leary (20:32):
Absolutely. I’m always happy to take a call. I obviously I can’t do full case reviews over the phone. I can do some very basic… I’ll, I’ll gather some basic information and essentially what I’m looking for is certain patterns of that a person might be looking, I’m running into that at least gives me something concrete to latch onto that I can say, okay, well I can at least tell you that here’s the things that won’t work in this scenario based on what you’ve told me. The other thing, um, that I will always advocate for is anyone who finds themselves in this scenario working with somebody who has hoarding disorder. So for example, if a DCF worker really doesn’t know how to fix this problem, they, you know, want to keep the family together at all possible, but they understand that there’s very real concerns here that could jeopardize that.

Dave O’Leary (21:24):
What I would say is go go to the drawing board, find out who the natural supports are, find out what’s potentially missing for supports in there. And if there is a single person in this entire thing, and that could be an intensive family based services worker, somebody who is going to have more hands on time with the family, anyone who is in a position to be in the home, more than likely that is the person who is best poised to be of service and of help. And I would say that there’s four or five different things that it, that person in that position can do that’s going to give them a headstart on helping on that. And I can, I can list those if you’d like. Okay. So the first thing I would say is do as much learning as you can about hoarding disorder.

Dave O’Leary (22:15):
And there’s a few things I would say to stay away from. Don’t watch TV shows about us. Typically it’s, they’re, they’re not terribly helpful. There are some really good books out there that give concise information and how to help. I would say that the Buried in Treasures workshop is vital reading for anybody doing in homework who comes across hoarding disorder. It’s a relatively short read and I would say that it’s a very good resource. That’s the first thing is try to get some information about us. It’s going to be a little less overwhelming when you find out some of the basic precepts around it. The second thing is to concentrate on the person as much as possible. When you first show up for a meeting, make eye contact with them and don’t let your eyes deviate left and right to the things that are in there.

Dave O’Leary (23:01):
You’ll get to see them eventually, and they will be appreciated that you will make it seem as if you’re there for the person and not just because of the stuff. Try to quantify as much as possible. Instead of saying things like, well, there’s no, there’s not enough space between the door and the window. It’s quite a nebulous common for somebody who struggled with hoarding disorder their entire life. Say that court code enforcement dictates that we have 36 inches of egress that are required. You put a measuring tape on that every single time it’s going to be the same. There’s a uniform at each of the measurement. Qualifying statements often come with baggage are, can be perceived to come with baggage. But not only that, if there’s a high degree of resistance that the person is, then they’re going to be more likely to fight you on qualifying statements when, especially when you use words such as too much, what is too much?

Dave O’Leary (23:53):
How do you measure that? Stick with the measurements.

Cassie Gillespie (23:56):
Can you give us an example of what a qualifying statement that someone might make with the best of intents that you’re suggesting we should stay away from?

Dave O’Leary (24:03):
Yeah. The qualifying statements can be quite innocuous and seemingly not that big of a deal, but saying something along the lines of, well, you got too much stuff here. That’s a big one for starters. First of all, they kind of know that they do anyway. It’s kind of a duh kind of moment. But it is also open for debate and the more debating that you’re doing around the premise of, of why you’re there, the less quality work that you’re doing to address the situation. Comments such as certainly I’m trying to give comparisons to your life or people that, you know, saying something like, well, in my house that’s something that is another statement that totally turns the person off.

Dave O’Leary (24:48):
They say, we’re not talking about your house. We were not talking about your values. We’re not talking about how you live your life. We’re talking about how I live my life. So things like that, which people will sometimes say wouldn’t be helpful. The fourth thing I would say is that once you start to get the trust of somebody and you’re looking for then the direction to help them, try to divide rooms into zones rather than saying, okay, today we’re going to tackle the living room. That can be a good gargantuan task in some people’s minds. The idea of tackling the entire room instead draw an invisible line down the room and then the other side of the room. So you create these four sections and I would say a maximum of four zones per room and say, well, today we’re going to tackle zone one.

Dave O’Leary (25:35):
Don’t finish zone one until you’re finished on one. Move on to zone to celebrate the victories that you have in zone one. Zone one is a constant reminder of what can be done, what’s possible, and move from zone to zone. The fifth and final thing that I would say is that when you finally come up with a methodology that works for the person, and that may be a keep box, a throw away box, a donate box, that could be through lots and lots of homework,… that’s expected. Or it could be no homework at all where the person only works diligently when another person is there. Um, whatever methods that works for the person, encourage them to master that method and repeat, master, repeat, master, repeat. Bouncing around in different strategies is often confusing for people. It’s the practice that ultimately will make the greatest amount of, inroads and progress. So if it works, once, it will work twice, it will work three times. So get a pattern and a methodology that works for the person and encourage that and repeat.

Pete Cudney (26:44):
So helpful. Dave, I really appreciate you sharing your experience and your wisdom with us and you know, being generous with your time.

Cassie Gillespie (26:55):
Well, yeah, the other thing I was going to say is if you want more of Dave in person Dave he just recently presented at the developmental trauma and chronic neglect.

Pete Cudney (27:04):
That’s right. It was brilliant. It was well received. We only had you for a half a day, but the feedback was a full day next year. So that’s our plan. So thanks again for joining us for this. It’s really helpful. It’s been my pleasure and thanks for having me.

Cassie Gillespie (27:18):
And David O’Leary is a local rostered psychotherapist in Shelburne, Vermont who specializes in hoarding disorder and squalor and we want to extend a big thank you. We’re so glad to sit down and chat with you. Thanks Dave. Thank you. Thanks for listening to the field.

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