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Hoarding refers to an excessive acquisition of objects and inability to part with apparently valueless possessions. While it can lead to excessive clutter, distress and disability, it is important to note that not all cases of hoarding are pathological. This article aims to suggest how one can make recommendations to patients and families when they encounter someone exhibiting hoarding behaviour. It also introduces the Hoarding Task Force and relevant legislation in Singapore to address the issue of hoarding in the community.
Mr Tan, who has not visited your clinic for six years, presented with a chronic cough. You asked how he has been after the consultation. Following a short silence, he explained that his wife was an ‘environmental activist’ who had been collecting various reusable things in their three-room flat, but he and his neighbours did not approve of her behaviour. He explained that he now sleeps on piles of old newspapers and has to frequently apologise to his neighbours, as it has become more difficult to keep household pests away from their flat. Mr Tan then asked for your opinion on this matter.
WHAT IS HOARDING?
Hoarding is defined as an excessive acquisition of objects and inability to discard or part with possessions that appear to have no value to others, leading to excessive clutter, distress and disability.(1,2) While hoarding disorder is now classified as a pathology, under obsessive-compulsive and related disorders, in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders,(1) it is important to note that not all hoarding behaviour is pathological. Nonetheless, this behaviour can manifest within several other psychiatric conditions, such as obsessive-compulsive disorder, major depressive disorder, acquisition-related impulse control disorders (including compulsive buying, kleptomania and acquiring free things), generalised anxiety disorder, social phobia, inattentive-type attention deficit hyperactivity disorder, obsessive-compulsive personality disorder,(3) schizophrenia or dementia, making it challenging to treat.
HOW RELEVANT IS THIS TO MY PRACTICE?
Hoarding can commonly lead to problems in both the social and environmental spheres, affecting the individual, family members, neighbours and the wider community, and resulting in isolation.(4-6) For instance, the clutter created prevents proper cleaning and impairs accessibility within the premises, thereby posing a fire hazard and increased health risks.(5) In the local context, a study has shown that the prevalence of hoarding is 2.0% in the community and 22.6% among sufferers of obsessive-compulsive disorder.(6) Coupled with the fact that over 80% of Singapore’s resident population lives in dense public housing, both the individual and the community could face loss of life and property due to the fire risk created by hoarding. As individuals with hoarding difficulties are often said to lack insight into their own behaviour(7) and are slow to seek help,(8) a non-clinical approach may be required to encourage affected individuals to seek recourse.
WHAT CAN I DO IN MY PRACTICE?
Doctors may, at times, be approached by someone other than the affected individual (e.g. family member, friend, etc) with complaints about the individual’s hoarding behaviour. In such cases, the most important advice is for that individual to seek medical attention for evaluation as well as further psychiatric assessment and treatment if the hoarding behaviour is deemed to be pathological. Hoarding is deemed to be pathological when the behaviour is associated with harmful effects on the individual or his family members, or when it causes “clinically significant distress or impairment in social, occupational or other important areas of functioning”.(1)
Referral to community and social services
An alternative community-based approach is to tap on resources such as the befriender services of organisations like the Singapore Association for Mental Health and the Singapore Anglican Community Services, or social services such as Family Service Centres to work with the individual, including performing home assessments. They can also persuade him to seek medical or psychiatric assistance when necessary. The hoarder can then be encouraged to get help to reduce or remove the clutter; should he give consent, these community organisations or even the respective town council may be approached for assistance to clear the premises.
Which government agencies are legally empowered to intervene?
Cases of hoarding can be referred to the Housing and Development Board (HDB) and the town councils, but they require the individual’s consent to intervene and enter the premises.(9-11) The police, who are often approached, have limited jurisdiction since hoarding within one’s residence is generally not a criminal offence.(12) The Singapore Civil Defence Force (SCDF) is the only enforcement agency with the legal power to intervene directly in hoarding cases without the hoarder’s consent. However, it can only intervene if the hoarding situation results in fire hazards and/or emergencies. In such cases, the SCDF is authorised to enter the premises to assess for fire hazards and serve a fire hazard abatement notice on the occupier or owner of the premises, who may or may not be the hoarder. If the individual fails to comply with the requirements specified in the notice or take the steps specified to prevent the recurrence of the fire hazard, he will be guilty of an offence.(13) In cases of compulsive hoarding, government agencies prefer a mediatory approach in which the HDB, the SCDF and grassroots leaders provide professional help, as hoarding is viewed as a behavioural problem.(9,13,14)
Seeking dispute resolution
The HDB has published some guidelines for residents who consider their neighbour’s activities to be a nuisance.(15) According to these guidelines, hoarding-related disputes must be resolved either through mediation via the Community Mediation Centre or by filing a claim with the Community Dispute Resolution Tribunals.(14) However, it must be noted that mediation can only be conducted with the consent of all individuals involved in the dispute. Furthermore, as mediation is a nonbinding form of dispute resolution, it might not yield satisfactory outcomes should there be irreconcilable differences in viewpoints and opinions.
The new Community Disputes Resolution Act,(16) which introduced a new statutory tort for the resolution of neighbourly disputes, was enacted in response to instances of friction between neighbours.(17) It complements current mediatory approaches by invoking the threat of criminal sanctions against recalcitrant offenders. In particular, the Act also addresses disputes involving mentally ill residents. Family members of the offender may be ordered to enter into a compliance bond to ensure that he goes for psychiatric assessment and/or treatment. If the offender remains recalcitrant and is found guilty of a criminal offence, the court that convicts the accused may serve a Mandatory Treatment Order(18) which requires the offender to undergo psychiatric treatment.(19) However, it must be noted that the Community Disputes Resolution Act seems to be targeted at more overt acts of unreasonable interference with a neighbour’s enjoyment or use of his residence(20) and may not address cases of hoarding within one’s residence.
Tapping on the Hoarding Task Force
When the aforementioned attempts have failed, parties adversely affected by an individual’s hoarding behaviour may consider invoking the law and seeking help from the Hoarding Task Force and its constituent agencies, by referring the case to the respective town council, HDB Branch Office or Family Service Centre. The task force was set up in late 2014 and involves the Ministry of National Development, Ministry of Health, Ministry of Social and Family Development, police, HDB, SCDF, National Environment Agency, People’s Association, and Institute of Mental Health. It brings together the expertise and respective powers of these public institutions to better tackle the issue of hoarding in the community.(21) The HDB functions as the lead agency looking into hoarding cases occurring in HDB flats and usually coordinates the case by bringing in the other members of the task force as required. The role of grassroots organisations and volunteers is invaluable to the task force, as legal remedies and reforms often do not take into account the unique nature of hoarding, which is not immediately apparent. Cooperation among enforcement agencies, government institutions and the grassroots will allow the task force to both receive information about and investigate such cases. However, it is important to note that in the absence of therapeutic or medical intervention and/or community support to address the root cause, the hoarding behaviour may recur in the cases referred to the task force.
Also, while the concept of the task force is appealing, its functions and powers remain largely unclear. Its existence and the available channels to report cases are not well known among doctors and the community at large. As such, the task force would benefit from greater publicity, better utilisation of existing community resources and the legal framework, and more coordinated integration of the functions and powers of its constituent institutions. Another possible limitation of the task force is its relatively limited powers of intervention for cases of hoarding occurring within private property.
You explained to Mr Tan that according to his account, his wife may be displaying hoarding behaviour, and that both medical and social interventions are available and could be helpful. Mr Tan was elated upon hearing what you had confidently explained. He would try to get Mrs Tan to seek medical consultation and also approach their nearby Family Service Centre for further assistance.
TAKE HOME MESSAGES
Hoarding is an excessive acquisition of objects and inability to part with possessions even though they appear to have no value. It can lead to excessive clutter, distress and disability.
Not all cases of hoarding are pathological.
There is legislation in place to address the issue of hoarding in the community.
Individuals who hoard should be referred for medical evaluation as well as community and social support. The law should be used as a last resort to deal with the adverse effects of their hoarding.
A Hoarding Task Force exists in Singapore and individuals can be encouraged to tap on it to help address the issue of hoarding in the community.
The authors would like to express their appreciation to Assistant Professor Calvin Ho Wai Loon of the National University of Singapore’s Centre for Biomedical Ethics for his assistance with the legal resources, as well as Dr Kelvin Ng Lin Chieh of the Institute of Mental Health’s Department of Community Psychiatry for information on the Hoarding Task Force.
|1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Washington, DC: American Psychiatric Association, 2013.
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|5. Pertusa A, Frost RO, Fullana MA, et al. Refining the diagnostic boundaries of compulsive hoarding: a critical review. Clin Psychol Rev 2010; 30:371‑86.
|6. Subramaniam M, Abdin E, Vaingankar JA, Picco L, Chong SA. Hoarding in an asian population: prevalence, correlates, disability and quality of life. Ann Acad Med Singapore 2014; 43:535-43.
|7. Tolin DF, Meunier SA, Frost RO, Steketee G. Course of compulsive hoarding and its relationship to life events. Depress Anxiety 2010; 27:829-838.
|8. Mackin RS, Arean PA, Delucchi KL, Mathews CA. Cognitive functioning in individuals with severe compulsive hoarding behaviors and late life depression. Int J Geriatr Psychiatry 2011; 26:314-21.
|9. Second Reading of HDB Amendment Bill 2015, 13 April 2015. Available at: http://sprs.parl.gov.sg/search/topic.jsp?currentTopicID=00007612-WA&curr.... Accessed August 8, 2015.
|10. Housing and Development Act 2004, c 229.
|11. Housing and Development (Common Property and Open Spaces) Rules 1999, c 129 r 3.
|12. Penal Code 2008, c 224.
|13. Fire Safety Act 2000, c 109A.
|14. Parliamentary Debate, "Number of reported cases of excessive hoarding in HDB flats", 11 November 2013. Available at: http://sprs.parl.gov.sg/search/topic.jsp?currentTopicID=00005289-WA&curr.... Accessed August 8, 2015.
|15. Ministry of Culture, Community and Youth. Guidelines for resolving disputes between neighbours. Available at: http://www.mccy.gov.sg/en/Topics/Community/Articles/Resolving_Neighbourl.... Accessed August 8, 2015.
|16. Act 7 2015.
|17. Setting the context for the Community Disputes Resolution Bill (13 March 2015). Available at: http://www.mccy.gov.sg/en/news/Parliamentary/2015/Mar/CDR2R-Speech1.aspx. Accessed July 11, 2015.
|18. Criminal Procedure Code 2012, c 68 s 339.
|19. Passing of the Community Disputes Resolution Bill (13 March 2015). Available at: http://www.mccy.gov.sg/en/news/Parliamentary/2015/Mar/CDR2R-Speech2.aspx. Accessed July 11, 2015.
|20. Community Disputes Resolution Bill 2015. Available at: https://www.parliament.gov.sg/sites/default/files/Community%20Disputes%2.... Accessed July 11, 2015.
|21. Tai J, Toh YC. Joint govt effort to better unclutter lives of hoarders. The Straits Times 2014 Sep 21.|