Council tenancies and hoarding behaviours: A study with a large social landlord in England

Abstract Hoarding behaviours are highly stigmatised and often hidden. People with problematic hoarding behaviours have a higher rate of mental health and other healthcare and social services utilisation. Hoarding is a community health problem, one factor being housing insecurity. Hoarding behaviours represent significant burden to housing providers, impact the community and dealing with it involves multiple community agencies. This study with a city council in England with a large housing stock (over 14,000 properties) in summer 2021 sought to understand the nature, circumstances and extent that hoarding presents. We developed a reporting system and conducted 11 interviews with housing officers in which they described a case to explain their involvement. Our report details the nature of 38 people who hoard: 47% had a known disability or vulnerability, 34% presented a fire and environmental risk, 87% lived alone and 60% were resident in flats. Our qualitative themes are: Working with others, Balancing an enforcement approach, Feeling conflicted, Complex needs of people who hoard and Staff needs. The cases described by the housing officers are combined into six case studies and illustrate the complex, multi‐agency circumstances around decision making and risk stratification. Our findings point to housing officers as frontline professionals dealing with a public health and social care issue which is often the manifestation of complex life histories and mental health conditions. We suggest a greater focus on risk stratification and a more holistic approach to hoarding cases to effectively deal with this most complex of community health and social care issues.


| INTRODUC TI ON
Hoarding disorder (HD) is defined in the DSM-5 as a persistent difficulty discarding possessions, resulting in an accumulation of belongings causing severe clutter and the obstruction and congestion of living areas that creates significant distress and impairment in functioning (American Psychiatric Association, 2013). Prevalence is estimated at between 1.5% and 6% of the adult population (Nordsletten et al., 2013;Postlethwaite et al., 2019;Samuels et al., 2008;Timpano et al., 2011) in developed countries. However, estimates of hoarding and the subsequent management of people who hoard are limited due to hoarding behaviour being hidden; associated with embarrassment and shame; hoarding being highly stigmatised; the strong emotional attachments people have to possessions and issues around defensiveness and lack of insight (Chasson et al., 2018;Frost et al., 2010;Kellett & Knight, 2003).
The risk factors and possible causes of hoarding are not entirely understood; it may well be due to a combination of factors (Dozier & Ayers, 2017); one study noted that 76% of their sample (n = 751 self-reported people who hoard) had a history of interpersonal violence  and there is evidence that it may be correlated with previous traumatic and stressful life events (Hombali et al., 2019;Tolin et al., 2010).
An early study to examine the economic and social burden of self-reported people who hoard found that they were more likely to have a higher rate of healthcare utilisation, reporting a broad range of chronic and severe medical concerns and a five times higher rate of mental health service use; between 8% and 12% experienced housing insecurity due to being evicted or threatened with eviction due to hoarding (Tolin et al., 2008a(Tolin et al., , 2008b. Hoarding symptoms are associated with workplace impairment (Mathes et al., 2019), increased psychiatric co-morbidity, childhood distress and family strain (Tolin et al., 2008a(Tolin et al., , 2008b. Hoarding is inversely related to household income (Samuels et al., 2008) and represents a community health problem involving multiple community agencies (Frost et al., 2000).
A study in the North East of England with Housing Association providers and Tyne & Wear Fire and Rescue Service found that although people who hoard comprise a relatively small sample of the population, they nevertheless present a significant economic burden to housing providers and emergency services with an estimated cost per person who hoards per year of £15,589 (Neave et al., 2017).
In the same study, additional costs were found such as the 2,108 properties (of the 30,000 home checks), which presented significant fire risks due to hoarding of materials constituting a fire hazard, with 51 of these properties identified as posing a significant danger to fire officers in case of a fire. The issue of dealing with people with hoarding behaviours presents many challenges to housing providers, balancing the care of their properties with their duty of care for their tenants. When cases of serious hoarding come to the attention of a council, often through mandated building or safety inspections, there is an obligation to intervene and deal with the hoarded items due to health and safety issues. However, it is known that intervening and the removal of clutter is vastly distressing and traumatic for the individual, often leading to more severe hoarding (Muroff et al., 2011).
Housing insecurity and eviction is the last, and worst option for all involved. Additionally, work in Canada points to difficulties (and the overwhelming nature of hoarding) for those who provide services around: consent for intervening, the lack of clinical management skills and training by those managing people who hoard; poor collaboration between state services, such as housing and fire services, a lack of resources for such a complex mental health problem and the need for and community partnership (Bodryzlova & O'Connor, 2018;Bodryzlova et al., 2020;Lacombe & Cossette, 2018). For people who hoard, a lack of collaboration; a lack of recognition and treatment for their complex needs and communication that is perceived as violent and threatening has the potential to worsen the clinical course of hoarding (Bodryzlova et al., 2020;Gibson, 2015).
The purpose of this research was to understand the nature, circumstances and extent that hoarding represents in one city council in England (Norwich in the east of England) with a large housing stock of over 14,500 properties. The aim was to enable the development of strategies to prevent serious hoarding, and its associated health and safety risks and understand how a housing provider can develop more holistic strategies to better support their tenants.

| ME THODS
We took two approaches. Firstly, to understand the nature and extent of hoarding we developed a new reporting system based on our review of the literature and our discussions with the council. For 3 months, staff in the Housing Department populated this system with information about their tenants with hoarding behaviours that they had contact with during this time. This was de-identified and shared with the researchers. Information included the Clutter Rating Index, vulnerability of the tenant, including safeguarding referrals, children as occupants, pets, duration of tenancy with the Council, environmental health and fire risks, and a short description. We also took a qualitative approach for our work with staff in the Housing Department to understand the circumstances and context of hoarding from their point of view. To conduct this exploratory qualitative work, the research was promoted by a senior manager in the Housing Department at the council via an email designed by the researchers. Staff were requested to What is known?
• When hoarding becomes known to statutory authorities it represents a time-consuming, multi-agency social and health problem.
• Dealing with the results of hoarding can be traumatising for the person who hoards and the hoarding behaviours usually re-occur.

What this paper adds?
• When working with people that hoard, housing officers are conflicted in balancing the autonomy of an individual to live in their home in a way that they choose, with risks to the property and the health and safety of the public.
• Housing officers often manage people with complex health, mental health and social needs which extend beyond the boundaries of their role, without access to the necessary expertise to best support people with hoarding behaviours.
• Due to the highly complex nature of hoarding issues, trauma informed approaches might be helpful to the person who hoards and those working with them.
email the researchers for further information if they were interested in taking part. After receiving this information, they could decide not to be involved or complete an on-line consent form. In total, 13 staff expressed interest and 11 consented to be interviewed. All interviews were conducted via Microsoft Teams, audio recorded and transcribed and all identifying information was removed. Interviews took approximately 60 min. The interview guide is appended and included asking the interviewee to talk through one of their cases to enable us to understand the complexities and circumstances of hoarding. Interviews were conducted by two experienced female post-doctoral researchers. There was no relationship with any of the participants prior to the study. The first three interviews were independently coded by the two researchers into broad themes and subsequently there was continual discussion about the interpretation of the data and to refine our themes.
The data were analysed inductively, due to this being an emerging field with little theory on the management of people who hoard, searching for patterns relevant to the questions and then themed by the two researchers using reflexive Thematic Analysis, acknowledging the highly contextual nature of the data (Braun & Clarke, 2006.

This study received institutional ethical approval from The
University of East Anglia Faculty of Medicine and Health (2020/21-144) in July 2021 including a collaboration agreement with the council for data sharing. One clear aspect of the ethical application was that staff involved would not be identifiable and representative case studies would be presented in such a way that they could not be identified.

| The city council hoarding reporting system (May to August 2021)
The trial reporting system was set up in May with information provided to the researchers in August 2021. This reported 38 tenants with indicative hoarding behaviours. Of these, 63% were male and the average age was 60 years of age (range 27-79 years). The report suggests that 47% had a known disability or vulnerability, with nearly twice as many male tenants having a reported disability (58%) than female residents (29%).

The mean duration of occupancy is 24 years (range 6-43 years).
Most commonly, people with hoarding behaviours were resident in flats (58%, plus 5% residing in tower block flat accommodation) or a house or bungalow (37%). Three properties were in Sheltered housing complexes. The large majority of properties were occupied by one person (87%). There were children present in 5% of the properties and pets in 11%. According to the Clutter Image Rating Scale, the majority of the properties were rated 4-6 (47%), or 7-9 (39%) on the scale  (link to the scale can be found here: https://hoard ingdi sorde rsuk.org/resea rch-and-resou rces/clutt erimage -ratin gs/. There were more male residents with Clutter Rating Scale scores of 7-9 (46%) than female residents (29%). There was an Environmental Health and Fire Risk identified in 34% properties.
Findings are further detailed in Table 1.

| Themes from our interviews
The 11 staff interviewed had worked in housing roles (as Housing Officers, Specialist Support Officers, Tenancy Management and Public Protection) for between 2 and 20 years. They had come from a variety of backgrounds including mental health support, working with older people and environmental health. From our analysis we developed five themes: Working with others, Balancing an enforcement approach, Feeling conflicted, Complex needs of people who hoard and Staff needs, as detailed below.

| Working with others
Managing hoarding cases involved multiple agencies, and partnership working with other services (e.g., local fire department), health professionals, other council teams, as well as working with individuals and their families and friends. There were acknowledged challenges when it came to working together (difficulty making TA B L E 1 City council hoarding report May-August 2021

| Balancing an enforcement approach
There was a recognition from all staff of the potential harm that enforcement action (e.g., house clearances, eviction) could take and that using a holistic, person-centred approach would have benefit.
Others raised the point that having enforcement as a type of lever-

| Staff needs
All the staff talked through a case study, and the challenges it presented. For example, one client had no heating due to her gas supply being cut off for safety reasons and spent the winter sleeping on the sofa with portable radiators and blankets. Staff described managing these cases as tiring and frustrating with susceptibility to fatigue and burnout and impacting their resilience. There were clearly identified support and training needs for staff, and there may have been missed opportunities to help staff process their experiences of challenging cases.

| Case studies
We developed six case studies from the information given to us from the 11 interviews. These can be found in the online supporting information provided to help the reader contextualise our findings and better understand the circumstances and nature of hoarding behaviours that the housing officers were working with. We were very mindful of the sensitivities and likelihood of underlying trauma relating to hoarding and therefore generalised some of the details in the case studies to ensure that individuals cannot be identified.

| DISCUSS ION
Hoarding is a community health and social problem with serious implications and risks for the person and their community. It represents a major challenge to housing providers and other statutory services.
Our research on housing-related issues clearly demonstrates these risks in council owned properties; for example, the particular risks for their neighbours found in flats (60% of those in our report lived professionals, such as social workers (Holding et al., 2020).
The role of the Housing Officer is very complicated (beyond hoarding) and they have a key role in building coherent and inclusive neighbourhoods (Blank et al., 2021). Ultimately, working with such major challenges, Housing Departments have the responsibility to balance the needs of tenants and their right to autonomy and self-determination (a freedom to live their lives in the way that they choose) with the responsibilities they have as a Council and public body to mitigate risk and maintain safe and habitable housing for the person who hoards, together with public safety within local communities. By its very nature, working with hoarding involves working with multidisciplinary teams and the different professions need to find common ground in effectively working together. This includes dealing with the difficult and challenging ethical dilemmas (such as resolving conflicts on rights to freedom and public safety) that are often present in hoarding cases (Koenig et al., 2010).
Our research points to the social isolation and hidden nature of hoarding. This, alongside the public stigma that people who hoard can experience, can mean that seeking help and engaging with services is a major barrier (Chasson et al., 2018). It may be that the coordinated, case-managed response developed in North America, which conceptualises hoarding as a complex community problem (rather than an individual mental health problem) and uses a supportive harm reduction approach, bringing together community organisations and networks to manage potentially dangerous hoarding behaviours (Bratiotis et al., 2019) could support the engagement needed with services. Similarly, in Vancouver a Hoarding Action Response Team (HART) works with people with severely hoarded homes in a harm reduction and case management approach to employ strategies that build relationships, set goals and coordinate services (Kysow et al., 2020). Our background work with Norwich City Council in England suggested that this is the approach that they would like to take.

Finally, The British Psychological Society's, Good Practice
Guidelines on hoarding (Hare et al., 2015) recommend that everybody working with people who hoard should have access to training and information on good practice to ensure competence in the assessment of, and interventions for, hoarding. Our research sought to address their recommendation for a need for research to understand the adaptations needed by service providers to significantly improve engagement and effectiveness with individuals. There are many potential agencies that are involved and affected by hoarding behaviours, including social care staff (e.g., social workers or homebased care providers) and voluntary organisations that work with people who hoard (Ryninks et al., 2019). There is limited research understanding the impact working with people with hoarding behaviours has on staff or volunteers (Brown & Pain, 2014;Holden et al., 2019;Ryninks et al., 2019), which would be a useful topic for future research in order to improve overall effectiveness in this area.
There are limitations to our study. The reporting system was a trial system and only recorded 38 cases as it was a new system.
Our interviews, where most had a caseload of 10-12 people with hoarding behaviours, suggest that this is significant under-reporting.
Our ongoing work in partnership with the city council addresses this, and the reporting system has been promoted and is now being more extensively populated. Our interviews were offered to maintenance staff who are often the first people to report hoarding in properties, when they attempt to conduct statutory safety checks (such as gas and electric checks) or building maintenance. Unfortunately, they were too busy with work (especially since the halt to work due to Covid). Understanding this first contact with people who hoard would have been helpful for a greater understanding. The strengths of our study are that the study was co-designed with the Council from the outset to address this, until now, neglected health and social care aspect of the housing officer role. Although a small sample, our understanding is that our sample is a fair representation of housing officers in a council.

| CON CLUS IONS
The remit of modern Housing Officers encompasses a wide public health role. In confronting and dealing with issues relating to tenants with hoarding behaviours, they are a frontline workforce dealing with what are often the manifestations of complex life histories and mental health conditions. In this aspect of their role, they are balancing the rights, freedom and autonomy of an individual to live in their home in a way that they choose, with responsibilities to protect the property and the health and safety of the public.
Negotiating the potential challenges of multi-agency collaboration within such situations is a further aspect of the role for which staff need additional practical and emotional support. Our findings strongly suggest a greater focus on risk stratification and a more holistic and community-based approach to hoarding cases to effectively deal with this most complex of social and health issues.

ACK N OWLED G EM ENT
The authors would like to acknowledge and thank Rachel Omori at Norwich City Council for her partnership work in helping to design this study and enabling this research to be undertaken.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on reasonable request from the corresponding author. The data are not publicly available due to privacy and ethical restrictions.