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San Francisco Task Force on Compulsive Hoarding - Q&A
What is compulsive hoarding and cluttering?
Compulsive hoarding and cluttering is a serious and treatable disorder that is often related to other mental illnesses. It can have significant negative effects on people who struggle with it, along with their friends and families and the wider community. Compulsive hoarding and cluttering is characterized by the acquisition and retention of overwhelming quantities of objects that do not—to an outsider—seem useful or necessary. It has been defined as:
The acquisition of, and failure to discard possessions that appear to be useless or of limited value, accompanied by living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed and significant distress or impairment in functioning caused by the hoarding.
Many people have some clutter in their homes, but compulsive hoarding and cluttering is readily distinguishable from ordinary clutter, from large, organized collections of objects that do not interfere with daily life, and from the temporary clutter that may follow a move.
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How big a problem is this?
An estimated 12,000 and 25,000 San Francisco residents struggle with this condition.
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What is the impact of hoarding and cluttering on hoarders?
Hoarding behaviors cause people who suffer from it to feel isolated. These behaviors impede the development of relationships, lead to safety concerns, result in eviction or the threat of eviction, and cause problems in family relationships, leading in some cases to loss of contact and even divorce and loss of custody.
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When and why was the Task Force formed?
The San Francisco Task Force on Compulsive Hoarding was created in 2007 to build on innovative, effective programs that were already being developed locally and to create a blueprint for action for San Francisco. The Task Force examined existing research and the experiences of other Task Forces and undertook locally specific research, including a groundbreaking analysis of the financial cost of compulsive hoarding to service providers and landlords.
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Who's on the Task Force?
Click here to see the Task Force membership.
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What data was used to develop the Task Force's recommendations?
This Task Force's report presents data collected from diverse local stakeholders, including people with hoarding behaviors, service providers who work with them, and landlords who have tenants with hoarding behaviors. The report also relies on a review of the scientific literature and best practices from other cities. A health economist conducted the cost analysis presented in the report.
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What is it costing the City?
The San Francisco Task Force on Compulsive Hoarding has for the first time quantified the costs of compulsive hoarding in San Francisco, and those costs are high: over $1 million a year in documented costs from a sample of existing agencies and landlords, with overall costs to San Francisco estimated at over $6 million per year.
Hoarding behavior may result in serious safety concerns, such as fire risk, risk of falls to occupants, and pest problems. The Fire Department may also become involved if a fire hazard is identified or a fire occurs. Police involvement may result from complaints filed by neighbors, family members, and others. If eviction proceedings occur, the property owner and the tenant might both incur legal costs. In the case of older individuals with hoarding behaviors, legal costs may also be incurred if the individual's capacity to make decisions and/or ability to live independently is questioned and guardianship is sought.
Costs to social service providers include the time of Adult Protective Services workers, other social workers, case managers, and homemaker/chore services. Agencies may also pay a role in providing education and training for clients, their family members, and the staff who work with them. Clients may use crisis hotlines and peer support or self-help groups.
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How much is it costing private resources?
Organizations providing services to people with hoarding behaviors noted additional staff time, costs, and challenges in finding staff to work with clients with hoarding behaviors. When asked if it cost the agency more to provide services to individuals with hoarding behaviors than to other clients, 29% of respondents noted higher costs, ranging from $50-$20,000 per client, with a mean of $3,191 per client. These additional costs were based on additional time required to work with clients, extra hours of case management, additional pest control services, increased number of medication refills and medical supplies, and legal services. One legal services attorney noted that he could resolve 20 non-hoarding cases in the amount of time it took to resolve one hoarding case. Twenty-nine percent of agencies surveyed reported higher costs, ranging from $50 to $20,000 per client.
Landlords also noted challenges resulting from hoarding, including pest infestations, the need for heavy cleaning, the need to involve animal control, injuries, and fires. Costs mentioned included pest infestations ($50-$1,499), animal control costs ($200-$1,499), foregone rent ($1,000-$3,999), eviction-related costs ($2,000-$74,999), and heavy cleaning ($75-$3,999). A small number of catastrophic events (evictions costing $50,000-$74,999 and a fire-related cost exceeding $500,000) were reported.
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Why do so many agencies get involved in hoarding?
People with hoarding and cluttering behaviors may use a variety of services, including healthcare services, behavioral health services, social services such as Adult Protective Services and case management, and legal services. Their behaviors may involve a number of public agencies in San Francisco, including the Department of Aging & Adult Services, the Environmental Health Section, the Department of Public Health, the Housing Authority, the Fire Department, the Police Department, Animal Control, legal aid, health clinics, behavioral health centers, and senior service agencies. They may also interact with private agencies, such as cleaning agencies, professional organizers, landlords, and medical and behavioral health programs. Use of these services result in significant costs being incurred.
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Is compulsive hoarding and cluttering a mental illness?
Researchers continue to debate whether hoarding behaviors are symptomatic of other underlying mental health issues, or whether compulsive hoarding constitutes a separate, independently occurring syndrome. Co-occurrence with a number of other conditions has been noted. In addition to obsessive-compulsive disorder hoarding behaviors often occur with other anxiety disorders such as generalized anxiety disorder, social phobia, and post-traumatic stress disorder. Studies have also shown a possible link between hoarding behaviors and dementia, schizophrenia, and depression. A small but growing body of research links compulsive hoarding with attention deficit hyperactivity disorder.
Compulsive hoarding can be caused or aggravated by problems associated with increasing age or physical disabilities. Sometimes, major life changes like divorce, death of a loved one, unemployment, severe illness or the birth of a new child can affect one's ability to discard household items.
Those with hoarding behaviors may also struggle with difficulties in categorizing, indecision, actual or perceived alteration in memory, and difficulties with concentration and focusing their attention. Emotional attachment issues, perfectionism, and procrastination or behavioral avoidance, and a strong sense of responsibility about objects are personality characteristics that are also associated with hoarding. Attachment to objects or a sense of responsibility for how objects will be disposed of can exacerbate the difficulty of making the decision to let go of objects, while perfectionism can contribute to fear of making the wrong decision about whether to keep or discard an item. Procrastination can contribute to putting off decision-making about discarding or letting go of possessions, cleaning, organizing, etc.
Several brain studies suggest that there may be a biological basis for some of the spatial, information processing, decision-making, attention, and attachment components of hoarding. Other research has noted a likelihood of multiple family members with hoarding behaviors, which may signal a genetic component, and specific genetic abnormalities have been identified.
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Why is hoarding a housing issue?
Hoarding is a housing issue because it can lead to pest infestation, fires and hazards to individual health. If an individual is living in an apartment or supportive housing, then their neighbors are also affected by pest infestations and the potential fire hazards.
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What is animal hoarding?
Animal hoarding is the accumulation of such a large number of animals that the person is unable to provide minimal standards of nutrition, sanitation, and veterinary care for them all. Animal hoarding tends to be accompanied by a failure to act on the deteriorating condition of the animals, the environment, and the person's own health and well-being. Animal hoarding poses serious threats to the well-being of both the humans and the animals in the household.
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What treatments are available for hoarding? How successful is treatment?
People with compulsive hoarding behaviors often refuse treatment and sometimes do not acknowledge that they have a problem. Demands on the part of family members, friends, service providers, and others that they change or that they get rid of their possessions can exacerbate conflict and resistance. People struggling with compulsive hoarding may experience strong ambivalence about making change – on the one hand they may see some of the negative effects of their behavior and feel intense shame at their situation, and on the other they may not be willing to part with their accumulated belongings.
Just as there are people who are reluctant to seek treatment, there are also many people struggling with hoarding behaviors who do want help – and because compulsive hoarding is frequently a hidden problem and often not well understood, they can find themselves facing an uphill battle in seeking appropriate mental health and social services supports. Indeed, they may not realize that what they are experiencing is not a unique, personal failing, but a diagnosable and treatable problem shared by others.
Until recently, the situation has been exacerbated by the fact that traditional treatment strategies have not shown significant effectiveness. Treatment through medication has, overall, shown limited results – although people with hoarding behaviors and other co-occurring mental health issues may of course benefit from appropriate medication for co-occurring conditions. Traditional cognitive behavioral therapy (CBT), and traditional CBT plus medications have similarly shown limited results.
A new CBT approach has been developed specifically for compulsive hoarding and cluttering and is showing greater promise. It includes: education; motivational interviewing, which is a behavioral health strategy to help people deal with ambivalence, recognize problems, self-motivate for change, make a plan, and take immediate steps to be effective in their new intentions; treatment for organization problems—including helping people to reduce the number of categories and locations for saved items, and categories for unwanted items; training in decision-making; exposure to non-acquiring and discarding—for example "non-shopping" trips and practice discarding items; and cognitive restructuring—a widely-used therapeutic process of recognizing, challenging, and ultimately changing patterns of faulty thinking.
Many researchers specifically caution against simply cleaning out, organizing, or discarding a hoarder's possessions without consent except in life-threatening situations. While such action may seem like a direct solution to the problem of having too much stuff, it only addresses the symptom rather than engaging the core decision-making problems that support the hoarding behaviors and can be very traumatic for the person with hoarding behaviors. Instead, researchers strongly recommend that the person with hoarding behaviors be directly involved in and supported in making decisions to let possessions go.
Approaches that deal with compulsive hoarding through a chronic illness management model—which addresses client self-care, coordination within systems of care, and consistent follow-up—or a harm reduction model—which focuses on managing and mitigating the negative impact rather than eradicating the hoarding behavior entirely—show promise as both respectful and effective ways of helping individuals with hoarding behaviors to improve their lives. Treatment using these approaches is not a "cure" or one-time fix, but must be continued over time.
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What treatment is available in San Francisco?
MHA-SF, with the support of the San Francisco Department of Aging & Adult Services (DAAS), created the Institute on Compulsive Hoarding and Cluttering in 2007. The Institute currently includes support groups for people with hoarding and cluttering behaviors. A 16-week treatment group led by a clinical psychologist from Family Service Agency (FSA) was launched for the first time this year. This group, the first of its kind in the Bay Area, is using the successful new cognitive behavioral therapy model developed by Drs. Randy O. Frost and Gail Steketee, leading experts in the field.
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Are people with compulsive hoarding and cluttering disabled?
People with hoarding and cluttering are suffering from a serious condition that can be disabling in their personal, social and professional lives. Compulsive hoarding can be a disability for purposes of the Americans With Disabilities Act.
Compulsive hoarding carries significant stigma. Much of the disability stemming from this condition arises from society's lack of education surrounding mental illness and its conditions. Many individuals are in fear of the further repercussions the stigma of uncovering their secret will have on their lives. The implementation of this report and its recommendations will aid in the reduction of disability on individuals by educating and preparing the City and its organizations to effectively deal with issues surrounding hoarding and cluttering.
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What is the Task Force recommending?
To improve local response to compulsive hoarding, the Task Force recommends that appropriate entities undertake the following activities:
- Develop an assessment team/crisis team to respond to referrals about hoarding cases and coordinate appropriate next steps to facilitate meaningful, long-term improvement for individuals.
- Increase access to treatment for hoarding, including in the person's home. Treatment can include therapists, organizers, coaches, and peers, using a team that aligns with identified best practices and local experience.
- Expand support groups available locally, including peer support groups, groups for family members and training for peer support facilitators. Build on the successes of support groups by offering groups for people at different stages of dealing with their hoarding behaviors, ranging from early awareness and those just starting out to those with substantial experience working on behavior changes.
- Create a services roadmap for people with hoarding behaviors and their families, service providers, and landlords so that people know what agencies to contact in different situations and have a way to identify and seek assistance. Establish a single point of entry into the system of supports and resources that uses a single form for referrals, follows the services roadmap, and engages the assessment team.
- Develop evaluation guidelines for landlords that coordinate with fire department and health regulations.
- Provide long-term case management services as an extension of initial assessment and treatment.
- Offer training for therapists, 211/311 staff, landlords, agency staff, and families; recruit and train trainers; provide cross-training for identification/screening/assessment across agencies.
- Ensure overarching coordination and evaluation of recommended priorities (hoarding and cluttering "czar"); track implementation of priorities and evaluate success.
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Have other cities looked at this issue? What have they done?
Approximately 35 cities have active task forces addressing compulsive hoarding. Many of these task forces facilitate stakeholders coming together to consult with regard to individual cases and to make recommendations. Some also engage in training and education for the court systems, other key personnel, and the general public, and/or provide support groups for people with hoarding behaviors. An unusual feature of the San Francisco Task Force is its focus on systemic and policy issues.
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Is investing in addressing compulsive hoarding a good investment for new city resources, given tight funding now?
Failure to address compulsive hoarding in an effective, coordinated way can result high-cost crisis interventions that do not address the root causes of the problem, and can ultimately fail to prevent eviction or other loss of housing.
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Click here to return to the San Francisco Task Force on Compulsive Hoarding Main Page.
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