Individual Treatment for Hoarding
Hoarding is a difficult problem to treat. Neither medicine nor psychological therapies that work well for OCD seem to be as effective for hoarding. A special form of cognitive behavior therapy has been developed to treat hoarding. This method combines:
- elements of motivational interviewing
- several features of cognitive therapy and behavioral practice for OCD, and
- skills training
The treatment focuses on three hoarding behaviors:
- excessive acquisition
- difficulty discarding or letting go of possessions, and
- disorganization and clutter that impairs functioning.
The treatment is designed to be done in 26 weekly sessions with some sessions completed in the clients’ home. A more detailed account of the treatment can be found in the treatment manual and workbook by Steketee & Frost (2007a & b).
To get a sense of how the treatment is done, please look at the Nonshopping video and the Downward Arrow video in this section of the website. The Nonshopping video shows a session in which the therapist (Dr. Randy Frost) investigates a client’s beliefs about and attachments to an item that he wants to get. The therapist helps him identify thoughts and feelings about not getting it and to test what happens when he walks away without it. The Downward Arrow video explores thoughts and feelings about getting rid of possessions, and shows the testing of predictions about how this will feel. These videos can be used to show clinicians and clients how this portion of the treatment is done. More strategies for organizing and decision-making are described in the treatment manual.
Several outcome studies of CBT for hoarding have shown it to be an effective treatment. In their first study, Tolin, Frost, and Steketee (2007) found significant improvement after 26 sessions for 10 hoarding clients who completed the therapy. Half of the clients were judged to be “much” or “very much” improved at the end of treatment. The amount of improvement was related to how much homework clients completed. Importantly, among clients who completed most of their homework, 8 out of 10 were judged to be “much” or “very much” improved. In the most recent study of 40 people, those who received CBT showed much more improvement in their hoarding symptoms than clients who simply waited and did not get CBT for hoardingl (Steketee, Frost, Tolin, Rasmussen, & Brown, 2010). At the end of treatment, nearly 70% of hoarding clients were rated by their therapists as “much” or “very much” improved. Similarly, over 75% of hoarding clients rated themselves as “much” or “very much” improved.
"Downward Arrow"For more information about individual cognitive behavior therapy for hoarding disorder see:Steketee, G. & Frost, R.O. (2007). Compulsive Hoarding and Acquiring: Therapist Guide. New York: Oxford University Press.
Steketee, G. & Frost, R.O. (2007). Compulsive Hoarding and Acquiring: Workbook. New York: Oxford University Press.
Steketee, G., Frost, R.O., Tolin, D.F., Rasmussen, J., & Brown, T.A. (in press). Waitlist-controlled trial of cognitive behavior therapy for hoarding disorder. Depression and Anxiety.
Tolin, D.F., Frost, R.O., & Steketee, G. (2007). An open trial of cognitive-behavioral therapy for compulsive hoarding. Behaviour Research and Therapy, 45, 1461-1470.
Group Treatment for Hoardingby Jordana Muroff, Ph.D.
Group treatment may be especially useful in helping people with hoarding problems. When people with a similar problem come together, it can sometimes reduce isolation and shame. Groups can also increase motivation, a big issue for many with hoarding. Listening to others’ experiences and sharing ones’ own may inspire and instill hope. Group members can support one another with understanding how their hoarding behavior may be influenced by their thoughts and emotions and also assist each other with various skills (e.g., sorting, creating rules for acquiring) during group time and sometimes between group sessions.
Group therapy for hoarding typically includes 6 to 8 people who meet with a clinician once a week for 20 weeks. The group sessions cover understanding how hoarding works, problem-solving and organizational skills, sorting and removing possessions, and decreasing the tendency to get more things. These strategies are described in Steketee and Frost’s (2007) client workbook and in Tolin, Frost and Steketee’s (2007) Buried in Treasures. Groups sometimes arrange home visits by the group leader to help each participant apply the skills at home where the problem is based. A recent study of the effects of group cognitive behavioral treatment (CBT) for hoarding showed moderately good benefits for the participants (Muroff et al., 2009). Additionally, group treatments have been found helpful for problems that are commonly linked to hoarding such as social anxiety and depression.
Group treatment may also take the form of self-help support groups for hoarding. These groups can include more participants and can be led by peers or trained coaches who are not necessarily mental health professionals. Participants in a recent study of the benefits of self-help groups that were led by undergraduate student coaches showed much improvement in their hoarding problems (Pekareva-Kochergine & Frost, 2009). Self-help support groups can also be web-based. In these, participants correspond through internet chat groups, postings, and other methods. A recent study evaluated an internet CBT-based self-help group that has been peer-led for over 10 years. On-line group members reported moderate improvement, especially those who had been in the group for longer periods (Muroff et al., 2010).
Because there are relatively few mental health providers who are trained in interventions aimed to reduce hoarding, group interventions are good alternatives that give more people access to clinicians and coaches who can help. Group methods may also be more affordable for hoarding sufferers.
Treatment and TechnologyJordana Muroff, Ph.D.
Technology, such as the internet, can support hoarding interventions. The internet lets people across the world connect with others with similar problems. For example, an internet-based self-help group for hoarding has been in existence for over 10 years. This peer-led support group provides a variety of resources for reducing clutter and controlling acquiring. For example, some information is aimed at understanding one’s thinking patterns to help people who hoard correct faulty beliefs about objects and their use. Participants can also post actions steps and recent progress toward their goals. They often share techniques, resources, and home photographs with each other. This intervention has been evaluated and has shown significant benefit (Muroff et al., 2010), especially for people who were more engaged in posting to the group and who remained in treatment for longer periods.
People with hoarding problems have also been included in studies that tested the benefits of treatment done with a clinician via videoconferencing. This method showed good success (Himle et al., 2006), although the equipment needed was expensive and requires the person to come to a special clinic location to be filmed for the conference.
Several new technology-based interventions are being developed to reduce hoarding. A recent pilot study tested the effects of CBT treatment delivered via a web camera mounted on a home laptop. Again, moderate benefits resulted from this method (Muroff et al., 2009). This technology is fairly simple to use because it employs readily available equipment and inexpensive software that requires only basic computing skills. Additionally, portable laptops and wireless internet enable people to work on their hoarding in almost any part of their home.
Some people worry that the use of technology may get in the way of the therapist and client developing a good relationship. However, studies have shown that this is not the case and that the relationships are as good as those developed in face-to-face treatment sessions. Technology enables clinicians and trained coaches to do more home-based practice so that items do not need to be brought in to the office and new skills do not need to be practiced again in the person’s natural environment. Clinicians are also better able to observe progress and/or safety concerns without having to make an in-person home visit. Other benefits include the reduced cost of travelling to therapy and reduced stigma some clients feel when they go to a therapist’s office.
Thus, technology-supported hoarding treatments help people get high quality hoarding information, treatments and trained practitioners that may not be available locally. Technology-supported treatments may be used with face-to-face visits or may substitute office-based treatments. More research is also needed to determine how these methods affect hoarding behavior and who may benefit most from technology-supported