For the 2016 Annual OCD Conference

1. Family Support and Intervention for Hoarding:
Introduction to Family-As-Motivators Training
Gregory S. Chasson, PhD
Department of Psychology
Illinois Institute of Technology
Chicago, IL
Alexandria M. Luxon
Sophia Alapati
Kristine Powers
Priyanka N. Divecha
Department of Psychology
Towson University
Towson, MD

2. 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.

3. 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

4. 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

5. ♫ 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

6. 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
).

7. 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

8. 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. Psychoeducation
2. Motivational Interviewing Training
3. Harm Reduction
4. Family Accommodation Prevention

9. 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

10. 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

11. 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

12. 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

13. 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)Collaboration
2)Evocation
3)Autonomy

14. 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 directive
4) Don’t take sides
5) Avoid blaming
6) Premature focus trap
•Complete MI Spirit exercises (worksheet adapted from
Rosengren8
)

15. Motivational Interviewing Training
Session 4 continued
•Introduce and define Stages of Change, with handout
(adapted from Whalley14
)
1) Precontemplation
2) Contemplation
3) Preparation
4) Action
5) Maintenance
•HW: Driving in Cars (adapted from Rosengren8
)

16. 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

17. 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

18. 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 situation
4) A willingness to commit to change
5) A recent history of taking steps to change

19. 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 resistance
2) Decreased discussion of the problem
3) Sense of resolve
4) Increase in change talk
5) Questions about change
6) Envisioning life after change
7) Experimenting with change behavior

20. 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

21. 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

22. 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 quickly
3) Reversing
4) Reframe problem
5) Acknowledge with a twist
6) Emphasize personal choice and control
7) Side with the negative
8) Encourage pacing
9) Feeling angry is okay, but try not to show it

23. 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

24. 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 CH
A. Priority = Decrease harmful
consequences of high-risk behavior
B. WITHOUT necessarily requiring the
individual to stop CH fully1-3
.

25. Harm Reduction
Session 8 continued
•Introduce principles of Harm Reduction for CH, from
Tompkins and Hartl3
1) Do no harm
2) Stopping all CH is NOT necessary
3) No two hoarding situations are alike
4) Loved one is essential member of treatment team
5) CH may not be the most pressing problem

26. Harm Reduction
Session 8 continued
•Discuss setting the stage for harm reduction
1) Letting go (with exercise from Tompkins and Hartl3
)
2) Understand
3) Forgive and introduce the 4 A’s from Tompkins and Hartl3
• Acknowledge
• Assign reasons
• Assure patterns won’t be repeated
• Ask for forgiveness
1) Grab hold with exercise from Tompkins and Hartl3

27. Harm Reduction
Session 8 continued
•HW: Read the following
1) “List of Forgiveness Resources” handout
2) 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

28. Harm Reduction
Session 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 honest
2) Be prepared
3) Explain assessment goals to loved one
4) Answer loved one’s questions
5) Complete the “Harm Potential Assessment Form”3
6) Leave time to chat

29. Harm Reduction
Session 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 conditions
2) Physical limitations
3) Alcohol or drug problems
4) Psychological conditions
• Acquisition factors  “Assessing Acquisition Factors”
handout from Tompkins and Hartl3

30. Harm Reduction
Session 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

31. Harm Reduction
Session 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

32. Harm Reduction
Session 10 continued
•Create a harm reduction plan, which includes 4
components3
• Realistic goals
1) Concrete and specific
2) Doable
3) Prioritized
• Monitoring progress
• Management strategies for
1) Reducing financial risk
2) Improving living situation
3) Facilitating saving and organizing
• Harm Reduction Contract
• Provide example contract

33. Harm Reduction
Session 10 continued
•Role Play 6: Creating the harm reduction plan
•Wrap up FAM Training
1. Review of components
2. Seek feedback about the program

34. 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 to
hoarding: 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

35. 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

36. Thank you!!!
Gregory S. Chasson, Ph.D.
Licensed Psychologist
Associate Professor
Department of Psychology
Illinois Institute of Technology
gchasson@gmail.com