Gregory Chasson - Family Support and Intervention for Hoarding

Family Support and Intervention for Hoarding: Introduction to Family-As-Motivators Training

Gregory S. Chasson, PhDDepartment of Psychology

Illinois Institute of TechnologyChicago, IL

Alexandria M. Luxon Sophia Alapati

Kristine PowersPriyanka N. Divecha

Department of Psychology Towson University

Towson, MD

Acknowledgments

• The FAM Training trial is financially supported by Partners Healthcare, Inc. and Towson University.

• Thanks to Ashley Carpenter, Brittany Gibby, and Jenna Ewing for helping with earlier drafts of FAM Training.

• Thanks to Michael Jenike for project support.

• Thanks to Jack Samuels and Gerald Nestadt for assisting with study recruitment.

An Origin Story

• FAM Training stands for Family-As-Motivators Training

• FAM was forged from the fires of helplessness• Continuous family cries for help for compulsive hoarding

(CH)• But treatment ambivalence is a common feature of CH;

how can you help somebody who isn’t willing to show up?

• Plus, there are limited empirically-supported packages to offer families

• Families and providers feel helpless

Domestic Disputes

• Relatives report high levels of distress and rejection of the individual with CH

• The loved one with CH often feels anxious and angry because of family involvement in CH matters

• CH can lead to arguing, estrangement, hurt emotions, physical altercations, financial dependencies, legal battles, sovereignty violations (e.g., unscheduled cleanouts), among other problems

♫ That’s the Power of Love ♫

• So much family emotion, usually driven by love and concern!

• How can this power be harnessed to bring about change?

• How do treatment providers encourage individuals with CH to get treatment without even getting a chance to speak with them?

• Answer: Family

Something from Nothing? Hardly!

• Integrating the help of family is not a novel concept

• Michael Tompkins and colleagues1-3 have been trailblazing family approaches for hoarding for many years• Served as inspiration for much of FAM Training• FAM research supplements this work by establishing

research evidence for a family program for CH

• FAM Training was also inspired by family accommodation work in OCD and anxiety disorders4-6, as well as motivational interviewing research and texts7, particularly Rosengren8).

Three Birds with One Stone

• FAM Training endeavors to 1. Increase treatment readiness and treatment-seeking

behavior among individuals with CH

2. Increase wellbeing and decrease distress in relatives

3. Reduce family tension and fighting

• The goal, however, isn’t necessarily to look like this family

The Skinny on FAM Training

• FAM Training is 10-sessions (60 minutes each)

• Manualized training program

• 1:1 training session with a grad student trainer

• Consists of four modules: 1. Psychoeducation2. Motivational Interviewing Training3. Harm Reduction4. Family Accommodation Prevention

Psychoeducation

Session 1•First 20 minutes—reserved for introducing FAM Training, building rapport with the relatives, and allowing them to open up about their experience dealing with a loved one’s CH

•Remainder of session focuses on instructing the relative on various CH info

• Course and prevalence, main characteristics, how/why CH may develop, nature of insight, risk factors, and family and economic impact

•Take-home handouts and list of local hoarding resources

Family Accommodation Prevention

Session 2•Family accommodation is defined; handouts of family accommodation model and process are provided and discussed

Family Accommodation = A. Participating in and encouraging rituals or avoidance behaviors of those with CH9,10

B. Modifying personal and family routines as a result of trying to deal with CH

Family Accommodation Prevention

Session 2 continued•Common types of CH family accommodations are reviewed; extra focus on 2-4 accommodations pertinent to the relative

•Introduction of expressed emotion (i.e., criticism, hostility, and emotional overinvolvement)11-12, with handout

•HW: read a handout on family accommodation prevention tips and avoiding expressed emotion

•Role Play 1: Expressed emotion

Family Accommodation Prevention

Session 3•HW discussed and questions answered about family accommodation and expressed emotion

•Discuss and create an example behavioral contract based on guidelines from Van Noppen and Steketee11

•Introduce the concept of extinction bursts

•Manage relative’s expectations of change

•Role Play 2: Family accommodation and behavior contract

Motivational Interviewing Training

Session 4•Introduce the concept of motivational interviewing (MI). What it is, and what it is not.

•Focus of module = in loved one with CH, addressing ambivalence about change and developing awareness of discrepancies

•Explain the 3 components of MI8

1)Collaboration2)Evocation3)Autonomy

Motivational Interviewing Training

Session 4 continued•Review MI pitfalls to avoid7,8

1) Trying to change all behaviors completely 2) The righting reflex 3) Too confrontational or directive4) Don’t take sides5) Avoid blaming6) Premature focus trap

•Complete MI Spirit exercises (worksheet adapted from Rosengren8)

Motivational Interviewing Training

Session 4 continued•Introduce and define Stages of Change, with handout (adapted from Whalley14)

1) Precontemplation2) Contemplation3) Preparation4) Action5) Maintenance

•HW: Driving in Cars (adapted from Rosengren8)

Motivational Interviewing Training

Session 5•Check in about Driving in Cars exercise

•Introduce and define OARS Method of listening skills8

• O Open-ended questions• A Affirmations • R Reflective listening• S Summary statements

Motivational Interviewing Training

Session 5 continued•Practice OARS Method with worksheets adapted from Rosengren8

•HW: 1) practice listening skills and 2) complete “Approaching Challenging Situations” worksheet8

•Role Play 3: OARS method

Motivational Interviewing Training

Session 6•Check in about Approaching Challenging Situations HW and practice of listening skills

•Explain concept of ambivalence

•Introduce concept of change talk statements reflecting8

1) Some desire or ability to change 2) Awareness of the benefits of change 3) Insights into the difficulties of the current situation4) A willingness to commit to change5) A recent history of taking steps to change

Motivational Interviewing Training

Session 6 continued•Review examples of change talk specific to CH

•In session, complete “Worksheet for Family Member Strengths” (modified from Rosengren8)

•Review signs of readiness to change8

1) Decreased resistance2) Decreased discussion of the problem3) Sense of resolve4) Increase in change talk5) Questions about change6) Envisioning life after change7) Experimenting with change behavior

Motivational Interviewing Training

Session 6 continued•Review ways of enhancing confidence to change8

• Asking about loved one’s success stories of change• Discuss strengths and supports• Brainstorm for problem solving • Reframing past difficulties or lack of success with change

•HW: Reinforcing Change Talk worksheet8 and Value Exercise8

•Role Play 4: Change talk, readiness signs, and how to enhance confidence to change

Motivational Interviewing Training

Session 7•Check in about Reinforcing Change Talk worksheet and Value Exercise

•Define and discuss the concept of resistance

• Resistance is normal!

•Define and discuss the concept of reversing

Motivational Interviewing Training

Session 7 continued•Discuss ways of responding to resistance8

1) Be non-resistant with simple and double-sided reflections, amplified reflections

2) Reassure that you’re not moving forward too quickly3) Reversing4) Reframe problem5) Acknowledge with a twist6) Emphasize personal choice and control7) Side with the negative8) Encourage pacing9) Feeling angry is okay, but try not to show it

Motivational Interviewing Training

Session 7 continued•Complete in-session exercise “Techniques for Responding to Resistance,” adapted from Rosengren8

.

•Complete in-session exercise, “Real Life Reflections,” which involves role-playing reflections with the trainer

•HW: 1) Complete “Resistance and Status Quo Statements” worksheet adapted from Rosengren8 and 2) practice using appropriate listening skills and reflections

Harm Reduction

Session 8•Check in about 1) “Resistance and Status Quo Statements” worksheet and 2) practice using appropriate listening skills and reflections

•Introduce the concept of harm reduction

Harm reduction = worldview about CHA. Priority = Decrease harmful consequences of high-risk behaviorB. WITHOUT necessarily requiring the individual to stop CH fully1-3.

Harm Reduction

Session 8 continued•Introduce principles of Harm Reduction for CH, from Tompkins and Hartl3

1) Do no harm2) Stopping all CH is NOT necessary3) No two hoarding situations are alike4) Loved one is essential member of treatment team5) CH may not be the most pressing problem

Harm Reduction

Session 8 continued•Discuss setting the stage for harm reduction

1) Letting go (with exercise from Tompkins and Hartl3)2) Understand3) Forgive and introduce the 4 A’s from Tompkins and Hartl3

• Acknowledge• Assign reasons• Assure patterns won’t be repeated• Ask for forgiveness

4) Grab hold with exercise from Tompkins and Hartl3

Harm Reduction

Session 8 continued•HW: Read the following

1) “List of Forgiveness Resources” handout2) Tompkins and Hartl’s3 “Do’s and Don’ts of Forgiveness”3) Read as a primer, “Guidelines for Conducting the Home

Assessment” (adapted from Tompkins and Hartl3)

•Role Play 5: Setting the stage for harm reduction

Harm ReductionSession 9•Check in about HW readings

•Introduce concept of harm potential

•Introduce guidelines of harm potential home assessment from Tompkins and Hartl3

1) Show respect and be honest2) Be prepared3) Explain assessment goals to loved one4) Answer loved one’s questions5) Complete the “Harm Potential Assessment Form”3

6) Leave time to chat

Harm ReductionSession 9 continued•Factors to assess during home visit

• Level of support “Assessing Level of Support” handout from Tompkins and Hartl3

• Insight and motivation “Assessing Insight and Motivation” handout from Tompkins and Hartl3

• Other factors “Assessing Other Factors” handout from Tompkins and Hartl3

1) Chronic or current medical conditions2) Physical limitations3) Alcohol or drug problems4) Psychological conditions

• Acquisition factors “Assessing Acquisition Factors” handout from Tompkins and Hartl3

Harm ReductionSession 9 continued•HW: conduct an assessment of the loved one’s home using

1) “Harm Reduction Potential Assessment”3

2) “Identifying Harm Reduction Targets”3

Harm ReductionSession 10•Check in about HW of conducting a home assessment

•In session, complete “Harm Reduction Planning Worksheet” from Tompkins and Hartl3

•Identify harm reduction targets across certain categories3

• safety• health• comfort• medical, physical, memory, and sensory limitations• accommodations that may be required (e.g., removing name form

junk mail lists)• financial harm

Harm ReductionSession 10 continued•Create a harm reduction plan, which includes 4 components3

• Realistic goals1) Concrete and specific2) Doable3) Prioritized

• Monitoring progress• Management strategies for

1) Reducing financial risk2) Improving living situation3) Facilitating saving and organizing

• Harm Reduction Contract• Provide example contract

Harm ReductionSession 10 continued•Role Play 6: Creating the harm reduction plan

•Wrap up FAM Training 1. Review of components2. Seek feedback about the program

1) Tompkins, M. A. (2015). Clinician's guide to severe hoarding: A harm reduction approach. New York, NY, US: Springer Science + Business Media

2) Tompkins, M. A. (2011). Working with families of people who hoard: A harm reduction approach. Journal Of Clinical Psychology, 67(5), 497-506. doi:10.1002/jclp.20797

3) Tompkins, M. A., & Hartl, T. L. (2009). Digging out: Helping your loved one manage clutter. Oakland, CA: New Harbinger Publications, Inc.

4) Stewart, S. E., Beresin, C., Haddad, S., Egan Stack, D., Fama, J., & Jenike, M. (2008). Predictors of family accommodation in obsessive-compulsive disorder. Annals of Clinical Psychiatry, 20(2), 65-70.

5) Steketee, G., Ayers, C., Umbach, A., Tolin, D., & Frost, R. O. (2013). Family response tohoarding: Assessment and features in an internet sample. Unpublished manuscript.

6) Amir, N., Freshman, M., & Foa, E. B. (2000). Family distress and involvement in relatives of obsessive-compulsive disorder patients. Journal of Anxiety Disorders, 14(3), 209-217.

7) Miller, W. R., & Rollnick, S. (2002). Motivational interviewing. (2nd ed.). New York: The Guilford Press.

8) Rosengren, D. B. (2009). Building motivational interviewing skills: A practitioner workbook. New York, NY: The Guildford Press.

9) Allsopp, M., & Verduyn, C. (1990). Adolescents with obsessive compulsive disorder: A case note review of consecutive patients referred to a provincial regional adolescent

psychiatry unit. Journal of Adolescence, 13, 157-169.

References

10) Livingston-Van Noppen, B., Rasmussen, S. A., Eisen, J., & McCartney, L. (1990). Family function and treatment in obsessive-compulsive disorder. In M. A. Jenike, L. Baer, & W. E. Minichiello (Eds.), Obsessive compulsive disorder: Theory and treatment (pp. 325-340). Chicago: Year Book Medical Publishers.11) Van Noppen, B., & Steketee, G. (2003). Family responses and multifamily behavioral treatment for obsessive-compulsive disorder. Brief Treatment and Crisis Intervention, 3, 231-

247.12. Vaughn, C. & Leff, J. P. (1976). The influence of family and social factors on the course of psychiatric illness: A comparison of schizophrenic and depressed neurotic patients. British Journal of Psychiatry, 129, 125-137.13) Whalley, M. (2008). Stages of change. Retrieved from http://www.psychologytools.org/

assets/files/Worksheets/Stages_Of_Change.pdf

References

Thank you!!!Gregory S. Chasson, Ph.D.

Licensed Psychologist

Associate Professor Department of Psychology

Illinois Institute of [email protected]