Research on hoarding disorder (HD) has revealed a number of problems with how people with HD process information. Deficits in paying attention, categorizing and organizing household items, making decisions, and solving problems each contribute to the compromised living spaces seen in HD. As a result of these difficulties, possessions end up in disorganized piles that cover floors and furniture. Cognitive behavior therapy (CBT) for HD includes exercises designed to improve these organizing skills.
Attentional problems are common among clients with HD and interfere with attempts to sort and organize possessions. The tasks of sorting and making decisions about possessions require great effort and can be experienced as unpleasant. Maintaining one’s focus in this context is especially difficult for individuals with HD who also have attention deficits, especially if they also suffer from attention deficit hyperactivity disorder (ADHD). Several CBT strategies can help. For instance, having a companion present during sorting can help maintain attention to the task. This need not necessarily be the therapist, but can be someone who knows enough about the HD to avoid arguments and coercion. Other strategies include covering piles of items with a sheet, leaving only the immediate working area visible in order to reduce distractibility.
The ability to identify the best category (and eventual location) for a possession is crucial for being able to organize, as most people organize their possessions categorically. For instance, an electricity bill goes into a folder with other utility bills. Office supplies like pens, pencils, and paper can go into a desk drawer with similar items. Unfortunately for people with HD, each item often seems so unique that it can’t be grouped with similar ones. Rather than organizing by category, people with HD might organize things visually and spatially. They put the electricity bill on a pile of papers so they have a visual memory of where it is located. They rely on a mental map based on where they last saw the object. When the number of objects organized this way reaches a critical mass, this visual organizing system breaks down and items are often “lost.”
Accordingly, a critical element of treatment for HD is teaching clients how to organize possessions by categories they can remember, rather than visually/spatially. The therapist and client work together to decide how to group their belongings, including categories for things to be discarded (e.g., trash, recycle, donation, sell) as well as items to be saved. In this process, each possession is assigned a category and a location. Finding a location for categories may be a challenge early in treatment since the best places may be already cluttered. In these cases, problem solving to find interim locations may be necessary.
Many HD clients rely on visual cues for memory retrieval, resulting in piles in the middle of a room rather than putting items in appropriate storage places. Unfortunately for many people with HD, putting objects out of sight can cause considerable discomfort due to fear that they will not remember or be able to find the object. Desensitizing clients to these fears is accomplished by identifying and placing objects in logical storage locations, and then helping them discover that they can retrieve objects relatively easily thereafter. Storing categorized items out of sight also increases the amount of functional living space, an added bonus that reinforces this work.
In addition to attention and categorization problems, perfectionism and concern about making mistakes are common among people with HD. All of these problems lead to great difficulty making decisions. Improving the process and speed with which people make decisions about what to save and discard, and how to organize possessions, is a critical skill that comes with practice over the course of therapy.
People with HD also have difficulty solving problems in a systematic way. CBT for HD teaches a step-by-step approach that involves: 1) defining the problem and identifying contributing factors; 2) generating as many solutions as possible; 3) evaluating the solutions and selecting the one or two that seem most feasible; 4) breaking the solution down into manageable steps; 5) implementing the steps; 6) evaluating how well the solution worked; and 7) repeating the process until a good solution is found.
Focusing on organizing provides an easy starting point for clients who can’t seem to get rid of anything. In addition to improved organizing skills, the time spent sorting and moving objects to more sensible locations provides an opportunity to begin discussing the beliefs about and emotional attachments to possessions. These beliefs are the keys to helping clients reduce their saving behavior in HD. Instead of describing this work as “discarding”, it seems more helpful (and more accurate) to describe it as practice in sorting and organizing possessions. Discussions about the value and meaning of possessions, and the subsequent decisions about keeping or removing items are worked into these sessions and form the framework for changing emotional attachments to possessions.