Hoarding 101 for firefighters

Hoarding disorder was added to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), in May 2013. If sufficient functional impairment exists, it can be considered a disability with the right to “reasonable accommodation” under Human Rights legislation.

“Reasonable accommodation” does not mean the right to hoard and put others at risk. It must be balanced with the fact that hoarding is not simply a mental health issue; it can also be a legal, personal, and public health and safety issue. Unidentified and untreated people living with this compulsive disorder will almost certainly continue until not only a personal, but also a community health and safety hazard has been created. Without hoarding-informed intervention, they will put their community at risk.

I, Elaine Birchall, co-author of this article, have been a hoarding behaviour and intervention specialist for over 18 years. I brought together 54 key stakeholders to form the first Canadian Hoarding Coalition. The group comprises a broad cross-section of community partners from all sectors including private and governments to tackle hoarding related issues and develop strategic response programs and services. Later, I also initiated and led the Canadian National Hoarding Coalition.

In 2005, I was invited to the Ontario Fire College in Gravenhurst, Ont., to present on hoarding to 100 fire inspectors. Here are the key pieces of information the fire service should be aware of when it comes to hoarding.

Hoarding Basics
Conservative estimates report that at least six per cent of the general population hoard. That data translates to over 2,255,400 Canadians with hoarding disorder.

Hoarding disorder has specific criteria, each of which must be met even to a minimal degree:

• Excessive accumulation and failure to resolve (proportionately) things, animals, or both.
• Some, or all the living spaces cannot be used for their intended purpose (for example, personal living spaces become reallocated for storage).
• Distress is being experienced by the person hoarding or others. This box must be ticked even if there is no current distress, but if the truth were known, others — family, neighbours, fire, children’s or animal services, mortgage or insurance company, etc. — would have cause for concern.
• Impairment in functioning is occurring because activities of daily living can’t be performed without extraordinary actions being required. Usually this is because the living space cannot be adequately maintained and kept in working order. (See Activities of Daily Living on www.hoarding.ca).

Successful outcomes depend on two elements, namely getting the person help for the underlying reasons they hoard, and cleaning up the environment that is the byproduct of untreated hoarding behaviour.

Types of Hoarding
There are three types of hoarding disorder.

1. Standardized hoarding (with three subtypes)

• Indiscriminate Hoarding: Anything can and is hoarded, insight and motivation fluctuate greatly, and the hoarding usually results in chaotic piles.
• Discriminate Hoarding: Saves one or more specific categories of items, items have high attraction value for the person and are given high importance, but are rarely displayed as “collections” (kept for having, not enjoying or sharing/displaying).

2. Combined hoarding

• Generally, occurs when discriminate hoarding exceeds the person’s ability to manage.
• Chaos and piles result resembling indiscriminate hoarding.

3. Diogenes Syndrome

• is often found in aging population and is hallmarked by self-neglect (lack of clothing, poor nutrition, medical, and dental care even when they can afford it), and domestic squalor that makes the residence unhealthy and unsafe.

4. Animal Hoarding

Accumulation of animals to the extent that there is failure to provide minimal nutrition, sanitation, and veterinary care, failure to act on the deteriorating condition of the animals or the environment, and failure to act on or recognize the negative impact of the collection on your own health and well-being.

Safety risk is rated on a scale of 0-5, with 0 being non-existent, 1 is mild, 2 is moderate, 3 is severe, 4 is extreme and 5 is crisis.

Here are some examples to consider of fire and the risk level in a hoarded environment.

• Piling combustibles close to a hot water tank – level 5: A minimum of 33-inches clear (see local fire requirements) is required around any heat source. The hot water tank is surrounded by combustible materials. Materials can simply conduct heat and cause smoldering/fire.
• Blocked or obstructed path to electrical panel – level 4: There must be a clear path to access to electrical panel.
• A cluttered kitchen stovetop – level 4-5: Smooth top stoves, if not cleared, can represent a significant risk. For example, a metal container left on the stove can conduct heat to the glass jar beside it. Then, an explosion of flying glass could cause injury, as would the saucepan creating ignition. A cardboard box left immediately beside the burners can ignite. Oven mitts left adjacent to cupboards could ignite.
• Piles in the doorway entrance/exit — level 3: Entrance and egress routes can be obstructed in the short term by garbage bags and shoes. Other items can be left “just for now.” When forgotten, they are left longer term. This is a level 3 because the recommended 33-inch clearance does not exist.
• Stairs are blocked chaotically with stored items —level 5: Passage is obstructed and only possible by moving many items. This increases the risk of tripping or falling.

The Environmental Risk Assessment
The best plan always starts with an excellent assessment. I begin by completing a three-part assessment, which includes mental health status, hoarding behaviour history and an environmental assessment.

For the mental health assessment, I do a narrative workup and complete the Depression, Anxiety, and Degree of Isolation Inventory developed by Dr. David Burns.

The environmental assessment is completed using a number of qualitative tools, and when necessary, an in-depth quantitative assessment rating tool developed by Birchall Consulting is completed (available on Johns Hopkins University Press website at jhupbooks.press.jhu.edu/title/conquer-clutter/supplemental-material).

I also work with the client to complete the Housing Clutter Checklist to determine where the clutter is, what is the risk level, and what the priorities are that would be required to reverse the situation. This checklist is available on hoarding.ca.

This environmental assessment helps the individual to gain an understanding of the shortcomings in their environment and starts a specific discussion about how to rectify it.

Motivating Change Behaviour
Motivating “change behaviour” requires two elements: The fact that making a change is and remains a priority, and that the person believes they are capable of making the change (they have the knowledge, tools, and support they need to do what is required).

The collaborative working relationship between enforcement agents and hoarding-informed soft service mental health professionals is the perfect combination of service to keep tasks a priority and keep the support in place to make progress possible.

No one organization can or should be responsible for responding and dealing with hoarding situations because they are too complex and costly. Hoarding requires the perfect marriage of enforcement mandates and support service skills. Community hoarding coalitions are the answer for all parties involved.

Elaine Birchall is the director of Birchall Consulting and works with people across the U.S. and Canada. Suzanne Cronkwright is a technical writer/editor. Their new book is titled, Conquer the Clutter: Strategies to Identify, Manage, and Overcome Hoarding.