Treatment of HD – Cognitive Behavioral Therapy (CBT)

Cognitive behavioral therapy (CBT) is designed for use by mental health clinicians who are treating clients with hoarding disorder (HD). It can also be used effectively by novice therapists and non-mental health professionals, as well as by peers or other laypersons who are well trained in understanding HD and in how to use these therapy methods. Whenever possible, regular practice inside the client’s home with help from home visitors (clinicians, coaches, peers, etc.) is recommended.  A study of CBT methods designed to treat hoarding disorder has indicated that 70-80% of people undergoing CBT were much or very much improved after 9 to 12 months of treatment, and these improvements were largely maintained one-year after treatment ended. However, it is important to be aware that most people who receive treatment still need additional help to fully resolve their hoarding problems.

The CBT protocol described here was developed by Drs. Randy Frost and Gail Steketee. It is designed for 26 weekly sessions over the course of 6 – 9 months. More sessions may be needed for people with severe HD, people who have other mental health issues, or for those who are ambivalent about working on their HD. Each treatment session follows a basic format – a brief check-in is followed by a review of homework and setting the session agenda. The therapist and client then work together on tasks during the session and end by setting homework for the coming week.

The components of CBT and the approximate number of sessions needed for each are:

  • Assessment of hoarding symptoms and other concerns: 2 sessions
    • NOTE: These sessions may take longer than the standard 1 hour.
  • Formulating a personal model to understand why the person hoards: 2 sessions
  • Motivational interviewing to address ambivalence and low insight: Ongoing as needed
  • Skills training for categorizing, organizing, and problem solving: 3 or more sessions
  • Practicing sorting, decision-making, and discarding: 15 or more sessions
    • It is recommended that clinicians allot up to 2 hours for home visit sessions.
    • For in-office sessions, therapists can stick to the standard 1 hour and invite clients to bring in items to practice sorting and problem solving skills, as well as decision-making about keeping or discarding.
    • Once the client has learned organizing and decision-making skills (usually after at least 15 sessions of practice), when the home is heavily cluttered, he or she might decide to work with a closely supervised “cleaning crew” in their home in order to make substantial progress in reducing clutter. Such an effort must have explicit permission from the client and should be carefully supervised by the therapist as the crew follows rules established by the client.
    • NOTE: It is very important to be aware that forced cleanouts by public authorities or relatives almost always lead to angry and hurt reactions and can make the treatment process much more difficult. Such cleanouts should only be used when required for health and safety, and should involve the person with HD as much as possible in the decision-making about possessions.
  • Cognitive therapy: Ongoing during most aspects of therapy and especially the sorting sessions
  • Preventing relapse: 2 final sessions

It is recommended that treatment involve regular home visits and visits to settings where clients have difficulty controlling their acquiring (e.g. flea markets, yard sales, shopping centers). Home visits help clinicians understand the context for the person’s hoarding behaviors and whether there are serious safety concerns that need to be addressed immediately (for example, fire risk, infestations, or other health concerns). In some cases, the use of photographs and/or video web connections (e.g., Skype) are especially useful as they enable the clinician to observe progress and participate in client activities within the home without having to travel.

The order of the CBT components listed above will vary depending on the client’s particular hoarding symptoms. Clinicians can rotate the focus among non-acquiring, sorting/organizing, and discarding. Many clients find it easier in the beginning to gain control over their acquiring and to develop the home organizing plan than to make decisions about discarding. However, some clients find that clearing clutter is their first goal and can tolerate the distress this brings. Progress on de-cluttering will depend on the client’s ability to change their thinking and reduce their emotional distress about “losing” possessions. Clinicians use discussion and cognitive therapy methods to help with this work.

Below are brief summaries of the therapy techniques listed above for treating HD:

Assessment. Therapists begin by reviewing the client’s specific HD symptoms, how they interfere with everyday living and whether they cause safety problems, and whether the person has other physical and/or mental health issues that might affect treatment.

Formulating a personal model of hoarding behavior. The therapist explains the causes of HD and helps the patient understand how their own symptoms developed into a serious problem in their life.  Causal factors typically include psychological vulnerabilities, problems with processing information, beliefs about the importance of objects, and emotions that are associated with those beliefs, both positive (pleasure, enjoyment) and negative (anxiety, guilt, sadness). Together, the therapist and client consider how these experiences have contributed to excessive acquisition, excessive saving, and clutter.

Motivational interviewing. Motivation for change is sometimes a problem in HD treatment. Motivational interviewing (MI) techniques are used throughout this treatment to help clients carefully consider how their hoarding behaviors fit with their own values and goals in their lives. Click here for more specific information on MI.

Reducing excessive acquisition. Initially, the therapist may encourage patients to avoid situations that are hard for them to resist because of strong urges to acquire. Gradually, however, clients are helped to expose themselves to increasingly challenging acquisition triggers. For example, they might first drive by a favorite store without going in, then enter the store but not touch anything, and then pick up and examine items but not buy them. This practice can begin in locations that are easier to resist and progress to more challenging ones.

Skills training. Hoarding is associated with a wide variety of information processing problems that lead to certain skill deficits. Among these are difficulty staying focused on tasks, problems with organizing items into logical categories, and limited ability to plan ahead to accomplish goals and to solve basic problems. Click here for more specific information on skills training.

Practicing letting go of possessions. Most clients are encouraged to work their way from easier to harder items as they make increasingly difficult decisions about whether to keep or part with their possessions. Some categories of items (especially sentimental ones) may be especially difficult and can be tackled later in the exposure process. Exposure provides an opportunity to learn to tolerate negative emotions, and also to challenge their beliefs about discarding.

Cognitive therapy for hoarding beliefs. Clinicians encourage patients to notice their thoughts and feelings about possessions in acquiring and discarding situations. They explore dysfunctional beliefs about possessions, including beliefs about future usefulness, concerns about waste, sentimental attachments, and the need to remember. Clinicians help clients to develop a series of questions about possessions to help them evaluate the accuracy and usefulness of their thinking. Therapists use various cognitive methods to help patients evaluate the validity of their beliefs and to consider alternative behaviors when their beliefs don’t seem sensible.

Relapse prevention. Once clients have made good progress, therapists use the last couple of sessions to ensure that clients have developed good habits to replace their former hoarding behaviors. These include putting away purchases immediately after bringing them into the house, washing dishes and putting them away quickly, removing trash and recycling on a regular basis, etc. They also discuss situations that might be especially difficult for them in the coming weeks and months after treatment.

For more information about this CBT protocol, Drs. Steketee and Frost have written a therapist guide for treating HD and a corresponding client workbook that contains information and instructions for clients that follow the format of the therapist guide. CBT for HD can also be done in a group psychotherapy format, and a therapist manual is also available to guide group therapists in delivering the treatment.  In addition, structured support groups based on these principles and facilitated by trained peer supporters and students have shown good outcomes.

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