Hoarding behaviors (excessive collection, difficulty discarding, and accumulation of large amounts of items) can become a debilitating public health problem that can lead to home eviction resulting from violation of building, fire, or property maintenance codes. Embarrassed by their hoarding, individuals rarely seek treatment and keep the problem hidden. Only in emergencies (such as a water leak, fire, or pest infestation) does this problem come to the attention of a landlord or family member. Current treatments for hoarding behaviors include selective serotonin reuptake inhibitors (SSRIs) and specialized cognitive-behavioral therapy (CBT). Taken together, hoarding behaviors represent a significant safety risk for the individual and the community, and treatments are available.

Eviction Intervention Services (EIS), founded in 1984 by Gloria W. Milliken, was designed to help individuals on the East Side of Manhattan at risk of eviction for any reason. These services are provided by both legal and housing advocates. Despite the efficacy that EIS has achieved in the court system for individuals at risk of eviction because of nonpayment, the judges and EIS organizers felt that individuals with hoarding behaviors needed a more individualized approach, because of the tenacity of the problem and therefore the continued threats of eviction.

A targeted intervention for individuals with hoarding behaviors was started by EIS in January 2009. This program combines on-site legal services for tenant housing issues along with a support group, workshops, educational material, referrals to other social services and resources, home visits, emotional support, and individual counseling sessions coordinated by a social worker. After intake, the social worker and the client create a personalized plan that takes into account the client's treatment preferences (individual or group support; legal counsel or management agency mediation). In crisis cases, where eviction is imminent and clients are unable to pay for the removal of items and cleanup of their homes, EIS will provide funding for a deep-cleaning service. Individualized attention by a social worker (including individual weekly meetings and reaching out to no-show participants) encourages attachment to the program.

Since the program's inception, 22 individuals with hoarding behaviors have participated. Demographic characteristics of current clients are 62% female and 80% white (the other 20% are evenly represented by African Americans and Hispanics), with a mean±SD age of 61.4±9.1 years. Forty-six percent of the clients are retired, 31% are unemployed, and 23% are employed. Most clients (77%) live alone. Most are single or never married (64%), 18% are divorced, and 18% are married or living with a partner.

With funding from the New York State Office of Mental Health Policy Scholar Program, Dr. Rodriguez initiated a collaboration between EIS and the Anxiety Disorders Clinic (ADC) at the New York State Psychiatric Institute. The goal of this collaboration is to promote the diagnosis and treatment of individuals with hoarding behaviors within New York City. Although this population is typically reluctant to seek psychiatric treatment, the threat of eviction is a strong motivation to seek such help. Building on the trust that EIS fosters with clients, this collaboration represents a unique opportunity to engage individuals who have not been visible to the mental health care system.

Case example: Susan, a 60-year-old, single Caucasian woman living alone had a water leak that was weakening her neighbor's wall. Because of embarrassment about her hoarding, she ignored multiple letters from the management company that sought access to her apartment over a three-month period. When Susan received an eviction notice, she contacted EIS; reluctantly, she agreed to crisis intervention with a full cleaning service and legal representation. In court, the lawyer was able to postpone her eviction with evidence that Susan sought help from EIS and was cooperating with the plumbing repairs. However, several months after the cleaning, the clutter had reaccumulated. Susan then accepted personalized EIS services, including weekly home visits from a housing advocate and weekly individual sessions with a social worker. Building on her confidence in EIS, Susan agreed to accept a referral to ADC. At ADC intake, major depression was diagnosed, and after a course of an SSRI and CBT, her mood and energy improved. With the help of EIS and ADC, she has changed her behavior in a meaningful way to minimize clutter and prevent eviction.

None of the participants in EIS's targeted program for hoarding behavior have been evicted, and two individuals are now actively engaged in psychiatric care. The goal of our collaboration is to track long-term outcomes and determine which interventions protect against eviction in order to increase the safety and health of individuals and the surrounding community.