Service providers' perspectives on hoarding management in the community in Singapore.

INTRODUCTION Hoarding behaviours are often associated with high disability, psychiatric comorbidity, care burden and adverse health outcomes in people with hoarding behaviours and their families, often requiring multidisciplinary and collaborative task forces with diverse specialisations to mitigate the situation. However, such task forces can face structural challenges in areas such as leadership, purpose, funding and membership. In such instances, stakeholder or service provider mapping and analysis can help in gaining a deeper understanding of the processes and challenges on the ground. Singapore is a developed Southeast Asian country comprising a multiethnic population. Considering the overall residential area, number of dwelling units and the population, it is estimated that there is one person per 22 m2 in Singapore. This proximity poses unique and complex social and environmental challenges for managing cases of hoarding here. In 2014, a multi-agency task force was set up to pool the expertise and legislative abilities of public institutions to better manage hoarding behaviours in Singapore.[1] An earlier article summarised the processes and roles of the hoarding task force and hinted that “while the concept of the task force is appealing, its functions and powers remain largely unclear”.[2] This qualitative study aimed to understand the challenges faced by the task force service providers and potential solutions to these from their perspective. METHODS An exploratory qualitative study was conducted among hoarding task force service providers in Singapore. A total of 18 hoarding task force team members were recruited for this study using purposive sampling. Participants included social workers, estate managers, centre heads, and counsellors from various social service, mental health, voluntary welfare and governmental organisations. The mean age of the participants was 43.2 (range 39–66) years [Table 1].Table 1: Sociodemographic background of service providers (n=18).Three focus group discussions (FGDs) were conducted between September and October 2017 following approval from the Institutional Ethics Committee of the National Healthcare Group, the Domain Specific Review Board. All participants provided written informed consent for participation in the study. Trained facilitators conducted the discussions and when necessary, probed or sought clarifications. A semi-structured interview guide was used to facilitate the discussion [Box 1]. Questions were designed to explore service providers’ perspectives of managing hoarding behaviours in the community, including their experiences in terms of challenges and expectations. The FGDs lasted for 1.5–2 hours, and each group had an appropriate mix of participants from different organisations and job roles.Box 1: Interview guide for focus group discussions with service providers in the hoarding task force:All FGDs were audio-recorded and transcribed verbatim for analysis. Saturation was assessed concurrently with data collection. Inductive thematic analysis was used to analyse the data.[3] Free pile-sorting was adopted to identify key themes.[4] Any disagreements during the sorting process were discussed within the team until a consensus was reached. RESULTS Two main themes emerged: (a) challenges faced by the service providers while managing hoarding and (b) suggestions for successful management of hoarding in the community [Table 2].Table 2: Overview of themes related to challenges in and solutions to managing hoarding cases from the service provider’s perspective.Theme 1: Challenges experienced while managing hoarding Four subthemes emerged within this challenge relating to processes, personal issues, client engagement and society’s expectations. Process challenges Service providers shared that they faced difficulty while gaining access to households, as they were not authorised by law to enter a private housing unit. In instances where the hoarding behaviour was confined within the unit and there were no obvious safety or environmental concerns, service providers felt powerless about the help they could extend. “Yes, in a way there are vectors coming in and out of the flat. I mean if it’s (hoarding) in the flat and there are no flammable items or vector issue, then there’s no enforcement power.” (FGD 1) Across all FGDs, service providers remarked that time and resource constraints made it difficult to initiate or sustain efforts to declutter. Manpower issues such as recruiting suitable volunteers to assist in the decluttering process, which could take a long time, were of concern for service providers. Service providers described the challenges encountered when they were not able to share confidential information with each other about their clients, particularly when it was pertaining to treatment. “The clients don’t want to take medicines, so doctor also says ‘Okay, no need’. Then OT (occupational therapist) says I will do more therapy, but I also don’t know what kind of therapy you are going to use in the hospital. so it’s very difficult for us in the community.” (FGD 2) Having dissimilar professional priorities was one of the challenges described by service providers, as they were affiliated with different organisations and had different service priorities. “…seems like every agency that comes into, let’s say, an issue about hoarding also has their own personal organisation interest that they need to do, and sometimes (these) interests also clash with each other.” (FGD 3) Personal challenges The poor cleanliness in the homes was challenging for some service providers. They mentioned that one needs “to be willing to get dirty” when entering the household premises. There was also uncertainty among some service providers in how to deal with hoarding cases. Some service providers were confused about the role they were supposed to play, and some felt that they were “at a loss with what to do” to specifically help a person with hoarding behaviour. Challenges in client engagement The persistent rejection of offers of help from clients and their family members, owing to poor insight into their behaviours, made it difficult for service providers to manage hoarding. “As far as they’re concerned, ‘Look, I got no problem why you always come and kacau (disturb) me, why you disturb me, it’s not your problem.” (FGD 2) Service providers noted the importance of getting family support and that their involvement was crucial to solving hoarding problems on the whole. However, they described difficulties in engaging the family owing to poor family relationships or the family’s indifference or denial of their relative’s behaviours. “They (family members) might have tried talking to their family members, to the hoarder, but because it’s not effective, they choose to just leave it and ignore and lead their own life.” (FGD 2) Service providers also described occasions when they found themselves in ethically tricky situations when engaging their clients, given their clients’ right to live as they choose, especially when they were mentally well. “So if the seniors have hoarding behaviour and they keep themselves very clean and they eat very well. Sometimes from a social worker’s point of view, I really don’t know how to approach them.” (FGD 2) Society’s expectations for resolving hoarding cases Service providers mentioned that neighbours of persons who hoarded expected a swift resolution for hoarding cases. “.we understand that we take a long time to engage the family or the hoarder itself… but sometimes, time is not on our side because, as I said, the complainer will expect us do something very quickly.” (FGD 3) Theme 2: Suggestions for successful case management and recommendations Service providers’ views and suggestions to address some of their challenges were classified into four broad subthemes. Suggestions to overcome process challenges Service providers suggested that having legislation would help to empower them, particularly if the cases involved vulnerable adults. Another suggestion they brought up was to establish a ‘hoarding specialist team’. The constituents and structure of the team, however, were not explicitly mentioned in the discussion. Nonetheless, the perceived merit of having such a dedicated team was to pool expertise and authority and make the process more straightforward. “.if there is… a specialised team to have all the resources. they have enforcement forces, or if they want someone to declutter. then they just call the contractor to clean, or to have any powers to ask the person to allow them to go in to declutter. Then it will be more straightforward.” (FGD 1) While acknowledging that regular meetings were already taking place within the multi-agency team, service providers noted the need to have regular communication to avoid potential inconsistency in action plans when executed by the different agencies. “At the end… all (stakeholders) are agreeable and informed about what they are going to do.” (FGD 2) Despite decluttering of the residence and the persistence of hoarding behaviour, some service providers highlighted the need to implement a support system to monitor hoarding cases and maintain the decluttered state of the homes. Suggestions to engage the community Engaging the community was deemed important by service providers to effectively manage hoarding in the community. In relation to handling complaints from neighbours, they suggested that engaging neighbours could eventually “tear down barriers” and would be “good for them because they are neighbours”. By inviting the complainers to be involved in the process, service providers felt that the neighbours would be encouraged to be more tolerant and less demanding. In the same vein, they expressed the need for mutual understanding between neighbours and grassroots committees, which could be achieved by public awareness and education on the issue of hoarding. First, it could provide an opportunity for individuals “to start to understand or (have a) better understanding of the concept of hoarding”, including the complexity of the issue at hand. This may, in turn, help to foster sympathy and tolerance within the community. Second, it could help in the detection of hoarding cases in the community: neighbours may “raise necessary alarm to correct people like next of kin, maybe sound them out”. They felt that media coverage was an effective mode in bringing attention to this issue. Strategies to engage clients more effectively Service providers touched on the topic of having a more client-centred approach when engaging residents who have hoarding behaviour. “I think the process of getting to know that person better, really engage and really know that person so well… until that person (is) really convinced that you know my story inside out, A to Z, you know my life.now (I) start to be open, to listen to… how are we going to manage the hoarding issue and all that.” (FGD 3) There was also a consensus among service providers that the involvement of the client’s family was essential to effectively manage hoarding cases and ensure the well-being of the household. “(There is) still some form of benefit. Because at the end of the day, it’s still a family, and people who stay there feel that they have a cleaner environment, a more spacious environment, isn’t that better for the family member?” (FGD 1) Speaking from personal experience, service providers highlighted the importance of family support as one of the key contributors to successful case management. Given their involvement in managing and even being in command of the situation, they felt that their efforts could be made more sustainable. “.we need the family to come along with us to work on the issue together, especially (since) we know that for hoarding, we don’t focus on the cluttering because it doesn’t solve the problem. Because if we clear, it can come back again, it can recur.” (FGD 3) Other practices to limit hoarding behaviour Several other suggestions were also briefly brought up, but participants did not delve into their likely effectiveness and feasibility. These included the use of an incentive system to encourage decluttering efforts, getting individuals who had resolved their hoarding behaviour to support existing clients, removing the clients from the current environment, and setting up a restricted area in the house to limit hoarding behaviour. In addition, strict control measures in the form of fines or the allocation of some restrictions within the residence were also brought up by a service provider as a countermeasure to curb hoarding behaviour. DISCUSSION Service providers’ barriers to service provision ranged from person-level factors to process challenges such as limited authority and enforcement power. A qualitative study assessing five hoarding task forces in the United States found that structural factors, including leadership and funding, can also impact the viability of the hoarding task force.(5) The author noted that workflows that clarified the roles and responsibilities of agencies involved in hoarding cases were useful. Our results replicate these findings with several common themes related to resource constraints, social needs, client engagement and enforcement-related issues. A unique theme identified in our work was the pressure to deliver, which was expressed by service providers, while ‘meeting expectations of the community’ more effectively and quickly. This may be, in part, due to the lower tolerance for unhygienic clutter of people in the neighbourhood of individuals with hoarding behaviour. Insufficient insight into the underlying causes of hoarding behaviour further compounds this problem. Refusal to declutter and to seek treatment, and poor response to interventions have been attributed to lack of insight among people with hoarding behaviour;[6-8] therefore, resistance to the task force service providers is expected. Similar negative experiences were also observed by other service providers such as community mental health teams [9] and chronic disease management services.[10] While the first study reported that service providers found “patient-centred flexibility more useful in ensuring engagement than an assertive outreach approach”, the latter postulated that “therapeutic relationship is a cornerstone for properly managing complex patients”, thus highlighting the significance of developing constructive relationships with clients to foster successful long-term health management. There is, therefore, a need to incorporate processes that allow adequate time for service providers to develop alliances with clients and their families. Current psychological approaches incorporated for managing hoarding include techniques such as motivational interviewing to promote client engagement[11] and cognitive behavioural therapy to improve the organisational skills of people with hoarding behaviour.[71213] Such interventions put individuals with hoarding behaviour at the centre of interventions, focusing on self-management and joint decision-making instead of resorting to legal enforcement. It is reported that there are currently “no quick fix” solutions for hoarding, and it was proposed that an “informal liaison” should be considered “to address the complexities of hoarding sensitively and effectively”.[14] This could also be achieved by engaging neighbours and families [Table 2]. Such informal models of hoarding management are currently not clearly documented; however, trials are underway to assess the impact of peer-led support groups that use cognitive behavioural therapy and are geared towards reducing hoarding symptom severity, functional impairment, physical clutter and cognition.[15] This study has some limitations. As our findings reflect the perceptions of service providers who were employees of the key agencies in the task force, there may have been a certain degree of social desirability bias, leading to participants expressing responses that seemed more appropriate. Their responses may also have been limited to perspectives from these organisations; feedback from other relevant stakeholders such as law enforcers, the police and clinicians should be obtained to understand their perspectives. Additionally, issues related to hoarding behaviours were explored for hoarding in general, regardless of the type of hoarding. An article that compared patterns related to compulsive hoarding of objects with those of animal hoarding proposed that the aetiology of animal hoarding could have its roots in dysfunctional primary attachment experiences in childhood resulting in feelings of “protective, comforting relationship with animals”, thus leading to such behaviour.[16] The authors stressed that managing animal hoarding may require different strategies. Future research should explore challenges faced by service providers in relation to specific types and forms of hoarding to adequately enhance current processes within the task force. Despite these limitations, one strength of this study was the direct feedback obtained from service providers who were involved in the day-to-day operations of the hoarding task force in Singapore. Moreover, these results underline the need for multiple, multi-level stakeholder groups to deal with the complexity of managing hoarding behaviours in the community. Finally, we obtained useful information concerning the gaps and needs in current hoarding management, as perceived by the service providers, the significance of client-provider relationships and solutions to aid the effective management of hoarding. For the implementation of community-wide initiatives targeting hoarding, a number of measures have been put in place in Singapore. For example, the Municipal Services Office has formulated end-to-end workflows to clarify the roles and responsibilities of the agencies involved and tighten coordination for complex issues related to hoarding.[17] In terms of legal framework, the Vulnerable Adults Act passed in Parliament in 2018 places importance on the protection of vulnerable adults from abuse, neglect or self-neglect and enforces alternative placement, counselling, de-cluttering and protection in cases of hoarding.[18] In addition, grassroots committees assist, as necessary, in engaging the clients, their families and neighbours to build trust and allow agencies to manage the cases. In the current team-based approach, information on processes and cases is shared between teams within these agencies, which are formed based on the geographic location of the hoarding cases through regular networking sessions.[19] Thus, this preliminary study provides useful insights into the challenges faced by service providers while managing hoarding in a community setting as well as their perspectives on possible ways to address these challenges. The study has also highlighted the need to continue exploring ways to encourage therapeutic alliances among service providers as well as between service providers and individuals with hoarding behaviour and their families. Financial support and sponsorship The study was supported and funded by the Agency for Integrated Care, Housing and Development Board and the Ministry of National Development, Singapore. Conflicts of interest There are no conflicts of interest.