Hoarding is a unique compulsion, so different from others that the DSM 5 now designates it as a separate disorder rather than a specific form of obsessive-compulsive disorder, as it was covered in earlier editions.
Heather M. Chik, Ph.D., who gave a presentation at the Indiana Psychological Association’s Fall Conference, said hoarding is so different from OCD that pharmaceutical drugs (antidepressant SSRIs) that often help relieve symptoms of other compulsive disorders are ineffective in hoarders.
“We need a different strategy,” Chik told about 40 listeners in a breakout session of the conference Nov. 7-8 in the Hilton North Indianapolis.
Psychologists interested in treating hoarding should attend continuing education courses, such as the one she conducted at the conference, and read updated publications from experts, Chik said. She recommended Stuff: Compulsive Hoarding and the Meaning of Things by Randy O. Frost, Ph.D., and Gail Steketee, Ph.D. (2010) Houghton Mifflin Harcourt Publishing Co., New York, N.Y.
Frost and Steketee also authored two guides on the treatment of hoarding, one for therapists and the other as a client’s handbook, which can be downloaded from the Oxford University Press website, she noted.
Chik said hoarding presents in many forms, including hoarding animals – often seen in headlines when scores of malnourished cats or other animals are removed from a home – or clothing, books, magazines, newspapers, practically any type of consumer goods or a mix of items so varied that it seems the hoarder will not dispose of anything once it comes into his or her possession.
“About 75 percent of hoarders engage in excessive buying,” she said, often creating a financial strain that causes friends or family members to urge them to seek treatment. Even those who hoard free items, such as stray animals or discarded goods, soon amass so much that living space is taken over.
In many cases, the outside agent may be civil authorities, such as animal control officers, housing code enforcers, fire marshals or the courts, which may remove children or the elderly from a home deemed unfit because of hoarding.
But, Chik said, forced removal of hoarded items doesn’t work for long. The hoarder is soon amassing more. She said hoarding is a problem that generally grows worse with age.
Hoarders typically assign undue value to goods collected and don’t see the clutter, she said. They enjoy acquiring more and have great difficulty discarding, even when the hoarding causes them shame to the point that they no longer invite anyone into their homes. Chik said hoarding usually involves problems with self-worth and is often co-morbid with other disorders, such as depression or ADHD.
Treatment commonly will involve weekly session for six months to a year, with assessment likely to occupy the first two to four sessions. “We need to know what part of them to work on,” Chik said.
Assessment would be followed with about two sessions on treatment planning, then two to three sessions on limiting further acquisitions and 15 to 20 sessions on developing coping and organizing skills and problem solving. The work cannot all be done in the psychologist’s office, she said. “As part of your evaluation you are going to go to the home.”
During the home visit, the therapist should not touch the hoarded materials but should help the patient designate an area where homework material will be kept so it is readily accessible and won’t be lost in the clutter.
Photographs should be taken so that as the problem is reduced, the patient can see the gains. Teaching a hoarder to discard will face strong resistance and the patient should retain full control of what goes first, usually starting in the easiest or most beneficial area, such as hallways or stairways.
It is also helpful to train a friend or neighbor of the hoarder as a “coach” or cheerleader to reinforce reducing acquisitions and discarding clutter. The first exercises in reducing acquisitions involve “walk-throughs” in which the hoarder is accompanied to a store or wherever he or she usually gets “stuff” and must walk through without touching anything and leave empty-handed.
Later, the therapist or coach will accompany the hoarder on “touch-only” outings, where the hoarder can pick up items but must leave without buying them. Chik showed a short video on a therapist working with a man in his 40s who hoarded cookbooks. They entered a bookstore and went to the cookbook section, where the man was allowed to leaf through the books. He found one with a recipe he said he would really like to try, but the therapist had him return the book to the shelf.
Outside the store, the therapist asked how strong the man’s urge was to acquire the book on a scale of 1 to 10. He replied it was at least a 9 and he really wanted to go back into the store and buy that book. The two then walked a block or so away and he was asked again to rate his urge to buy. He said it was then about 6 or 8.
Chik said such exposure continues until the patient is able to go alone into wherever the hoarded items are sold without buying anything.
All along, the therapist helps the patient develop values on what is really important to them, such as family, being able to receive friends in the home and making the home more personally comfortable.
Once the patient is controlling acquisitions so the problem is not getting worse, the process of discarding can begin – again with the patient in charge. As noted earlier, the process should begin with the easiest areas, then establish a sorting area to begin a systematic room-by-room review over time of items amassed.