Challenging Dogma


...Using social sciences to improve the practice of public health

Monday, April 30, 2007

Why Local Board of Health Regulations are Ineffective in Addressing the Public Health Impacts of Animal Hoarding-Kathleen MacVarish

The Massachusetts Constitution (1) provides governmental powers to cities and towns which allow for the adoption of local ordinances and by-laws. This is commonly referred to as home rule. Further, the Massachusetts General Laws Chapter 111: Section 31 provides authority for Boards of Health to make reasonable health regulations (2). In Massachusetts there are 351 cities and towns which are governed by either a Board of Health or Health Commission; either governing body has the ability to adopt local health regulations. This authority has resulted in the adoption of many local regulations that impact public health covering areas such as abrasive blasting, body art, dredging, dumpsters, hazardous materials, land application of sludge and tobacco (3).

Background
In the summer of 2005 the Randolph Board of Health received a housing complaint involving a single family home and an excessive number of cats living in the home. Boards of Health in Massachusetts are charged with enforcing the State Sanitary Code 105 CMR 410.000: Minimum Standards of Fitness for Human Habitation (4). The Randolph Board of Health Agent obtained permission to enter the home for inspection along with the Massachusetts Society for Prevention of Cruelty to Animals (MSPCA). A cat hoarding situation was identified and the Board of Health, in close cooperation with the MSPCA, took immediate action. Approximately 25 cats were removed from the home by the MSPCA and the Board of Health initiated enforcement efforts to achieve compliance with the minimum standards set forth in the State Sanitary Code.

To resolve this case considerable time and effort were expended by the Board of Health members and the Board of Health staff. The workload stressed the resources of this small town department (3 staff members and 3 volunteer Board of Health members). In an effort to preserve the Board’s limited resources and to prevent future cat hoarding issues in the town, the Board adopted a regulation that stipulated that no person within the Town shall keep more than three cats/kittens and if they do, they shall be punished with a fine (5).

Failure to Consider the Complexities of Hoarding Behavior
Hoarding is a complex behavior associated with many different mental disorders and has been defined as “the accumulation of possessions that are useless and that interfere with the ability to function” (6, 7). While severe hoarding has serious health consequences, the information available about this behavior is diverse, not well integrated and lacking in details about the frequency and severity of the problem. Also lacking is an understanding of the nature of compulsive hoarding (is it a symptom of another disorder or one in its own right?), a formally recognized diagnosis and successful treatment options (8, 9).

Efforts have been made to characterize this multi-faceted problem and a systematic definition with three characteristics has been proposed by Frost and Hartl (10 p. 906):
1. The acquisition of, and failure to discard a large number of possessions that appear to be useless or of limited value;
2. Living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed;
3. Significant distress or impairment in functioning caused by the hoarding.

The reasons that local Boards of Health get involved in hoarding cases include concerns for the health and safety of the individual hoarders, their families, their neighbors, and the general public. These concerns include fire hazards, egress issues, safety (trip and fall) hazards, health concerns, and lack of access for emergency personnel. These are difficult cases to manage as individuals who come to the attention of the Board of Health for hoarding face possible home eviction, homelessness, enforcement orders, court actions, and expensive cleanup efforts. They also face pressure from family, friends and neighbors and may suffer from anxiety, shame, helplessness and frustration (11).

The hoarding of animals is even less well understood than general hoarding behavior and there is a lack of scientific attention, psychiatric research, formal recognition and systematic reporting for it (12, 13, 14). As with general hoarding behavior, what distinguishes the syndrome is not how many items are accumulated or collected (in this case animals) but the fact that the individual is overwhelmed by the ability to provide acceptable care. Dr. Patronek defined an animal hoarder as “someone who has accumulated a large number of animals, which has overwhelmed that person’s ability to provide even minimal standards of nutrition, sanitation and veterinary care; failed to acknowledge the deteriorating condition of the animal (including disease, starvation and even death) and the household environment (severe overcrowding, very unsanitary conditions) and failed to recognize the negative effect of the collection on his or her own health and well-being, and on that of other household members” (15, p. 1).

Animal hoarders may have dozens to scores of animals in their home; both living and dead. When officials get involved, many animals face euthanasia due to poor health (from inadequate living conditions and inadequate medical care) and poor socialization. Self-neglect and neglect of dependent family members is of real concern and sanitary conditions in the home can also deteriorate to the point that officials may have to consider condemnation. Frequently observed sanitation problems include: an accumulation of feces and urine; filth of the dwelling, furniture and other items; and inoperative appliances and basic utilities. Additional health hazards are created for the residents and neighbors that include exposure to zoonotic diseases, respiratory irritants (ammonia), potential insect and rodent infestations and community nuisance odor conditions (13, 15).

The Regulation that the Randolph Board of Health adopted failed to recognize that hoarding behavior, especially when animals are involved, is a complex issue that is not well understood and is difficult to diagnose and treat. A regulation that simply states that you can not have more than three cats will have little impact on an individual who exhibits hoarding behavior.

Failure to Consider the Transtheoretical and Cognitive Behavior Therapy Models
Compulsive hoarding is traditionally thought of as a condition where the hoarder is resistant to treatment. In fact, many hoarders don’t recognize they even have a problem. Animal hoarders not only lack insight into their living conditions but are often in denial about the risks and harm to the animals that they claim to love; they often strongly believe that they are providing proper care (13). However, research studies show that dead or sick animals were discovered in 80% of reported cases and nearly 60% of the hoarders involved would not acknowledge a problem (14). This denial and the lack of successful treatment models lead to a high recidivism rate; estimated to be between 60% – 100% (14, 16).

Despite these facts, after one animal hoarding incident in Randolph, the Board of Health quickly decided to adopt a local regulation at their September 12, 2005 meeting, to be effective on Monday, October 3, 2005. This simple, four paragraph (187 word) regulation states little more than “No person, firm or corporation shall keep within the Town, in any building, or on any premises…. or house any more than three cats/kittens for a period of time not to exceed six weeks… whoever violates any provisions of the foregoing regulation or order made thereunder shall be punished by a fine of $25.00 dollars for each day such violation continues”.

The Board of Health crafted and adopted this regulation without public input and without discussion with interested stakeholders such as the Board of Selectmen, Animal Control Officers, local Veterinarians and mental health experts, and the Town’s Animal Welfare Committee. The Regulation provided no treatment options or community resources and certainly did not account for any of the complex social and behavioral issues that surround hoarding behavior.

The Randolph Board of Health should have considered the transtheoretical and the cognitive behavior therapy models to develop an approach to deal with the public health impacts of hoarding behavior. The Transtheoretical Model (TTM) has three components: states of change, processes of change; and levels of change. There are five stages of change (precontemplation; contemplation; preparation; action; maintenance) that are facilitated by different processes. These different processes must be matched to the particular stage an individual is in for effective treatment (17). As explained above, hoarders exist in the pre-contemplation stage; they are not even considering changing their behavior because they are unaware they have a problem. When these matters come to the attention of public health officials or concerned family members, hoarders can be moved to the contemplation stage. While they may now have some understanding that they do indeed have a problem, many are ambivalent or even unwilling participants, in treatment (18).

If hoarders are successfully moved through the contemplation stage and into the preparation stage, cognitive behavior therapy (CBT) has been shown to have some success (18, 19). The CBT model suggests that the symptoms of hoarding (excessive acquisition, difficulty discarding and clutter) are the result of three factors: information processing deficits; maladaptive beliefs about, and emotional attachment to, possessions; and emotional distress and avoidance (20). CBT helps patients to organize, to make decisions, to distinguish between items of real and perceived value and to begin the cleanup. The patient must be made aware that treatment is a long and difficult process (18).

If hoarders move into the action stage, the CBT model can be utilized to develop a treatment protocol. One treatment protocol proposed by Tolin et al. involves a multi-method assessment and motivational interviewing to evaluate the patient and plan the treatment. These sessions take place in the therapist’s office and in the patient’s home. The treatment plan involves interventions that target the three manifestations of hoarding: disorganization, compulsive acquisition and difficulty discarding (20). Successful treatment of hoarding is rare but if one is successful, the maintenance stage is critical to avoid recidivism. Further research is needed to explore effective hoarding treatments (19).

The Randolph Board of Health should have considered the complexities and the unknowns when it comes to successful treatment of hoarding behavior when they developed their plan of action to address hoarding in their community. They should not have relied only on a punitive regulation which does not take into account the necessity of treatment for this problem.

Failure to Consider Addiction Models
Similarities have been noted between hoarders and others with impulse control problems such as substance abusers and compulsive gamblers (15). An addictions psychiatric model has been suggested for animal hoarding due to the similarities to substance abuse: preoccupation; denial of the problem; excuses for the behavior; social isolation; and self-neglect (14). Due to these similarities, the Randolph Board of have should have given consideration to the unsuccessful attempts to control substance abuse with punitive measures during their regulation development process.

Decades of research on substance abuse and the criminal justice system illustrate that punitive measures such as imprisonment and fines are not effective at preventing or controlling the addictive behavior. In fact, the percentage of drug offenders in the federal prison system has increased from 25% in 1980 to 59% in 1998 despite stricter drug laws, “three strikes and you’re out”, and mandatory minimum sentencing. Untreated substance abusers are more likely to relapse and resort to criminal behavior. What does seem to work is treatment of the substance abusers and it has been estimated that for every dollar invested in treatment, approximately $7 in future costs are saved (21, 22, 23).

Successful treatment requires an appreciation for the cognitive and behavioral processes that influence personal choice; punishing individuals rather than understanding these processes won’t lead to successful rehabilitation (24). A treatment approach with multiple options that integrate public health and public safety is an effective strategy for reducing crime and substance abuse (25).

In response to efforts by communities to prosecute animal hoarders Dr. Patronek states “Besides being inefficient and expensive, this moves what may be a mental or public health issue into the criminal justice arena, which can impede timely recognition of important health issues and delivery of needed services….Prosecution offers at best an incomplete solution…” (12, p. 86).
Regulators whose goal is to address the public health impacts of hoarding should incorporate this body of knowledge into their approach. While an initiative may include the adoption of regulations, it should not be the only solution. There must also be recognition of the social and behavioral factors that influence individuals and impact effective treatment options. A suggestion for a successful community initiative to address hoarding behavior includes creating a community task force which will work to: identify community resources (i.e. mental health agencies, legal aid services); identify individual resources (i.e. health insurance); initiate connections to these resources; provide information and referrals; and develop programs to treat hoarders (11).

Conclusion
While the actions of the Randolph Board of Health were well-intended and properly executed they failed to address the actual root cause of the behavior that created the public health problem and were therefore futile. Other communities have attempted to prevent or remedy hoarding by passing local ordinances similar to Randolph’s but there is no data to support their effectiveness. What the literature and news reports indicate is that these regulations are “widely unpopular, difficult to enforce, and likely to be opposed by a broad coalition of pet fanciers, breeders, rescue groups, and animal protection organizations” (15, p. 3). For a number of reasons the Randolph Board of Health did rescind their regulation in January of 2006. Residents quoted in the local newspaper summed up the issue: “The proposed three cat limit in Randolph is an awful idea. While wanting to prevent animal hoarding is admirable, the people who hoard will not care about the limit” (26) and “… the regulation didn’t address the problems” of hoarding and the health issues they cause (27).

References
1. Massachusetts Government. Massachusetts Constitution. http://www.mass.gov/legis/const.htm.
2. Massachusetts Government. Massachusetts General Laws. http://www.mass.gov/legis/laws/mgl/111-31.htm.
3. Massachusetts Association of Health Boards. http://www.mahb.org/Library/library.htm.
4. Massachusetts Government. State Sanitary Code. http://www.mass.gov/Eeohhs2/docs/dph/regs/105cmr410.pdf.
5. Randolph Board of Health. Cat Regulation adopted on Monday, September 12, 2005. Randolph, MA, 2005.
6. Maier, T. On Phenomenology and Classification of Hoarding: A Review. Acta Psychiatrica Scandinavica 2004; 110(5): 323.
7. Frost R, Steketee G, Williams L. Hoarding: A Community Health Problem. Health & Social Care in the Community 2000; 8(4): 229.
8. Frost R, Hartl L. A Cognitive-Behavioral Model of Compulsive Hoarding. Behavioral Research and Therapy 1996; 34(4):341-50.
9. Obsessive Compulsive Foundation Compulsive Hoarding Website. Roadblock to Successfully Treating Compulsive Hoarding. New Haven, CT: http://www.ocfoundation.org/hoarding/treatment.phpttp.
10. Sketekee G, Frost R. Compulsive Hoarding: Current Status of the Research. Clinical Psychology Review 2003; 23: 905-927.
11. Hoarding Task Force. Hoarding: Too Much Clutter—A Resource Guide. Hampshire, Hampden & Franklin Counties, MA.
12. Patronek G. Hoarding of Animals: An Under-Recognized Public Health Problem in a Difficult to Study Population. Public Health Reports 1999; 114: 81-88.
13. Hoarding of Animals Research Consortium. Health Implications of Animal Hoarding. Health and Social Work 2002; 27(2) 125-136.
14. Frost R. People Who Hoard Animals. Psychiatric Times 2000; 17(4).
15. Patronek G. The Problems of Animal Hoarding. Municipal Lawyers 2001; 19: 6-9.
16. Patronek G. Animal Hoarding: A Public Health Problem Veterinarians can take a Lead on Solving. Journal of the American Veterinary Medical Association 2002. http://www.avma.org/onlnews/javma/oct02/02105a.asp.
17. Wikipedia. Transtheoretical Model. http://www.wikipedia.org/wiki/Transtheoretical_Model.
18. Obsessive Compulsive Foundation Compulsive Hoarding Website. Motivation and Compulsive Hoarding Treatment. New Haven, CT: http://www.ocfoundation.org/hoarding/treatment.phpttp.
19. Frost R, Skeketee G, Kamala A, Greene M. Cognitive and Behavioral Treatment of Compulsive Hoarding. Brief Treatment and Crisis Intervention 2003; 3 (3): 323-337.
20. Tolin D, Frost R, Steketee G. An Open Trial of Cognitive-Behavioral Therapy for Compulsive Hoarding. Behavior Research and Therapy 2007; 1(1).
21. Executive Office of the President Office of National Drug Control Policy. Drug Treatment in the Criminal Justice System. Drug Policy Information Clearinghouse Fact Sheet, 2001.
22. National Institute of Health National institute on Drug Abuse. Treatment for Drug Abusers in the Criminal Justice System. NIDA Info Facts, 2006.
23. National Library of Medicine TIP 44. Substance Abuse Treatment for Adults in the Criminal Justice System. http://www.ncbi.nlm.nih.gov/books.
24. Committee on the Addictions of the Group for Advancement of Psychiatry. Responsibility and Choice in Addiction. Psychiatric Services 2002; 53(6) 707- 713.
25. American Correctional Association On the Line. The National Criminal Justice Treatment Practices Survey. 2004 27(3).
26. Patriot Ledger Article. Reader’s View: Cat Limits Awful. November 18, 2005. http://www.ledger.southofboston.com/articles/2005/11/18/opinion/opin04.txt.
27. Patriot Ledger Article. Cat Limit on Hold, Could be Ending Ninth Life. November 29, 2005. http://www.ledger.southofboston.com/articles/2005/11/29/news/news07.txt.

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