Treatment for Hoarding Disorder: Therapist Guide [2 ed.] 9780199334964, 019933496X

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Treatment for Hoarding Disorder

editor-in-chief David H. Barlow, PhD scientific advisory board Anne Marie Albano, PhD Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G.Terence Wilson, PhD

Treatment for Hoarding Disorder Therapist Guide Second Edition Gail Steketee • Randy O. Frost

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3 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trademark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016

© Oxford University Press 2014 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-in-Publication Data Steketee, Gail, author. [Compulsive hoarding and acquiring] Treatment for hoarding disorder : therapist guide / Gail Steketee, Randy O. Frost.—Second edition. pages cm.—(Treatments that work) Revision of: Compulsive hoarding and acquiring. 2007. Includes bibliographical references and index. ISBN 978–0–19–933496–4 (pbk.) 1. Compulsive hoarding—Treatment. 2. Obsessive-compulsive disorder—Treatment. 3. Behavior therapy. I. Frost, Randy O., author. II. Title. RC569.5.H63S74 2013 616.85´227—dc23 2013028803 9 8 7 6 5 4 3 2 1

Printed in the United States of America on acid-free paper

About TreatmentsThatWork™

Stunning developments in healthcare have taken place over the last several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benefit, but perhaps, inducing harm. Other strategies have been proven effective using the best current standards of evidence, resulting in broad-based recommendations to make these practices more available to the public. Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, which has led to the development of new, more precisely targeted interventions. Second, our research methodologies have improved substantially, such that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Third, governments around the world and healthcare systems and policymakers have decided that the quality of care should improve, that it should be evidence based, and that it is in the public’s interest to ensure that this happens (Barlow, 2004; Institute of Medicine, 2001). Of course, the major stumbling block for clinicians everywhere is the accessibility of newly developed evidence-based psychological interventions. Workshops and books can go only so far in acquainting responsible and conscientious practitioners with the latest behavioral healthcare practices and their applicability to individual patients. This new series, Treatments ThatWork™, is devoted to communicating these exciting new interventions to clinicians on the frontlines of practice. The manuals and workbooks in this series contain step-by-step detailed procedures for assessing and treating specific problems and diagnoses. But this series also goes beyond the books and manuals by providing ancillary materials that will approximate the supervisory process in

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assisting practitioners in the implementation of these procedures in their practice. In our emerging healthcare system, the growing consensus is that evidence-based practice offers the most responsible course of action for the mental health professional. All behavioral healthcare clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to close the dissemination and information gap and make that possible. This therapist guide and the companion workbook for patients address the puzzling and difficult problem of hoarding and acquiring. This disorder, characterized by a profound inability to discard material items that are no longer useful and a compulsive urge to acquire unneeded or excessive possessions, can result in severe disruption of interpersonal relationships, threats to health, and even death in some extreme cases from the dangerous accumulation of “clutter.” Estimates suggest this problem afflicts as many as 2 to 6% of the population, who seldom present for treatment until late middle age when, evidently, they have had sufficient opportunity to accumulate overwhelming clutter. The treatment program presented in this updated therapist guide and accompanying workbook represents the latest research on treating hoarding disorder. This evidence-based program, created by world-renowned, widely acknowledged experts in the field Gail Steketee and Randy Frost, leads to substantial improvement in most patients. With the designation of hoarding as its own distinct disorder in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), more people affected by this problem will be recommended treatment, and this timely update of the successful program will give many patients hope to reduce clutter, organize their lives, and restore a peaceful order in their homes. David H. Barlow, Editor-in-Chief, TreatmentsThatWork™ Boston, MA

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References Barlow, D.H. (2004). Psychological treatments. American Psychologist, 59, 869-878. Barlow, D.H. (2004). Psychological treatments. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century.Washington, DC: NationalAcademy Press.

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Contents

Acknowledgments xi Chapter 1

Introduction to Hoarding Disorder 1

Chapter 2

Evidence-Based Treatment for Hoarding Disorder 13

Chapter 3

Assessing Hoarding 23

Chapter 4

Case Formulation 38

Chapter 5

Enhancing Motivation 64

Chapter 6

Planning Treatment 82

Chapter 7

Reducing Acquiring

Chapter 8

Training Skills 124

Chapter 9

Making Decisions About Saving and Discarding 143

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Chapter 10 Cognitive Strategies 159 Chapter 11 Complications in the Treatment of Hoarding Disorder 181 Chapter 12 Maintaining Gains 193 Appendices 1. Clinician Session Form 206 2. Hoarding Interview 208 3. Hoarding Rating Scale (HRS) 214 4. Saving Inventory—Revised (SI-R) 215 5. Clutter Image Rating (CIR) 217

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6. Saving Cognitions Inventory (SCI) 218 7. Activities of Daily Living in Hoarding (ADL-H) 219 8. Safety Questions

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9. Home Environment Index (HEI) 221 10. Scoring Keys 223 11. General Conceptual Model of Hoarding 225 12. Brief Thought Record 226 13. Acquiring Form 227 14. Clutter Visualization Form 228 15. Unclutter Visualization Form 229 16. Acquiring Visualization Form 230 17. Practice Form 231 18. Thought Record 232 19. Instructions for Coaches 233 20. Family Response to Hoarding Scale (FRHS) 236

References 243 Readings and Resources 251 About the Authors 255 Index 257

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Acknowledgments

The authors gratefully acknowledge the contributions to this book from all of the participants in our research studies—especially those in our treatment trials, which form the basis for this therapy for hoarding disorder. We also acknowledge our clinical and research colleagues from around the world whose fine work has enabled us to advance our understanding of hoarding disorder. We could not have done this work without our own longstanding collaboration and partnership as researchers and co-authors. Oxford University Press has been highly supportive throughout the writing process, with help from Sarah Harrington, Andrea Zekus, and Prasad Tangudu and others who have facilitated the planning, writing, and editing of this Guide and Workbook. Gail is especially blessed to have the support of her husband Brian McCorkle throughout the many months of writing and editing for the revised Guide and Workbook. Randy has special thanks for his wife Sue, whose support and encouragement have helped make this work possible.

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Treatment for Hoarding Disorder

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Chapter 1

Introduction to Hoarding Disorder

Background Information and Purpose of This Treatment Program The relationship people have with their possessions has a fascinating history and ranges from purely utilitarian to intensely emotional. The number of personal possessions owned by ordinary people has exploded in the last 50 years. For most people, their personal possessions provide them with a sense of security, comfort, and pleasure. However, if someone loses the ability to distinguish useful or important possessions from those that make life overly complicated, then the objects can become a prison. Almost all of us keep some things we don’t need and don’t use. When these unneeded objects impinge on our living space, we no longer want them and usually get rid of them. But for people who suffer from hoarding disorder (HD), this process is not so easy. For them, possessions never “feel” unneeded or unnecessary and trying to get rid of them is an excruciating emotional ordeal. For some it is easier to divorce a spouse, sever ties with children, and even risk life and limb. Although people with this problem are overly attached to their possessions, they actually derive very little enjoyment from using them. Rather, they collect for a future date that never arrives. Until then, the clutter prevents them from living normally. A major goal of this treatment is to recapture the positive role of possessions in the lives of people with hoarding problems. This manual is the culmination of more than 20 years of work on understanding hoarding and building an effective intervention to address its myriad components. The intervention program is the result of a treatment development project funded by the National Institute of Mental Health. A comment on language and terminology is warranted here. We recommend avoiding language that some clients find stigmatizing. On TV and

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most news programs about the problem, people who hoard are often referred to as “hoarders.” Unfortunately, the term describes a person rather than a behavior and, in our view, should be avoided in working with clients. Indeed, sometimes clients object to the term “hoarding” itself and prefer “saving,” “collecting,” or “cluttering.” Agreeing on terminology early in treatment can help form the bond of trust necessary to treat this problem. In line with this, clients who hoard also often object to references to their possessions that reflect the therapist’s values rather than their own. For example, referring to objects as “junk” or “trash” will often result in an emotional reaction regardless of the objective value of the object. Try to use the client’s own words or choose neutral ones like “your things” or “the items in your living room.” This intervention relies on collaboration between clinicians and clients to achieve a shared understanding of the client’s hoarding problem. Although the 12 chapters in this manual suggest a sequence of intervention strategies, we do not provide session-by-session instructions but, rather, adopt a modular approach because it is difficult to determine in advance the order of interventions because of the many features that contribute to clients’ hoarding symptoms. We strongly recommend that clinicians read all chapters before starting. After completing a basic assessment and case formulation, decide what aspects of hoarding to focus on first and what methods to use. Understanding clients’ hoarding problems fully will help you empathize with their struggle to overcome very powerful emotional attachments and strong beliefs as they make steady, often uneven, progress toward the goal of ridding their homes of debilitating clutter. This manual first describes hoarding in sufficient detail to enable clinicians to diagnose and understand the problem and answer clients’ and family members’ basic questions. We consider this crucial information to dispel misunderstandings about hoarding behavior before trying to provide effective intervention. The next several chapters prepare clinicians to conduct the intervention. Chapter 2 reviews the evidence base for treatments described in this manual, and Chapter  3 covers methods for assessing the problem, along with illustrations of several forms for this purpose. In Chapter 4 clinicians collaborate with clients to formulate a model for understanding how the hoarding symptoms develop and occur in real time. Chapter 5 addresses a major problem in

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hoarding: ambivalence about change. It includes methods to enhance motivation, drawing from motivational interviewing strategies originally developed for substance abuse problems. Chapter  6 focuses on treatment preparation and planning to select intervention methods based on the case formulation. The next four chapters cover the core behavioral and cognitive interventions for acquiring, organizing, and saving problems. Chapter 7 focuses on cognitive and behavioral methods for reducing acquiring. In Chapter 8 clinicians train clients in skills for making decisions and organizing possessions and how to solve problems that inevitably arise in this process. Chapter 9 covers practice methods to habituate discomfort while sorting, and Chapter 10 outlines cognitive strategies for restructuring automatic thoughts and problematic beliefs. Chapter 11 gives recommendations for dealing with comorbid problems and complications that are common among people with hoarding disorder. The final chapter (Chapter 12) reviews treatment methods and provides tips on preventing relapse. Throughout these chapters, we illustrate the use of various forms for use during assessment and intervention to gage client’s symptoms and progress. Blank copies of these forms are available in the accompanying client Workbook, as well as on the TreatmentsThatWork™ website at www.oup.com/us/ttw.

Hoarding Disorder Diagnosis The first systematic study of hoarding was published in 1993 (Frost & Gross, 1993), and the first operational definition appeared shortly after that (Frost & Hartl, 1996). What followed was a tremendous surge in research on hoarding by a variety of research teams mainly in the United States and Europe (Mataix-Cols et al., 2010). Early conceptualizations assumed that hoarding was a subtype of Obsessive Compulsive Disorder (OCD), like checking or cleaning. However, subsequent research indicated that hoarding differed from OCD in critical ways. Consequently, investigators concluded that it was a distinct condition and proposed that it be defined as a separate psychiatric disorder (Mataix-Cols et al., 2010; Pertusa et al., 2010b). In May 2013 when the American Psychiatric Association published the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), hoarding disorder (HD) was

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included as a separate diagnosis in the Obsessive Compulsive and Related Disorders chapter along with Obsessive Compulsive Disorder, Body Dysmorphic Disorder, Excoriation (skin picking), and Trichotillomania (hair pulling). The diagnostic criteria for HD include: A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. B. This difficulty is due to a perceived need to save the items and distress associated with discarding them. C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities). D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). E. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi Syndrome). F.

The symptoms are not better accounted for by the symptoms of another DSM-5 disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder).

Specify if: With Excessive Acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space. Indicate whether hoarding beliefs and behaviors are currently characterized by: Good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.

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Poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. Absent insight (i.e., delusional beliefs about hoarding): The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. Several features of the diagnostic criteria are worth noting. First, difficulty discarding is the primary behavioral problem. Clutter, which is the first thing people notice in hoarding, refers to the condition of the home and is the consequence of the behavioral problem. Treatment must focus on changing the behavioral problems (difficulty discarding and excessive acquisition if it is present). Clearing and sorting the clutter can be addressed in this context. Addressing them outside the context of therapy (e.g., cleaning services, etc.) may change the condition of the home temporarily but will not address the behavioral problem and may create problems establishing a trusting relationship with the client. The difficulty discarding must be persistent to qualify for the diagnosis, which rules out temporary difficulties (e.g., inheritance of possessions from deceased family members; a recent move to a new home). Further, the real or objective value of the possessions saved in hoarding is irrelevant. A common misconception about hoarding is that it refers only to the saving of worthless or worn out things. Hoarded objects vary in objective value and are not limited to what others would consider worthless. Many HD cases involved rooms full of new clothing and items with price tags still attached. Criterion B refers to the perception of need on the part of the individual for the possessions. This is at the heart of the hoarding problem and understanding it is key to treatment. The nature of attachments to possessions in hoarding ranges from utilitarian to intensely emotional. Most people who hoard view their possessions as having sentimental (emotional), instrumental (useful), or intrinsic (aesthetic) value. These reasons for saving are no different from most people, but they are applied to a much larger number and wider range of possessions and

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may be experienced more intensely. People who hoard are often able to discard some items, but the process of doing so is so elaborate and time-consuming that the number of newly acquired items easily exceeds removed ones so the home gradually fills with things. In subsequent chapters we outline the nature of these attachments and beliefs about possessions. The therapy will largely focus on these attachments. Criterion C details the consequences of A and B—the accumulation of possessions and the congestion and clutter that goes along with it. Two things are important here. First, the clutter must occupy the active living areas of the home. If it is confined to an attic, basement, closets, or storage facility, then this criterion has not been met. Second, the clutter must substantially compromise the ability to use the space in the way it was intended. In other words, normal functions are difficult or impossible (e.g., eating at the table). A  few caveats should be noted. If the clutter is not severe because there are other people managing the clutter, then the diagnosis is still warranted. The presence of clutter reflects, in part, a deficit in the ability to organize possessions (Wincze, Steketee, & Frost, 2007). The potential impairments in HD are wide-ranging. At severe levels, HD can make the home unsafe. Fire danger is associated with the presence of large volumes of flammable material (e.g., newspapers, magazines), limited ability to move easily throughout the house, and blocked exits. The loss of life and cost of fires is considerably higher for those that occur in hoarded homes compared to non-hoarded ones (Lucini, Monk, & Szlatenyi, 2009). Hoarding can also result in infestation, squalid conditions, and health problems (Frost, Steketee, & Williams, 2000a; Norberg & Snowdon, 2013; Tolin, Frost, Steketee, Gray, & Fitch, 2008a). The quality of life in patients with HD is significantly impaired, especially in the domains of safety and living conditions (Saxena et al., 2011). Work appears to be impaired by hoarding as well (Tolin et al., 2008a). Family conflict and marital disruption characterizes the personal lives of people with HD (Tolin, Frost, Steketee, & Fitch, 2008b). Each of these areas needs careful assessment before beginning therapy to ensure that the most serious conditions are targeted first in treatment. Several medical and mental disorders can result in hoarding behavior and must be ruled out for diagnostic purposes. Each of the conditions

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mentioned in the diagnostic criteria E and F can result in hoarding and would preclude an HD diagnosis. For example, certain obsessions and compulsions can lead to the accumulation of objects but not qualify as hoarding. Contamination obsessions can result in the inability to touch (and therefore dispose of ) objects believed to be contaminated. Similarly, checking compulsions required before disposing of objects are sometimes abandoned, resulting in accumulation of large numbers of objects. Material collected in such cases is often more bizarre and trash-like than in typical HD cases (Pertusa et al., 2008). It is not clear whether the intervention described here would work for hoarding behaviors that result from these conditions.

Acquisition Specifier Excessive acquisition is not included as a core diagnostic criterion, but diagnosis of HD requires a specification of whether the hoarding is accompanied by excessive acquisition. Research on excessive acquisition in hoarding indicates that the vast majority of HD patients acquire possessions excessively (see Frost & Mueller, 2013, for a review). In various studies, the frequency of excessive acquisition in hoarding ranged from 60% to 100%. Among HD patients who deny excessive acquisition, most report having had problems with acquisition in the past (Frost, Rosenfield, Steketee, & Tolin, 2013). Some clients deny acquisition problems, but partway through treatment, these problems emerge when they stop avoiding places where urges to acquire are strong. Such avoidance behaviors take the form of avoiding store aisles, stores, particular streets, parts of town, or whole cities. Two forms of acquisition are most prominent: compulsive buying and the excessive acquisition of free things. Compulsive buying occurs in a variety of contexts including retail, Internet, and local (i.e., tag or garage sales). Excessive acquisition of free things occurs with give-away items (e.g., promotions) and items left on the street, in trash cans, and in dumpsters. Stealing occurs in a small number of HD cases (Frost, Steketee, & Tolin, 2011b). Acquiring is often associated with positive feelings (even euphoria) that reinforce the behavior and make it difficult to curtail. Both current and past experiences with each of these forms of

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acquisition must be carefully assessed along with any avoidance behaviors associated with them.

Insight Specifier The second specifier concerns level of insight. Many people who hoard do not consider their behavior unreasonable (Frost, Tolin, & Maltby, 2010; Tolin, Fitch, Frost, & Steketee, 2010a), and this may be particularly true among the elderly (Hogstel, 1993; Kim et al., 2001; Thomas, 1997). A study of complaints made to health departments about hoarding indicated that less than one-third of those identified in the complaint willingly cooperated with health department officials, and only half recognized the lack of sanitation in their home (Frost et al., 2000a). A large sample study indicated that more than half of family members believed their hoarding loved one had no insight or was in fact delusional with respect to their hoarding behaviors. This lack of insight may also contribute to the high rates of dropout and poorer treatment outcomes observed for compulsive hoarding (e.g., Black et al., 1998; Mataix-Cols, Rauch, Manzo, Jenike, & Baer, 1999). This problem can be particularly troublesome for family members seeking help and for service providers. Careful consideration of the nature of beliefs about symptoms is needed in hoarding cases. Pure insight (anosognosia—inability to recognize a problem) appears to characterize relatively few hoarding cases (Mataix-Cols, Billotti, de la Cruz, & Nortsletten, 2013). Several related phenomena can be mistaken for absence of insight. For example, overvalued ideation or beliefs about the importance of seemingly unimportant possessions can be interpreted as a form of insight problem. However, such beliefs are part of the symptom pattern in hoarding and should be dealt with accordingly. Also, people with hoarding problems appear to have strong defensive reactions to other people’s attempts to remove their possessions (Frost et al., 2010). Such reactions can appear to indicate lack of insight as well. Regardless of the source of the insight problem, motivation to change is often compromised. Even those who seek help for their hoarding become ambivalent when faced with decisions about removing clutter. For this reason, Chapter 5 includes specialized interviewing techniques for motivational problems.

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Differential Diagnosis and Comorbidity Hoarding disorder must be distinguished from other conditions that it may resemble (for a review see Pertusa & Fonseca, 2013). Research indicates that the distinction between hoarding and extreme collecting is easily made, although extreme collectors sometimes display similar behaviors with respect to acquiring (Mataix-Cols et  al., in press; Nortsletten & Mataix-Cols, 2012). Similarly, the differential diagnosis with OCD is relatively easy to make (Pertusa, Frost, & Mataix-Cols, 2010b). Up to 20% of HD cases are comorbid for OCD symptoms that may need to be addressed separate from hoarding. Compulsive buying, an impulse control disorder, is present in the majority of HD cases. For treatment purposes, it is probably best to conceptualize this in the context of HD rather than as a separate comorbid disorder. HD is associated with several other disorders that can complicate treatment. Up to half of HD patients meet criteria for major depressive disorder (MDD) (Frost et  al., 2011b), and the accompanying low mood and low motivation may need to be addressed if these appear to interfere with progress in treatment. Attention problems associated with ADHD (but not hyperactivity) are also prominent in HD (Frost et al., 2011b; Tolin & Villavicencio, 2011) and can interfere with the ability to organize, work outside of the therapy session, and persist at tasks such as sorting and discarding. Social phobia and generalized anxiety disorder (GAD) occur in up to one-third of HD cases and may need separate attention (Wheaton & Van Meter, 2013). Social phobia can make it difficult for patients to marshal social support and may exacerbate the social isolation reported among elderly hoarding clients (Kim et  al., 2001). Such clients may rely on hoarding to shield them from social interaction. Worry associated with GAD may make difficulty discarding worse. Assessment of these complicating comorbid conditions is important for planning the intervention and preventing relapse. Chapter  11 provides a variety of suggestions. Hoarding is also associated with various personality problems (e.g., Frost, Steketee, Williams, & Warren, 2000b; Samuels et  al., 2002), such as perfectionism, indecisiveness, dependency, and compulsive personality traits. We have also observed avoidant, schizotypal, and

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paranoid traits among some of our clients. The treatment program outlined here includes cognitive and behavioral strategies to reduce perfectionistic standards and rigid rules for saving and discarding and to reduce dependency on others to make decisions. When clients exhibit paranoid personality traits, clinicians must work harder to gain clients’ trust, and interventions move more slowly to accommodate these concerns.

Prevalence, Course, and Family Patterns In 2007 when this treatment manual was first published, there were no good epidemiological studies to indicate the prevalence of hoarding. Our best guess at the time was that it afflicted 1% to 2% of the population. Now at least five different epidemiological studies have been conducted, and taken together, they suggest that the prevalence of hoarding is between 2% and 6% of the population (Bulli et al., 2013; Iervolino et al., 2009; Mueller, Mitchell, Crosby, Glaesmer, & de Zwaan, 2009; Samuels et al., 2008; Timpano et al., 2011). This makes HD one of the most frequent of the mental disorders. Research on onset and course of HD suggests that it begins early (Grisham, Frost, Steketee, Kim & Hood, 2006; Tolin, Meunier, Frost, & Steketee, 2010c), often between ages 11 and 15 years and rarely after age 25 years, but the problem does not become serious for several decades. Most cases report moderate or severe hoarding by age 40 years with little decrease in severity (Tolin et al., 2010c). In some cases trauma precipitates the hoarding, usually at a later age of onset (Grisham et al., 2006). Hoarding disorder is associated with an increased frequency of adverse and sometimes traumatic life events, but not PTSD (Frost et al., 2011b). Although several epidemiological studies have suggested that men suffer from hoarding problems more than women, the preponderance of evidence suggests no difference by gender (Steketee & Frost, 2013). People with HD are less likely to marry and more likely to divorce (Samuels et al., 2002; Kim et al., 2001). Clients who live alone in their own home may have difficulty with motivation to change their hoarding because no one in the home is encouraging them to change.

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Hoarding appears to run in families (Samuels et al., 2002; Winsberg, Cassic & Korran, 1999), and there is growing evidence for a genetic component (Hirschtritt & Mathews, 2013). This suggests that many of those seeking help will have family members who also engage in (and likely condone) hoarding behavior. This has proved problematic for some clients when only one family member is interested in reducing hoarding behaviors whereas the other sees no reason to change and resents the intrusion of clinicians. Neuropsychological and neuroimaging studies have reported abnormal activity in orbitofrontal cortex, dorsal anterior cingulate cortex, and superior temporal regions, as well as performance deficits on tasks of planning, contingency learning, and sustained attention. These findings are consistent with clinical reports of decision-making problems in hoarding patients and warrant training in decision-making and other cognitive skills as described in Chapter 8.

Special Features Occasionally, hoarding occurs in squalid conditions that constitute a serious public health problem that threatens occupants of the home (Norberg & Snowden, 2013). (See the squalor questions in Chapter 3.) In such cases, public health officials or other agencies may become involved. Another serious variant of hoarding is animal hoarding, defined as the accumulation of a large number of animals, typically in excess of 20, that are not intended for the purpose of breeding or sale (Ayers & Patronek, 2013). The owner fails to provide an adequate living environment for the animals, as indicated by overcrowded or unsanitary living conditions, inadequate veterinary care and/or nutrition, and the unhealthy condition of the animals. Even when they are clearly unable to provide adequate care, most people who hoard animals are reluctant to place the animals in the custody of others. Animal hoarding is often identified through complaints by neighbors to legal authorities such as animal control agencies. This manual is not designed to address animal hoarding, as there is currently limited research to indicate what causes this problem (e.g., Steketee et al., 2011) and how to treat it. For further information about animal hoarding, contact the Hoarding of Animals Research Consortium (HARC) at their website

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www.tufts.edu/vet/cfa/hoarding and see the Angell Report (2006) published by this organization.

Treatment Program The next chapter reviews the types of treatments (behavioral, pharmacological) that have been used for hoarding before development of the cognitive behavioral model and how successful these therapies have been. This is followed by a description of the cognitive behavioral model for understanding the hoarding disorder based on the symptoms described above. The CBT methods that result from this model have proven to be efficacious in research studies as indicated in Chapter 2.

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Chapter 2

Evidence-Based Treatment for Hoarding Disorder

Development of Cognitive Behavioral Treatment (CBT) for Hoarding Disorder The intervention program described here grew out of our work with individual clients studied intensively in single case and small group designs. The clients who received treatment exhibited moderate to severe hoarding behaviors and substantial comorbidity such as that described earlier, included major depression, attention deficit disorder, and sometimes problematic personality traits. Some were highly functional in their employment and social lives, but struggled to make headway with severe clutter that filled all living spaces and rendered the home useless for all but bathing and sleeping. Others who exhibited work, social, and family impairments responded to the intervention but sometimes with less overall improvement. Although we recommend that clients with severe symptoms be treated by more experienced clinicians who can field the range of personality traits and motivational problems often evident among those with HD, novice clinicians can deliver this treatment effectively (Turner, Steketee & Nauth, 2010)  and can also play supporting roles with regard to coaching during home visits (Muroff, Steketee, Bratiotis, & Ross, 2012). Davidow and Muroff (2011) determined that people with hoarding problems wanted coaches (students, peers, and family members or friends) who were trustworthy and had good listening skills to help them organize their things. Although the therapy content is somewhat similar to CBT methods for other conditions, in our pilot and wait-list control trials every fourth meeting occurred in the client’s home, usually for extended periods of 1.5 to 2 hours. The chronicity of hoarding and the associated motivational difficulties have led us to conclude that work in the home is important to successful outcomes in most, although undoubtedly not all, cases.

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We provide recommendations for identifying alternative home visitors who can help clients implement treatment methods in their home environment when clinicians are unable to do so on a regular basis. The procedures described in this manual have demonstrated good outcomes for hoarding disorder as described below.

Evidence Base for CBT for Hoarding In contrast to the disappointing results of early attempts to treat hoarding, CBT specifically designed to treat hoarding and based on our cognitive behavioral model of compulsive hoarding (Frost & Hartl, 1996; Frost & Steketee, 1998) has shown good promise. Hartl and Frost (1999) reported a successful outcome in a single case experimental design using the modified CBT approach for a 53-year-old woman with a long-standing hoarding problem. Using similar methods, Cermele, Melendez-Pallitto, and Pandina (2001) also reported a successful outcome for a 72-year-old woman with chronic hoarding. We also found modest benefits for seven clients treated individually and in a group format using an updated version of Hartl and Frost’s approach (Steketee, Frost, Wincze, Greene, & Douglass, 2000). Among these seven clients, all of whom also suffered from major depression and/or social phobia, four improved moderately after 20 weeks (15 sessions) of intervention, and of the four who continued on in individual therapy, three continued to improve at a 1-year follow-up. Self-rated improvement was greatest in the areas of acquisition, confidence in their ability to improve, and recognition of cognitive errors. In other early work, Saxena et al. (2002) reported good success using a combination of hoarding-specific CBT modeled after Hartl and Frost (1999) plus SRI medication in an intensive 6-week intervention program. As in other trials, OCD clients without hoarding improved more than those with hoarding problems, but the latter group showed significant reductions in YBOCS scores (10 points on average) after intervention. They concluded that multimodal intervention tailored to specific features of hoarding led to clear improvement and SSRIs may help clients tolerate the CBT more easily.

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We (Tolin, Frost, & Steketee, 2007a) tested an earlier version of methods described in this treatment manual in an open trial in which 10 clients (all women) with primary hoarding problems (mean age, 49 years) completed 26 sessions over a period of 6 to 9 months, with every fourth session held in the home (or occasionally in acquiring settings). Therapists were graduate students with limited experience in CBT methods who were trained by the authors. The clients showed significant reductions in global measures of hoarding severity (28%), in ratings of difficulty discarding (25% improved), acquiring (37% improved), and clutter (25% improved), and on an observational measure of clutter (31% improved). In 50% of treatment completers, the therapist rated the client as “much” or “very much improved.” However, full remission of hoarding behaviors and clutter was infrequent, and substantial residual symptoms remained in this preliminary test of CBT methods. The treatment manual was revised prior to a second waitlist-controlled study in which we randomly assigned clients with primary hoarding problems of at least moderate severity to either treatment or a 12-week waitlist followed by treatment (Steketee, Frost, Tolin, Rasmussen, & Brown, 2010). Participants were excluded if they showed significant cognitive impairment that would interfere with learning, were not stable on psychotropic medication, or were unable to participate consistently in this relatively lengthy intervention. Doctoral students in psychology and social work, trained and supervised closely by the authors, provided 26 sessions that followed the format described in this manual. Treatment duration ranged from 9 to 12  months. In contrast to our pilot study where 4 of 14 patients (29%) discontinued treatment prematurely, in this study, the dropout rate was only 10%. The average age of clients was 54. Treated clients showed significant reductions in hoarding symptoms (15%–27%) at week 12, outperforming waitlisted patients (2%–11% reductions). After 26 sessions, 37 patients had received the full treatment; they showed a 27% to 39% reduction in hoarding symptoms depending on the measures used. Seventy-one percent were rated by the therapist as “much” or “very much” improved, whereas 81% of clients rated themselves in those categories. These data indicate very positive outcomes based on the methods employed in this manual. We were able to follow 31 patients for 3 to 12 months after treatment and to study longer term maintenance as well as predictors of outcome

15

(Muroff, Steketee, Frost, & Tolin, under review). Clients with significant improvement after therapy were able to sustain those gains at the follow-up point, with clinical global improvement (CGI) ratings by clinicians and clients indicating that 62% and 79% were rated “much” or “very much” improved, respectively. More severe hoarding and worse general functioning at the outset of treatment predicted less benefit (as might be expected). Perfectionism also emerged as a significant predictor of worse outcome. More research is needed on outcomes and predictors for larger samples to direct efforts to improve treatment for hoarding. At the present time we do not have information on the generalizability of CBT treatment for HD to people with different backgrounds. Our sample contained both men (25%) and women from various backgrounds (five African-American clients, one Asian, one Latina), but the sample was too small to determine any differential effects by gender or ethnicity. It was our impression that men and women did not differ in their outcomes and that our African-American clients did benefit.

CBT Model of Compulsive Hoarding The cognitive and behavioral model of compulsive hoarding is based on our research and clinical experience with this problem and thus, must be considered a work in progress. Nevertheless, a number of studies have supported the various features of this model (see Frost & Steketee, 2013). The model presumes that problems with acquiring, saving, and clutter result from (1) personal vulnerabilities that include past experiences and training, negative general mood, core beliefs, and information processing problems. These vulnerabilities contribute to (2) beliefs about possessions, which in turn result in (3) positive and negative emotional responses that trigger (4) hoarding behaviors of acquiring, difficulty discarding and saving, and disorganized clutter. These behaviors are reinforced either positively through the pleasure gained from acquiring and saving or negatively through the avoidance of negative emotions of grief, anxiety, and/or guilt. The overall model is depicted below in Figure 2.1. This model (Steketee & Frost, 2007) is intended to illustrate many variants of hoarding elements seen across clients. In Chapter 4 we provide a simplified version of this model that is suitable for use with individual clients.

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Vulnerability Factors Information Processing Perception Attention Memory Categorization Decision-making

Early Experiences Core Beliefs Unworthy Unlovable Helpless Personality traits Perfectionism Dependency Anxiety sensitivity Paranoia Mood Depression Anxiety Comorbidity Social phobia Trauma Health problems

Beliefs/Attachment

Emotional Reactions

Hoarding Behaviors

Clutter Beliefs about Possessions Instrumental Value Intrinsic Beauty Sentimental Value

Beliefs about Vulnerability Safety/comfort Loss Beliefs about Responsibility Waste Lost opportunity Beliefs about Memory Mistakes Lost information Beliefs about Control

Positive Emotions Pleasure Pride Joy Excitement Acquiring

Negative Emotions Sadness/Grief Anxiety/Fear Guilt/Shame Anger Difficulty Discarding and Saving

Figure 2.1

Model of Compulsive Hoarding

The components of this model are described further in Chapter 4 on how to assess hoarding-related vulnerability factors, beliefs about possessions, emotions, and behaviors. Chapter 4 clarifies how to construct idiosyncratic models for clients who hoard.

Risks and Benefits of CBT for Hoarding There are few risks associated with the hoarding treatment program described here, but we believe they are low and strongly outweighed by the potential benefits. Risks include encountering traumatic memories and unresolved grief reactions (e.g., past rape, childhood losses) that provoke strong emotions and require extra clinical time to help clients process their feelings. Another risk is that clinicians will encounter a home environment that triggers mandated reporting because of abuse or neglect of children or elders (including self-neglect for older clients). Clinicians should warn clients that if the assessment indicates that children or older adults are living in home conditions that may impair their health or safety, then they may have to report these problems to the relevant authorities. In our

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experience, the investigative authorities are usually cooperative with the therapeutic efforts aimed at hoarding and may also provide a motivational “stick” to the clinician’s “carrot” of treating the problem. A third concern is the extent of squalor present, which may require clinicians to wear masks or protective clothing when in the home or to request the aid of sanitation crews to remove waste that could cause health problems. The benefits of treatment are apparent in the earlier description of outcomes following treatment in our recent studies. Treatment takes time and clients may be improved but not recovered at the end of the intervention. However, most people experience significant reduction in clutter, difficulty discarding, and excessive acquiring and have gained important skills to continue their work independently or with the help of a coach. The comprehensive intervention methods typically have positive side effects of improving self-esteem, mood and functioning, along with improvements in hoarding behaviors and clutter.

Alternative Interventions At the present time, there are few alternative treatments that can be considered evidence-based. Standard exposure and ritual prevention (ERP) for OCD symptoms does not appear to work in most cases (Abramowitz, Franklin, Schwartz, & Furr, 2003). The treatment described in this manual has been applied in a group format with good success (Muroff et al., 2009; 2012) and is now available in manual form in the Oxford Treatments That Work series (see Muroff, Steketee, & Underwood, 2014). Also, highly structured, facilitated support groups based on these principles have shown some promise (Frost, Pekarava-Kochergina, & Maxner, 2011a; Frost, Ruby, & Shuer, 2012). Many of our clients have experienced forced cleanouts by authorities or relatives. Their strong angry and hurt reactions and continuing struggle with hoarding indicate that this is not an effective alternative. Such cleanouts should only be used when required for health and safety, involving the person with hoarding problems as much as possible in the process of decision making about possessions.

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Role of Medications Several investigators have reported poor outcomes with selective serotonin reuptake inhibitors (SSRIs) in retrospective studies. In large samples, Black et al. (1998) found that hoarding symptoms were the strongest predictor of nonresponse to medication, and Mataix-Cols et al. (1999) found that more severe hoarding predicted worse outcomes. Winsberg and colleagues (1999) also reported poor response to medication treatment among people with compulsive hoarding. However, in a prospective study, Saxena, Brody, Maidment, and Baxter (2007) reported that the SSRI paroxetine produced similar benefits for both hoarding and non-hoarding OCD patients, although improvement was modest in both groups. In a more recent small uncontrolled trial, Saxena (2013) reported good outcomes with venlafaxine. Our own treatment studies have not included clients receiving SSRI or other medications, so we cannot provide useful information on combining medications with the CBT methods described here.

Outline of this Intervention Program This cognitive and behavioral intervention program is designed for 26 weekly sessions spaced over a period of approximately 6  months. However, the number of treatment sessions might vary from a minimum of 15 for a case of mild hoarding to 30 or more spaced over a 1-year period or longer in severe hoarding cases. Duration of treatment will likely be related to motivational factors, the amount of clutter, presence of comorbid conditions that slow progress, and availability of cooperative assistants in decluttering the home. The approximate number of sessions for various aspects of the CBT intervention is given below: ■

Assessment: 2–3 sessions at the beginning of treatment

■

Case formulation: 2 sessions following assessment

■

Practice limiting acquiring: 2–3 sessions

■

Skills training: 2–3 sessions, including organizational and problem-solving skills, repeated as needed during other sessions

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■

Sorting and discarding practice and cognitive therapy: 15 sessions; add cognitive methods as needed during sorting and decision making

■

Motivational interviewing to address ambivalence and low insight: portions of several sessions, especially early in treatment

■

Relapse prevention: 2 final sessions

Ideally, three weekly clinic sessions alternate with one monthly home visit or visit to an acquisition site throughout treatment. We recommend that you do at least one home visit at the outset to understand the hoarding environment, features, and severity. But, if you are unable to visit the home on a regular basis, consider whether a “coach” might be able to assist clients in their homes or in acquiring contexts. Coaches can be friends or family members whom clients consider supportive, helpful, and reliable, or they could be students, professional organizers, or others whom clients feel comfortable hiring to assist them with practice in the home. The first two assessment sessions may require approximately 1.5 hours each. Thereafter, allow approximately 1 hour for each office visit in which boxes or bags of items brought from the home are used for sorting. In-home appointments will typically last 2 hours. We have also had good success with two or three “marathon” sessions of several hours duration in the home or a “cleanout” in which we enlisted the help of a closely supervised cleaning crew (always with the client’s permission). These sessions produce substantial progress that enhances motivation, helps clients feel less overwhelmed, and helps clients consolidate skills to work more independently on the remaining clutter. The flow of the CBT methods varies considerably from client to client as clinicians alternate their focus among the three problems of organizing, acquiring, and removing objects depending on the client’s immediate goals and needs. Developing an organizing plan and gaining control over compulsive acquiring are usually more easily accomplished than removing items. However, many clients are more strongly motivated to clear their clutter because of outside pressure or because the clutter is the most frustrating aspect of their symptoms. Skills are

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taught whenever needed. Alternating among cognitive and exposure strategies for clearing clutter will be necessary, as progress on sorting and removing items depends on changing thinking and reducing distress. For example, a clinician may begin by sorting items in the kitchen, using cognitive strategies as problematic beliefs surface, and then switching focus to acquiring as the client faces an immediate need to purchase a birthday present for a family member and fears losing control.

Session Structure Each treatment session follows a basic format outlined briefly below. Clients use the Personal Session Form from the Workbook to make notes during and between sessions. These forms provide a record of what clients learned during therapy and are used to facilitate recall of helpful treatment methods during relapse prevention. Clinicians check in briefly (5 minutes) to ask about mood, recent events, and important issues discussed during the previous session and then set the agenda for the session together with the client. Encourage clients to express their own wishes and, if the agenda seems overly long for one visit, prioritize and hold less important items until the next session. Be sure to discuss previous homework early in the session to emphasize its importance. Following this, introduce agenda topics and intervention strategies to ensure that important points are covered within the time available. After any segment with new information, ask clients to summarize what they learned to consolidate new learning. New homework assignments for the week can be developed during the discussion or devised at the end of the session to fit the topics covered. Clients should write down the assignment on their Personal Session Form to prevent uncertainty and minimize avoidance of homework. Sessions end with clients summarizing what was covered. Then ask for feedback about the session (“How did you feel about today’s session? Is there anything I  did or said that bothered you?”), encouraging clients to be honest about their reactions. Clinicians should complete their own Clinician Session Form (Chapter 3) to keep an accurate record for future reference.

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Use of the Client Workbook The accompanying client Workbook contains briefer information and instructions to clients that follow the format of this manual, as well as blank versions of all forms used during treatment and for homework assignments. These include scales for assessment, a Personal Session Form for recording notes and homework, and various forms for recording thoughts and beliefs as they occur naturally, case formulation, treatment goals, organizing plans, behavioral experiments, cognitive techniques, and a list of interventions learned during treatment. Thus, the client Workbook reinforces what is learned during sessions and is a critical part of therapy. Clinicians should advise clients what parts to read and which forms to complete. Books are easily lost in the clutter at home, so it is critical to refer regularly to the Workbook so clients become accustomed to bringing it to all sessions. Discuss where they will keep the Workbook to avoid losing track of it.

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Chapter 3

Assessing Hoarding

(Corresponds to Chapter 2 of the Workbook)

Materials Needed ■

Camera for home visit

■

Clinician Session Form

■

Hoarding Interview

■

Hoarding Rating Scale (HRS)

■

Saving Inventory–Revised (SI–R)

■

Clutter Image Rating (CIR)

■

Saving Cognitions Inventory (SCI)

■

Activities of Daily Living for Hoarding (ADL-H)

■

Safety Questions

■

Home Environment Inventory (HEI)

■

Personal Session Form from Workbook

■

Set agenda

■

Complete assessment measures (see Appendix)

■

Conduct home visit within first four sessions

■

Work with client to choose a family member or friend for the “coach” role

■

Negotiate homework

Outline

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This chapter will walk you through the components for assessing hoarding symptoms and related problems before commencing the formal intervention. This should require two to four sessions, depending on the complexity of the case, although in some complicated cases with limited motivation, it can take more than four sessions. You will undoubtedly begin treatment before you understand all aspects of the client’s situation, learning more about your client and the hoarding problem as you go along. This is typical of most cognitive and behavioral interventions— more understanding occurs as you actually do the treatment. Chapter 4 helps clinicians build a model for understanding the client’s symptoms based on the assessment. As you begin assessing clients’ symptoms, ask them what terms they prefer to use to describe their problem. Sorting and removing items may be called “de-hoarding,” “de-cluttering,” “uncluttering” or other terms. “Letting go,” “parting with,” “removing,” or “getting rid of ” objects may be preferred over “discarding” because the latter implies wastefulness to many clients and does not encompass recycling, selling, or giving away, alternatives preferred by many clients.

Assessment Plan If you have the flexibility, allow about 90 minutes for the first assessment session in the office and 1.5 to 2 hours for the second appointment held in the client’s home. Additional assessment sessions can be scheduled in the office for about an hour. The home session can also include some discussion with adult family members living in the home, as described later in this chapter. At the first office visit, provide your client with the Workbook containing all handouts and instruct him to bring it to each session. At this and all subsequent sessions, clients can make notes about their agenda, points they want to recall from the session, homework assignments, and any topics they want to discuss next time on the Personal Session Forms found in the Workbook. Remind them to use the form at times that seem especially helpful so they get in the habit of doing so. You can also suggest that these forms will provide a good record of the therapy to help them recall the treatment methods that were most useful. Ask clients where they will keep

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their Workbook at home so they can always find it. This question is especially important as many clients misplace things in their clutter. Use the blank Clinician Session Form found in the Appendix to guide  each session and to record any special information based on the  session discussion. A  completed sample form is also included below. You may photocopy the blank form from the Appendix or download multiple copies from the TreatmentsThatWork™ website at www.oup.com/us/ttw. Establish a collaborative agenda by indicating the type of information you plan to collect about hoarding, including organizing problems, acquiring, and difficulty getting rid of clutter. Inquire what topics the client wants to include in this first session and record these on the agenda.

Example of Completed Clinician Session Form Client: PK

Session #: 2

Date:  11/6/13

Basic Session Content:  Assessment Client’s mood and symptoms: Felt good about starting work on clutter, some anxiety during past week, mild trouble focusing at work, no significant depression Agenda: 1 - Review self-report forms 2 - Finish hoarding interview 3 - Answer PK’s questions about her symptoms 4 - Discuss family issues Homework report:  PK read Chapter 1 of Workbook and finished half of her questionnaires, made note of a few questions

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Example of Completed Clinician Session Form continued

Degree of homework compliance (1 to 6):  6 (1 = did not attempt; 2 = attempted but did not complete; 3 = did about 25%; 4 = did about 50%; 5 = did about 75%; 6 = did all homework) Symptoms and topics discussed during session: Some acquiring this week—mainly clothing for self and kids on sale Reviewed reasons for saving—mainly concerned about missing opportunities, sometimes losing information. Effects of acquiring, saving, clutter: financial problems, conflict with husband about money spent, electricity may be cut off, kids can barely sleep in beds because of clutter Family history—mother saved but not this much, grandmother a neatnik Serious clutter began after rape in current home 15 yrs ago—discussed trauma effects Intervention strategies used or reviewed: Hoarding assessment and questions to clarify reasons for saving and effects of hoarding symptoms, probed for severity (moderately severe), questions to clarify motivation indicated some ambivalence, esp. giving up shopping Homework assigned: Finish remaining questionnaires Ask husband if he is available to meet for half an hour at end of home visit next week Comments on client’s summary and feedback: Client happy with start of treatment, found questionnaires and my comments on these interesting Goals for next or future sessions: Complete assessment, maybe begin work on acquiring depending on family meeting

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During the assessment phase, try to allay clients’ fears about treatment, especially about the prospect of having to get rid of hoarded items, by listening closely to their responses to questions about their experiences. Focus especially on creating functional living space and on recapturing the usefulness of possessions, not on discarding objects. The amount of discarding needed will become apparent as you move through the treatment. Take care to communicate that clients are not to blame for their hoarding behavior (or related symptoms) and that treatment is likely to be successful but will require patience, time, and homework. Ask clients about their expectations and concerns about the intervention and address these as appropriate.

In-Office Assessment Much of the assessment takes place in the clinician’s office and includes interviews about hoarding symptoms and any comorbid problems. Several formal measures can be completed by clients in your office, although some should be done during the home visit.

Assessing Hoarding Symptoms Questions from the Hoarding Interview (see Appendix) will occupy most of the first and part of the second session. This interview provides a template for collecting detailed information about clients’ compulsive hoarding symptoms, degree of impairment, and general life situation. It will also help you develop a conceptual model for each client’s hoarding symptoms. In addition to this interview, we recommend using the following standardized measures to assess the type and severity of hoarding symptoms. All of them can be found in the Appendix, followed by a scoring key for each of the measures. These instruments can be given as self-report measures, but you may prefer to administer some directly with the client in their home, depending on the nature and severity of their hoarding and on their capacity to complete the forms accurately by themselves. ■

Hoarding Rating Scale (HRS; Tolin, Frost, & Steketee, 2010b) is a brief five-item scale that assesses the major features of

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Table 3.1 Cut-Off Scores and Typical HRS Scores in Hoarding and Non-Hoarding Samples Cut-off scores (scores at or above this indicate hoarding)

Average scores for people with HD (standard deviation)

Average scores for people without HD (standard deviation)

Total HRS

14

24.22 (5.7)

3.34 (5.0)

#1 Clutter

3

5.18 (1.4)

0.64 (1.1)

#2 Difficulty discarding

4

5.10 (1.4)

0.82 (1.4)

#3 Acquisition

2

4.08 (1.9)

0.75 (1.3)

#4 Distress

3

4.83 (1.3)

0.73 (1.0)

#5 Interference

3

5.03 (1.4)

0.42 (1.0)

hoarding disorder (Clutter, Difficulty Discarding, Acquisition, Distress, Interference). The HRS takes 5 to 10 minutes and can be administered as an interview or as a self-report questionnaire. Optimal cutoff scores (Tolin et al., 2010b) for distinguishing clinically significant hoarding along with typical scores in hoarding versus community control samples can be found in Table 3.1. The HRS can also be found in the client Workbook.

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■

Saving Inventory–Revised (SI–R; Frost, Steketee, & Grisham, 2004) is a 23-item scale with three subscales. These include the Acquiring subscale to determine the extent of compulsive buying and the acquisition of free things, the Clutter subscale to report the amount of clutter and problems associated with it, and the Difficulty Discarding subscale to measure discomfort about removing the clutter. Optimal cutoff scores for distinguishing clinically significant hoarding (Tolin, Meunier, Frost, & Steketee, 2011), along with typical scores in hoarding versus community control samples can be found in Table 3.2. This scale can also be found in the client Workbook.

■

Clutter Image Rating (CIR; Frost, Steketee, Tolin, & Renaud, 2008) is a pictorial measure that includes 9 pictures varying from 1 = no clutter to 9 = severe clutter for a kitchen, a living room, and a bedroom; a rating of 3 to 4 or higher represents clinically significant clutter characteristic of hoarding. Typical scores for people with and without hoarding disorder are provided in

Table 3.2 Cut-Off Scores and Typical Saving Inventory–Revised (SI–R) Scores in Hoarding and Non-Hoarding Samples Cut-off scores (scores at or above this indicate hoarding)

Average scores for people with HD (standard deviation)

Average scores for people without HD (standard deviation)

Total SI–R

41

62.0 (12.7)

23.7 (13.2)

Clutter

17

26.9 (6.6)

8.2 (7.1)

Difficulty discarding

14

19.8 (5.0)

9.2 (5.0)

Excessive acquisition

9

15.2 (5.4)

6.4 (3.6)

Table 3.3. Clients simply select the picture that most closely matches their own room to provide a rating of the amount of clutter in that room. This instrument is very easy to use for the initial assessment of clutter and also helps gage progress during treatment. The measure works best when printed in full color. We have included black and white samples in the Appendix and the client Workbook. You can download color versions from the TreatmentsThatWork™ website at www.oup.com/us/ttw. Both clients and clinicians can complete this measure for each room in the home. This measure can also be found in the client Workbook. ■

Saving Cognitions Inventory (SCI; Steketee, Frost, & Kyrios, 2003) is a 24-item self-report questionnaire that assesses beliefs and attitudes clients experience when trying to discard items. Four subscales focus on emotional attachment to objects, beliefs about objects as memory aids, responsibility for not wasting possessions, and the need for control over possessions. Average scores for those

Table 3.3 Typical Clutter Image Rating Scores in Hoarding and Non-Hoarding Samples Average scores for people with HD  (standard deviation)

Average scores for people without HD (standard deviation)

Living room

3.7 (2.0)

1.3 (1.0)

Kitchen

3.4 (1.6)

1.2 (0.6)

Bedroom

4.1 (1.6)

1.3 (0.8)

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Table 3.4 Typical Saving Cognitions Inventory (SCI) Scores in Hoarding and Non-Hoarding Samples Average scores for people with HD (standard deviation)

Average scores for people without HD (standard deviation)

Total SCI

95.9 (31.0)

42.2 (20.9)

Emotional attachment

37.7 (16.0)

14.8 (8.7)

Control

15.8 (4.2)

8.4 (5.1)

Responsibility

22.3 (8.2)

10.4 (6.0)

Memory

20.3 (8.1)

8.8 (4.8)

who have or do not have hoarding problems are given in Table 3.4. This questionnaire can also be found in the client Workbook. ■

Activities of Daily Living for Hoarding (ADL-H; Frost, Hristova, Steketee, & Tolin, 2013) inquires about how much the clutter interferes with clients’ ability to complete ordinary activities like bathing, dressing, and preparing meals (15 items). Items are rated from 1 (none) to 5 (severe). This scale can also be found in the client Workbook. Scores for hoarding and non-hoarding individuals are given in Table 3.5.

We recommend classifying the scores as: 0–1.4: None to minimal 5–2.0: Mild 2.1–3.0: Moderate 3.1–4.0: Severe 4.1–5.0: Extreme

Table 3.5 Typical Average Scores for the ADL-H in Hoarding and Non-Hoarding Samples

Total ADL-H

30

People with HD

Community Controls

2.20 (.74)

1.15 (.75)

■

Safety Questions help identify common hoarding situations that compromise the safety of people’s homes. These include questions about fire hazards, blocked exits, whether emergency personnel can get through the house with equipment, and so forth. Items are rated from 1 (none) to 5 (severe). Evaluation of client safety is critical early in treatment (especially if there are children or elders living in the home) and helps identify priority areas for treatment. A score of 2 or above on any item warrants attention to that item early in treatment. You can complete these questions during a visit to the client’s home.

Squalor is a concern in some hoarding cases and is best assessed by clinicians during a home visit. The Home Environment Index (HEI; Rasmussen et al., under review) includes 15 questions that provide a useful index of the extent of a squalor problem in the home. Questions on this measure focus on the presence of moldy or rotten food, dirty surfaces, odor in the home, and so forth. Each question is rated from 0 = no problem to 3 = severe problem. The average score for a large Internet sample of people with hoarding was 12.7 (standard deviation  =  6.9; range = 0–43). A score of 2 or above on any item warrants attention to that item early in treatment. You can also ask your client to complete any of the measures listed above. If your client rates himself or herself significantly lower than you do on any of these measures, then there may be significant problems with insight that will require your attention using motivational strategies described in Chapter 5. All of these measures are included in the Appendix, and the self-report measures are in the client Workbook as well.

Identifying Other Psychiatric Problems Several psychiatric problems are often comorbid with hoarding disorder, and you should be aware of their presence to determine whether they affect the hoarding problem or the treatment. These conditions are mentioned in Chapter 1 and include Major Depressive Disorder, Social Phobia, Obsessive Compulsive Disorder, and Attention Deficit Hyperactivity Disorder (ADHD). Depression and attention deficit tend to be the most frequent and problematic of these conditions during the treatment

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process. Chapter 11 provides recommendations for managing these other psychiatric, health, and safety conditions if you encounter them.

Planning the Home Visit A home visit is important to confirm impressions gained during the office interviews. During this visit you can determine the amount and type of clutter and whether the home environment poses an immediate health or safety threat. You can also meet with family members if this is appropriate (see below). Try to schedule the home appointment within the first four sessions of treatment. We prefer to arrange this for the second session, unless clients are unwilling to agree to this “invasion” of their privacy until a stronger therapeutic relationship is established. Assume your client is worried and embarrassed about the visit and will find your walking through the home and taking photographs intrusive. Many hoarding clients have had no visitors for years, and in some cases, relatives or local officials have removed their belongings against their will. To allay their fears, describe the goals of the home assessment and the procedures you will follow during the visit. Indicate that you will not touch any items and that any photos taken are part of the client’s confidential record. Language similar to the following may be helpful: “The home visit is very important for us to understand your thoughts and experiences about the things you own. So far I’ve asked you a lot of questions about the hoarding problem during this office visit. When we are at your home, I’ll be asking how you feel and think about your things as you actually look at them and also what you typically do at home and how the clutter affects this. We can take pictures of your home to use during treatment to decide on next steps and to track your progress. The home visit helps me understand how you think and feel about your home and your things. Do you have any questions about the process or about anything else so far?”

In-Home Assessment On entering the home for the first time, be careful not to react with shock or dismay, regardless of the level of clutter or state of the home.

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This avoids confirming your client’s worst fears that you will judge them harshly. As for all treatment sessions, begin the home visit by establishing the agenda, inquiring about reactions to the previous session and reviewing any homework assignments. The major agenda items for this session are completing assessments of daily activities and the amount of clutter and beginning to plan the intervention with clients. You can complete the Activities of Daily Living for Hoarding, the Safety Questions, and the Squalor Questions during the walk-through, as well as the Clutter Image Rating pictorial measure. As noted, a mismatch in your client’s and your own scores may reflect a lack of awareness of the severity of the problem. These measures will help establish treatment goals to improve functioning, goals that may later prove useful when motivation wanes. We recommend photographing all rooms to capture an accurate visual record of clutter contents and provide a baseline assessment of the severity of clutter for reference during therapy to evaluate progress and decide on next steps. Photos help point out visible progress when clients are discouraged during what can be a lengthy treatment process with ups and downs. If clients live too far from the clinic, or if a home visit is not possible, then they can take the photographs themselves with a little training. Plan to take two to four photographs per room to capture the full extent of the hoarding and to help decide which items clients bring to office sessions for practice during treatment. Try to devise a consistent method that is easy to follow at the next picture-taking occasion to match the first pictures. We suggest doing all photographing digitally, printing the pictures, and storing them in a folder for easy reference in subsequent sessions.

Deciding Where to Begin At some point during the home assessment or when reviewing pictures of the home, decide with clients where to begin the sorting, organizing, and removing clutter. This requires a discussion about whether to proceed room-by-room or to use some other system such as one based on type of item (e.g., gathering up all paper items or all books from all the rooms and then sorting these). We usually begin with the easiest

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space or the one that will have the most immediate benefit for clients. For example, some clients may prefer to begin with a hallway because it impedes access to parts of the home they’d like to use. Others might begin in the kitchen because it is least cluttered and/or offers the most benefit in terms of resuming important activities like cooking or eating. Other considerations like reducing family members’ criticism or complying with building codes may also contribute to this decision. Help clients assemble a box or bag of typical saved items for use during office sessions to learn and practice new skills. This box should contain a mixture of clutter items, such as junk mail, newspapers, magazines, small objects, receipts, notes, ticket stubs, clothing, books, and so forth. These items should be selected mainly from the room where treatment will begin.

Discussion With Family Members When clients are living with family members whose lives are affected by hoarding, try to meet with the client and family members together for some portion of the first or second home session, preferably after you have walked through the house and completed the clutter assessment. We usually reserve the last 30 minutes for this meeting, asking family members not to be present for the earlier walk-through with the client. Ask the client about any special concerns or arrangements for meeting with family members in advance and decide what topics to cover. If the client agrees, you can speak to family members by phone before the meeting. Introduce yourself and inquire about family members’ questions about you, the treatment, or other matters related to hoarding. Ask whether family members engage in behaviors that accommodate the client’s hoarding. These might include doing sorting tasks for clients, throwing out items clients would otherwise deal with, buying or saving things for clients that they would not otherwise do, keeping the credit card to prevent overspending, and so forth. Describe the treatment plan and ask whether they would be willing to follow your directions to refrain from doing things that might interfere with treatment progress or homework assignments. If family members ask what they should do, then suggest they continue with their usual behaviors unless you or the client asks for changes.

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Frequently, family members are highly critical of the client’s ineffective efforts at reducing clutter. Warn them that progress will undoubtedly seem slow to them while the client is learning new skills; ask them to try to avoid criticism and notice small changes. Explain that change will take many weeks and even months because the client must learn new ways of doing things and how to think differently, and this takes time. You can also ask family members how effective their criticisms have been so far in changing the client’s behavior. If they haven’t been effective, would they be willing to respond differently to improve the hoarding? Then make specific suggestions about when to refrain from comments and what to say when progress occurs. Ask whether any family members living at home also have similar problems with acquiring, organizing, and removing possessions. Turf wars over space can erupt when clients reduce clutter only to have family members fill the new space with their things. Some negotiation may be needed to give the client appropriate control over some spaces in the home. Questions about who has the right to handle belongings and to control household spaces will need to be negotiated as the intervention progresses. The final plan must ensure that clients use new skills in problem solving, decision-making, and organizing, as well as evaluating their own beliefs and managing their emotional reactions to resisting acquiring and learning to let go. Ask family members to refrain from special accommodations (making decisions, providing unnecessary reassurance, and taking over duties like trash removal and controlling acquiring) that prevent clients from learning new behaviors. Once spaces are cleared, rules about how to handle new clutter can be negotiated.

Coaching and Visiting by Friends or Family Members Some family members or friends who are especially calm, thoughtful, and empathic can be enlisted as official coaches during the intervention. Discuss this plan with the client to determine whether anyone qualifies for this role, and then include the coach in one or more treatment sessions with the client to outline the rules for helping and to provide guidance. “Instructions for Coaches” in the Appendix provides written suggestions for this purpose.

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Encourage clients to allow visitors into their home as early in treatment as possible. Most hoarding clients actively avoid having people visit, and many have not had anyone in their home for decades. But visitors increase motivation and activity to clear clutter, even among people with severe hoarding problems. However, visitors must be sensitive to the problem and should not attempt to help unless asked. Their role is to provide the semblance of normal interactions in the home.

Special Issues During the Home Visit Severe hoarding problems may complicate home visit procedures. Although it is difficult to know how severe the problem is, you may be able to gage this based on your client’s CIR ratings (6 and above are very severe) and clutter scores on other measures. However, even with moderate scores on these scales, you may encounter unhealthy and even dangerous problems in the home. If your client has children or elders living at home, then have a frank discussion about the level of risk to them and your professional responsibilities for reporting dangerous conditions if they exist. Such a discussion should occur in the office before the home visit and should cover information about the reporting process and how you can help them with it. It is important that your client understand that the health and safety of their loved ones may necessitate more drastic action than they may have anticipated. Also necessary before the home visit is a discussion of steps to protect your own health and safety if you suspect this may be necessary. These could include wearing gloves, protective clothing, and/or a breathing mask. Take these with you just in case, but use them only if you feel it necessary. Also be prepared to have no place to sit down and little room to move around during the home visit. Anticipating these issues will make it easier for you to accomplish what is needed for this visit.

Homework A special note about homework is warranted for people with hoarding problems. We have noticed that some clients become defensive when

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homework is discussed. This seems to be a form of therapeutic reactance in which any request from an authority figure is actively resisted. This may be as simple as reactions to the term “homework,” which implies a teacher and a student. You may fare better by initiating a discussion about how to decide on and structure work between sessions and to clarify terminology. Homework assignments for early assessment sessions depend on the degree of motivation and skills of clients. Consider requesting self-education tasks, and gathering certain information, and engaging in self-observational skills. In general, be thinking in the back of your mind during all therapy sessions whether some aspect of the topic being discussed might lend itself to a homework assignment to help move the therapy along. The following are some recommended homework assignments for assessment sessions, but you may wish to design your own that follow logically from your discussion during sessions. Ask your client to: ■

Read Chapter 1 of the Workbook to learn more about hoarding behavior.

■

Complete self-report questionnaires (e.g., Saving Inventory-Revised, Clutter Image Rating, Saving Cognitions Inventory, Activities of Daily Living); also complete Safety Questions and/or Home Environment Inventory if desired.

■

Assemble a box or bag of items to bring to office appointments for sorting.

■

Discuss the possibility of coaching assistance with an appropriate person.

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Chapter 4

Case Formulation

(Corresponds to Chapter 3 of the Workbook)

Materials Needed ■

Reading: “What is Hoarding”, Workbook Chapter 1

■

General Conceptual Model of Hoarding

■

Brief Thought Record (optional)

■

Acquiring Form

■

Review previous homework assignments, such as:

Outline

■ ■ ■

■

“What is Hoarding” reading Assessments completed at home Discussion with family members or potential coaches about assisting with practice at home Inquire about box or bag of items brought from home

■

Summarize assessment findings

■

Work with client to develop a model of hoarding

Begin by reviewing materials from the previous session, including client’s questions about the “What is Hoarding” reading and any conversations with others about helping the client with practice sessions at home or acquiring outside the home. Summarize findings from assessment

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materials to date, including any forms completed at home. If the client brought in a box or bag of items from home, set these aside for later use, and if not, ask for this for the next session. This chapter describes how to develop a model collaboratively with your client to enable both of you to understand how the hoarding problem developed and why it continues. The process usually takes one to two sessions with homework assigned between sessions to collect additional information to complete the model. Model building is often an ongoing process throughout treatment as new information emerges from practice experiences. At this early stage we may not try to identify the client’s core beliefs; these gradually become more apparent during work on clutter and acquiring problems. Core beliefs are discussed in Chapter 10. Why Develop a Model of Hoarding? Recall from Chapter 1 that hoarding behavior is complex, deriving from a combination of personal and family vulnerabilities, informationprocessing problems, beliefs about possessions, positive and negative emotional responses, and learned behaviors. The assessment process helped identify the features of your client’s hoarding problem. Now it is time to draw this information together into a conceptual model that explains how and why the hoarding symptoms occur. Table 4.1 lists the most common factors to look for during the model building process. We advocate developing two types of models: (1) A general conceptual model that incorporates all aspects of the problem for reference during treatment to help clients understand their behavior in the context of their life experience, and (2) a specific functional analysis that describes individual episodes of acquiring or difficulty removing clutter in real time to help clients grasp why they have just behaved the way they did. Both of these models lead directly to intervention strategies that target the problems identified in the models. We begin with the general conceptual model.

General Conceptual Model Conceptual models for problems with organizing, acquiring and discarding may be slightly different, but the elements are usually similar

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Table 4.1 Elements Useful in Developing the Conceptual Model Basic elements Components

Examples

Personal Family history of and family hoarding vulnerabilities Comorbid problems

Hereditary traits, biological underpinnings

Information processing problems

Meaning of possessions (What gives them value?)

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Depressed mood, social anxiety, obsessive compulsive symptoms, attention problems

Parental values and behavior

Acquiring, difficulty discarding, clutter in the home, decision making, beliefs and values about waste, sentimentality

Physical constraints

Health, time, household space

Adverse life events

Loss of caregiver, moving, deprivation, assault

Attention

Difficulty sustaining attention on a difficult task

Categorization

Problems grouping and organizing objects into categories

Memory

Poor verbal or visual memory leading to reliance on visual cues

Perception

Strong visual attraction to objects, failure to notice clutter

Associative or complex thinking

Generates lots of ideas about or uses for objects, creative ideas, focus on nonessential details, inability to separate important from unimportant details

Decision-making problems

Considering too many facets of a problem, ambivalence; may be related to fear of making mistakes

Beauty

Finding beauty and aesthetic appeal in unusual objects

Memory

Belief/fear that memories will be lost without objects or that objects contain or preserve memories

Utility/opportunity/ uniqueness

Seeing the usefulness of virtually anything; seeing opportunities presented by objects that others don’t

Sentimental

Attaching emotional significance to objects; anthropomorphism

Comfort/Safety

Perceiving objects (and related behaviors like shopping) as providing emotional comfort; objects as sources of safety (safety signals)

Identity/validation of self-worth

Belief that objects are part of the person or represent who the person can become; objects as representation of self-worth (continued)

Table 4.1 Elements Useful in Developing the Conceptual Model continued Basic elements Components

Examples

Control

Concern that others will control one’s possessions or behavior

Mistakes

Perfectionistic concern about making mistakes or about the condition or use of possessions

Responsibility/Waste Strong beliefs about not wasting possessions, about polluting the environment, or about using possessions responsibly

Emotional reactions

Learning processes

Outcomes

Socializing

Buying or collecting items provides social contact not available in other ways

Positive

Excitement, joy, pleasure, comfort, satisfaction

Negative

Anxiety, guilt, grief, sadness, anger

Positive reinforcement

Saving and acquiring produce positive emotions

Negative reinforcement

Saving permits escape or avoidance of negative emotions

Effects of hoarding behaviors

Prevent the opportunity to test current beliefs and develop alternate beliefs

Hoarding behaviors

Acquiring, saving, clutter

enough that one model can adequately describe these features. As noted in Chapter 2, the model should include special vulnerabilities, information processing deficits, meaning of possessions and emotional experienced during efforts to acquire, organize, and remove clutter; the model also includes information about how these features are connected, reinforced, and maintained. We suggest drawing the contributing factors in pictorial form, with arrows leading from the various components to resulting emotions and behaviors. Developing a model collaboratively helps clients adopt an external perspective, learning to observe and critically examine their thoughts and emotions to better understand them. Thus, model building enables clients to take the first step toward distancing themselves from the problem and adopting a more rational rather than purely emotional stance. Model building also establishes the client’s role as detective and

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collaborator, working with the clinician to understand and resolve the hoarding problems. To facilitate this, use open-ended curiosity questions like “That’s interesting, where do you think that thought comes from?” and “How to you think these two components are connected?” Once developed, the conceptual model can be used throughout treatment to determine goals and methods for achieving them. Of course, the model should be revised whenever new information comes to light.

Beginning to Build the General Conceptual Model Reading Chapter 1 of the Workbook helps remind clients of common factors that contribute to and maintain hoarding. Begin working on the model by asking a series of questions and commenting about what you have already learned during the Hoarding Interview or observed during the home visit. Use the blank General Conceptual Model in the Appendix to begin recording the elements of your client’s model. Then specify the consequences and their role in reinforcing the behaviors. See the example in Figure 4.1. The first “working model” usually needs to be revised a few times before it accurately captures the complete picture. Developing the model also helps identify goals and points for intervention, such as reducing anxiety about losing valuable information, re-evaluating beliefs about responsibility for possessions, and reducing shopping patterns that add to the clutter. Here is an example of the beginning dialogue.

Case Vignette

Clinician: To understand how your problem with clutter has developed and what keeps it going, we find it helpful to work out a model on paper. It seems pretty clear to me that you are most unhappy about the clutter at home and you also have a problem with acquiring, especially at tag sales. Would you agree? Client:

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Yeah, I really need to get rid of some of this stuff.

Clinician: Right. So let’s start by understanding how the clutter happens and why you have trouble getting rid of it. So first, I’ll put the words “Difficulty Discarding and Clutter” here at the bottom of the page. Above it we’ll figure out what contributes to this. Client:

I usually like to see things visually, so that’s okay.

Clinician: Lots of things can contribute to clutter. In your case, we’ve talked about your family history and you’ve also mentioned some personal events in your past that seem related to the clutter. Let’s put a box up here on the left that we’ll call “Personal and Family Vulnerability Factors” and list the things we think have contributed. What would you include in there? Client:

Well, when my mother threw out my old toys when we moved, that really upset me so that might be one.

Clinician: Okay. I’ll write that as “Mother threw out toys.” What else? Client:

Um, I think I react against my mother’s housecleaning. You know, she was so particular and everything had to be so neat. I hated it. I don’t like a neat house. I like a little clutter.

Clinician: Okay, can I put that down as “Family rules about neatness?” Client:

Yeah, geez, she never would let me make my own decisions about my room. I honestly think that’s part of why I have trouble deciding about my stuff.

Clinician: Okay, so we can add, “Not allowed to make decisions.” Client:

Yes, that’s part of it for sure. And also, my grandparents’ home, my Dad’s parents you know, was pretty much a mess, but we had a lot fun there, my cousins and I. So maybe that’s part of it too. I think I liked their house better than my own.

Clinician: That sounds important. I’ll add, “Grandparents’ cluttered home was fun.” Would that capture it?

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Client:

Yeah.

Clinician: [Summarizing to consolidate the points:] So far, what we have are several past experiences that contribute to making you vulnerable to having clutter. These are your mother’s strict standards for tidiness and not allowing you to make decisions about your own things and having fun at your grandparents’ cluttered home. It sounds like you associated neatness with unhappy emotions and clutter with happy ones. Does that sound right? Client:

Yes, that’s certainly right. But now I hate the clutter here, it’s over the top.

Clinician: That’s why you’re here. It’s interesting to see some of the reasons why some clutter appeals to you and these might have something to do with avoiding cleaning up. Now, let’s talk about other things that might make you vulnerable to clutter. What else occurs to you? This dialogue illustrates the collaborative style of helping clients recall events they have reported during the assessment that seem relevant to causal factors. Open-ended questions are used to elicit other possibilities.

Vulnerability Factors The example above begins with childhood history as a vulnerability factor. Table  4.1 offers a variety of other vulnerability factors to explore. Ask about each of these in turn, especially on those identified during assessment. Once the model is clear, you and your client can decide what problems to work on and in what order. Dialogue about vulnerability factors might go as follows.

Case Vignette

Client:

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I’m not sure, maybe the break-in I had in my 20s might have contributed. I felt so violated that the burglars took my stuff. I was really upset.

Clinician: How do you think that contributes to clutter now? Client:

Well, I started getting seconds and thirds of things, in case something got stolen, and I put the duplicates in places burglars might not look.

Clinician: Okay, so the burglary led you to try to make sure you had back-ups in case things were stolen. Does that belief that you might need extras in case things are stolen still operate now? Client:

Yes, I think it does. I always think, “Just in case,” you know. And also, I think I use the clutter to stop somebody from coming in. Nothing happened in the burglary because I wasn’t home, but I started thinking I could have gotten hurt and I started piling heavier items up near the door so it would stop someone from getting in. I think that’s why I keep it so the door is hard to open.

Clinician: That’s really important, so we’ll need to work on thoughts about safety before you can clear that clutter. I’ll add “past burglary” to the section on vulnerability factors. Also, I’ll add the part about “keeping items just in case” and the idea that “clutter prevents people from hurting me” down here in a section on “Meaning of Possessions.” We can come back to that in a bit. Client:

Yeah, I think that part is important. It’s why I keep a lot of stuff.

Clinician: Good. Now, any other vulnerability items? I’m going to name a few and you tell me if you think they are related to the clutter problem at all. What about depressed or sad mood? You told me there was a family history of this and you have had some periods of depression. Are they connected to hoarding in any way? Client:

I suppose that when I’ve been depressed about something, you know, like my Dad dying last year, I really don’t do much at all on the clutter. Now that I think about it, sometimes my low mood makes it hard to do any work. Like I really don’t even want to bother.

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Clinician: Okay, so we’ll add “depressed mood” here on the vulnerability factors list. What about your physical health. Anything there that contributes? Client:

No, not really. I don’t have any real health problems. If I’m really sick I go to bed but it isn’t that often.

Clinician: What about social anxiety? We’ve talked about that a bit and I know you avoid some social gatherings. Has the clutter got anything to do with this?” Client:

I’m not sure. I’d have to think about that.

Clinician: Okay, good idea, I’ll put it here on the model with a question mark after it. Would you be able to think about that more for homework? Client:

Yeah, sure. I can do that.

Clinician: Great. Let’s both of us add that to the homework section of our session forms.

Information Processing Components Table  4.1 lists common information processing problems related to hoarding. Comment that many people with hoarding problems have one or more of these symptoms. Then ask whether they have difficulties in any of these areas, such as attention problems as children and learning difficulties in school. Ask clients to compare themselves with others they know well to determine whether they may have deficits in these areas. Focus only obvious deficits for which clients have clear evidence. If other problems emerge later during treatment (e.g., in working on organizing possessions), then revise the model at that time. The following dialogue illustrates the method of questioning.

Case Vignette

Clinician: As you read in the “What is Hoarding?” reading in your Workbook, most people with a lot of clutter have some difficulty processing information. For example, lots of

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people can’t pay attention to a task long enough to get the work done. They get distracted and move onto something else before they are finished with the first task. Is this a problem for you? Client:

Yeah, actually. My mother used to complain about this, and I had some special classes as a kid—I’m not sure what it was called but now I think I had ADD or something like that.

Clinician: Has this problem got anything to do with your clutter? Client:

Oh, yeah, in spades. I can never seem to finish stuff. You know, I start sorting a pile of papers on my desk and pretty soon I’ve found a photo and that gets me thinking about when it was from and pretty soon I’m looking at old photos instead of sorting. It happens all the time.

Clinician: We’ll put “attention” here under information processing deficits. What about the sorting itself. When you work to organize your papers, do you have any problems deciding what to put with what? Client:

Yup, that too. I can’t figure out what filing method to use. I start to label folders and then I get confused about what to put where. Like the other day, I was trying to file some papers and I just couldn’t do it. I picked up a travel brochure from a Vermont resort, but I couldn’t decide whether to write travel or brochure or Vermont. I get so caught up in questions like that a lot and I just give up.

Clinician: So these kinds of decisions are difficult. What about decisions about other things? Client:

Absolutely. People hate to go to dinner with me because I can’t make up my mind about what to get.

Clinician: So let’s put decision-making problems in our model and we’ll explore it as we go along. Also, it sounds like categorizing or organizing is a problem as well. Together with the vulnerabilities noted above, the information processing deficits help define what possessions mean and the role they play in your client’s life. These meanings are outlined below.

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Meaning of Possessions: Thoughts and Beliefs As noted in Chapter 1, the meaning we attach to possessions (our beliefs or appraisals) drives hoarding behavior. Various types of attachments are shown in Table 4.1. Clinicians can use any of the following methods to help clients identify these during sessions. 1.

Examine the Saving Cognitions Inventory (see Chapter 3) to identify individual items and subscale scores that are high.

2.

Ask clients to review the Meaning of Possessions from the Workbook (page 32) to select those they recognize in themselves, such as emotional comfort in possessions, loss and mistakes, value of possessions, identity, responsibility, memory, control, and perfectionism.

3.

Thought-Listing task: Tell your client you’d like to understand more about their reasons for saving by having them talk aloud about several of the objects brought in from home, one at a time, to say why they acquired or kept it and what they think about it now. Be sure they understand you are not asking them to get rid of anything, just to talk about it. Dialogue illustrating this is given below.

Later in treatment, you and your client might discover additional beliefs about acquiring and saving that emerge from using (1) the Downward Arrow method when clients experience very strong feelings about acquiring or getting rid of possessions or (2)  Behavioral Experiments to test for beliefs and attachments during acquiring and/or sorting and discarding. These are found in Chapters 7 and 10.

Case Vignette

Clinician: Let’s talk about these items you brought in to understand how you think about these things. Can you pick up the top one and tell me your thoughts as you do so? Client:

Okay, this is a magazine from last summer that I’d like toread.

Clinician: Say a little more about why you’d like to read it.

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Client:

Well, it’s a news magazine and it might have something in it I should know about.

Clinician: So, in our model, the thought goes something like, “I might need to know information from this,” is that right? Client:

Yup, I don’t want to miss out on information that might be important.

Clinician: We could phrase this as “might need to know.” Is that a pretty common reason for you to save things? Client:

Yes, I think so.

Clinician: Let’s try another item that’s different. Client:

Okay, this is a box of note cards I haven’t used yet. So I’d like to keep them to use.

Clinician: For the cards, then, the thought is something like “These are useful,” yes? Client:

Yes. I don’t want to waste something that’s useful.

Clinician: Okay, we can add the thought “avoid wasting useful things.” Any other reason to save this? Client:

Nope. I don’t really like them so it’s not that they are pretty, just useful. That’s probably my dad talking—he always kept a lot of stuff that might be useful.

Clinician: So we might add “keeping useful things.” I’m also going to put up under vulnerability factors what you just mentioned about your dad teaching you not to be wasteful. Okay, so far we have several reasons for saving—needing to know information, concerns about waste, and thoughts about the usefulness of objects. Also, earlier you identified thoughts about keeping items just in case, as well as the thought that the clutter might somehow keep you safe. Let’s try a few more to see if any other thinking emerges that’s different from these.

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Emotional Responses Most of the thoughts about possessions identified above are followed by immediate emotional reactions that make discarding difficult. Emotional responses can be identified while clients are reporting their thoughts. Typically, these emotions are negative—anxiety, fear, sadness, grief, guilt, anger. These feelings occur when clients contemplate or attempt discarding or not acquiring. Clients often identify positive feelings like pleasure, excitement, joy, comfort, or satisfaction when describing possessions, sometimes even when they are considering getting rid of them (e.g., in finding lost objects, in passing items along to someone who might use them). These positive feelings, even if fleeting, help reinforce saving and acquiring behavior. Ask about recent acquiring, sorting and decluttering experiences that are fresh in mind to determine the emotions and connect them to the triggering thoughts and subsequent behaviors. The usual sequence is thoughts—emotions—behaviors. For example, fear and anxiety probably follow from thoughts about losing items, about vulnerability, and about safety. Grief may stem from clients’ beliefs about their identity being defined by possessions. Anger could result from perceived threats to free choice and personal control. The following conversation illustrates this questioning.

Case Vignette

Clinician: So far we have several reasons for saving—needing to know information, concerns about waste, ideas about the usefulness of objects, clutter providing safety, and so forth. Let me make sure I understand the emotions that follow from these types of thoughts. If you think “I need to know what’s in this” but then threw it out anyway, then how would you feel? Client:

Oh, I feel pretty anxious about not knowing what’s in there. I’d feel afraid I would miss out on something I should know.

Clinician: You’d feel afraid, anxious. Client:

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Yes.

Clinician: So the thought that you might need to know this leads to an emotion of anxiety about missing out on something important. In the model, let’s connect the thought about needing to know to the emotion of anxiety. What about the idea of wasting something; what emotion does that provoke? Client:

I don’t know, uncomfortable.

Clinician: Guilty? Client:

Yeah, a little I think.

Clinician: Okay, guilt. So we can add guilt to our model, right after the thought about being wasteful. [The clinician continues to ask about other negative emotions tied to beliefs until no more are identified.] Do you have any positive emotional reactions when you are going through your stuff? Client:

Sure. Once I get going, I often enjoy going through my stuff. I start out trying to sort it, but then I find some little treasure I haven’t seen for a while. I wouldn’t want to miss that by throwing everything away.

Clinician: Okay, I hear a belief that removing clutter will cause you to miss something important and also that you feel happy when you find some items. Let’s add that emotion of pleasure to the model. Now, let’s go on to see what actually happens when you’ve had these thoughts and feelings.

Learning Processes Once the meanings and emotional responses are clear, figure out how these features result in clutter. Table 4.1 gives several avenues to hoarding symptoms. Positive reinforcement of saving or acquiring comes from the short-term benefits of acquiring or saving—the excitement, joy, or other positive emotions make it more likely that the client will continue to collect and keep things. This is most evident when clients feel pleasure at finding a treasured item that has been buried in the pile for a long time. Avoidance behaviors are negatively reinforced by removing the distress associated with discarding. For example, putting the newspaper back

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on the pile rather than recycling it allows the client to avoid the distress associated with the idea of missing out on important information or opportunities. Each of these actions (acquiring, putting something in sight) or avoidance behaviors (avoiding discarding, not putting an item away, etc.) contributes to the clutter. At the same time, the actions also help clients feel better by reducing their negative emotions (less anxiety, less guilt). Negative reinforcement is a powerful mechanism for maintaining clutter. The clinician might proceed as follows below.

Case Vignette

Clinician: Let’s add in the behaviors you do after you have one of these thoughts about an item you picked up from the clutter. So you picked up the magazine, thought about needing information from it, felt anxious about getting rid of it, and then what? Client:

Oh, I put it down. [laughs] You know, back on the pile.

Clinician: Okay, so feeling anxious about needing information doesn’t lead you to pick up the magazine and read it? Client:

Well, maybe eventually, but not right away.

Clinician: Why not? Client:

I don’t have time right now.

Clinician: Got it. So in your mind it goes something like, “This might have important information. I need the information. I better not get rid of this.” Then you feel anxious and think, “I don’t have time to read it now. I better put it back on the pile.” And then you set it down. Client:

Yes, that about captures it.

Clinician: And for the note cards, what do you do with them? Client:

I just set them down on the back of the counter because they don’t belong in the kitchen, but I can’t really put them away anywhere.

Clinician: Why not?

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Client:

Well, I don’t really know where they go yet. And I can’t get into my study, for example, to put them away, it’s too cluttered right now.

Clinician: So the sequence is that you find the note cards in a pile, you think, “These are useful. I better not waste them.” You would feel a bit guilty if you don’t keep them, and then you set them down in a different place. Then how do you feel at the moment when you’ve set them down? Client:

Well, I suppose I feel a little relieved, but it doesn’t last long. Because, really, I’m just moving stuff around, but not much goes out.

Clinician: That’s what it sounds like but that brief period of feeling relieved is an important reinforcer of the whole process. Let’s go over the whole sequence for these types of items. You see an object in your home, you have a thought about it—for example, about needing information or wasting things—and this triggers an emotional reaction like anxiety or guilt. You respond to that by keeping the item and moving it to a different place. This helps you avoid the unpleasant emotions of fear and guilt that would happen if you got rid of the item. But from what you’ve told me, it doesn’t actually help you make much progress to clear the clutter. Client:

Yeah, I think I understand and you’re right, I don’t clear the clutter very fast, but I wouldn’t want to just throw stuff out that might be important.

Clinician: I agree. Right now we are learning how the process works for you, and then we can decide what to do about it. We have figured out some important vulnerability factors, and we’ve just been looking at how your thoughts produce certain emotions that lead to your behavior in relation to clutter. So far, here is our model. What do you think? Figure 4.1 is a graphic representation of the model as developed so far with this client.

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Personal/Family Vulnerability Factors: Mother threw out toys Mother too neat Not allowed to make decisions Grandparents’ clutter was fun Burglary

Information Processing Problems: Attention Decision-making Categorizing/organizing

Meaning of Possessions: I might need to know this. It’s bad to waste useful things. Keep items just in case. Clutter keeps me safe.

Emotional Responses: Fear of missing out Fears about safety Guilt over being wasteful

Negative Reinforcement:

Positive Reinforcement:

Escape or avoidance of unpleasant emotions

Excitement at finding a lost treasure

Behaviors: Acquiring free items and buying Difficulty discarding Clutter

Figure 4.1

Hoarding Model Example

Brief Thought Record Clinician: We want to make sure our model captures the problem well. I wonder if you’d be willing to do a task at home? Client:

I suppose so.

Clinician: Would you be willing to observe yourself at home while trying to sort a little pile of your things, maybe the items on the kitchen table because that’s a place you wanted to work on first. There’s a form in your Workbook called a Brief Thought Record that you can use to put down your thoughts at times when you have a strong emotional reaction. So, when you start feeling quite anxious or unhappy or guilty or angry, that would be a time to stop what you are doing and ask yourself what you were

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Initials: PK

Date: 11/16/13 Thought about Meaning of Possessions

Trigger situation

Emotions

Actions/Behaviors

Sorting stuff on kitchen table, found some old financial forms

I don’t know if we need these for taxes or something else. I’m afraid to throw them out.

Anxious

I put them in another pile on the kitchen counter

Found some old magazines

I should read these. There might be something important in them.

Anxious

I put some of them into a bag to give them away later.

Somebody could use them. I could give them to my neighbor, she likes this kind of magazine.

Guilty that I haven’t read them.

Figure 4.2

Example of Completed Brief Thought Record

thinking. You would also do this when you have strong positive feelings of pleasure or enjoyment. This gives us a way to see if there are other thoughts or beliefs besides the ones we have here in the model that contribute to clutter. What do you think? Client:

I can do that. You mean not for every thought, but just the ones I react to strongly.

Clinician: Exactly. You can just fill out three or four Brief Thought Records for a few different sorting situations. Let’s take a look at it now so you can see what to do. Then we’ll review them next time to see if we need to add anything to the model. Client:

Okay.

Show your client the blank Brief Thought Record forms (p. 226) and give examples of what might go into the four columns. Figure 4.2 depicts a completed record and a blank form can be found in the Appendix.

Special Considerations for Models of Acquiring Clients’ acquiring behaviors are usually based on elements similar to those that drive saving and clutter, but usually there are more positive

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feelings and fewer negative ones. Acquiring problems may be evident in several types of behaviors: ■

Collecting free items or accepting items from others

■

Picking up things others have thrown away

■

Compulsive buying in stores, yard sales, flea markets

■

Buying multiple items “just in case” something happens to the original

■

Stealing

■

Ordering subscriptions, mail order items, home shopping networks, and so forth.

Use the Acquiring Form in the Appendix to identify the types of items clients commonly acquire. You can also ask clients to complete this form in the Workbook as a homework assignment to determine what they accumulated during a specified period (e.g., 1 week). An example follows in Figure 4.3. You can use information from the Acquiring Form to add to the client’s model. Ask clients about their attempts to resist or control acquiring. It is likely that they use avoidance strategies. A discussion of the dangers of relying on avoidance to control acquisition may be warranted.

Functional Analysis of Hoarding Behavior The model described earlier is a general conceptual model that outlines the main factors contributing to the hoarding problem. You can also help clients understand their behavior by developing models of the functional relationships between triggering situations, thoughts, feelings, and behaviors. This is especially useful to help clients understand what just happened; also, they can be used to develop treatment strategies. Because this is especially helpful for acquiring problems, we describe and illustrate this functional analysis model using acquiring as the target behavior. Start with information from the general conceptual model and tie this to a recent situation the client recalls vividly.

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Instructions: Make a list of the types of items you typically bring home and how you acquired it. Think about items you got in the past week and keep a record of the items you bring home during the coming week. Do not include groceries or other perishable goods unless you are buying many duplicates. Rate how uncomfortable you would feel if you didn’t acquire this item when you saw it. Use a scale from 0 (no discomfort at all) to 100 (the most discomfort I’ve ever felt). Item and where you typically find it Shoes for me or kids, consignment shop

Discomfort if not acquired (0 to 100) 90

Clothes for me – dresses, skirts, blouses, pants consignment shop

80

on sale at department store

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Kids clothes consignment shop

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on sale at department store

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Kitchen items like nice knives, utensils

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Decorative items for the house, figurines, pictures mainly at 5 & 10 store

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Mystery books at my favorite used book store

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Magazines at corner store, esp. house decorating

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Figure 4.3

Example of Completed Acquiring Form

Case Vignette

Clinician: Can you tell me what happened over the weekend? Client:

Well, I went out to run some errands, and I drove by that clothing store I like. Before I knew it, I turned into the parking lot and was in the store. I bought $200 worth of clothes I really don’t need. My husband was furious when I got home. We’ve been trying to pay off our huge credit card bills, and this won’t help.

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Clinician: Do you mean you had not planned to go to this store or to buy clothes? Client:

No, but I had to drive by it to get to the grocery store.

Clinician: So the sight of the store was a sort of trigger for going in and buying? Client:

Yeah, I just can’t seem to pass by that store without stopping.

Clinician: So this has happened before? Client:

Yeah, way too often.

The immediate triggers for buying episodes for most clients are varied. Often they involve the sight of a sale sign in a favorite store window, a newspaper or TV ad, a picture of a product, or seeing other people buying something. The list is endless. Once the trigger is identified, ask about the precursors: Clinician: The sight of the store seems to be a powerful cue or trigger for your shopping. What happened just before you went to the store? Client:

Well, I just had a fight with my husband. It was over money and how much I spend. He blames me for our money problems and for the clutter and mess at home. Granted most of the stuff is mine, but no one in the family helps me with it. He is always trying to tell me what I should do and buy, and it makes me mad. He doesn’t appreciate what I do around the house.

Clinician: So you were upset when you left the house, and then you went by the store and couldn’t resist stopping. Do you ever stop at a store like that without intending to or do you buy excessively when you aren’t angry or upset? Client:

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Yeah. Sometimes I buy when I am in a good mood, like after the last session when I thought I was making great progress. I was on my way home and drove by the same store. Traffic was heavy, and I just veered off into the store parking lot and bought a bunch of stuff. That’s what prompted the argument last weekend.

Now a pattern begins to emerge. Clients frequently acquire when they are in a highly emotional state—in this client’s case, the emotion can be either positive or negative. From here we move on to the thoughts and beliefs about the buying and the immediate consequences. Clinician: What happened when you went into the store? Client:

I just walked around and looked at the dresses. I was still pretty upset.

Clinician: Do you remember what thoughts you were having at that moment? Client:

Yes, I was thinking about being told not to buy anything, and I thought to myself, “I deserve to have nice things. Why should someone else tell me what to do?” That’s when I decided I was going to buy something.

Clinician: What happened then? Client:

After a few minutes I wasn’t upset anymore. In fact, I was enjoying myself. I like clothes, they make me feel good. I just kept piling things onto the counter, and at that moment I really liked the things I was buying.

Clinician: So this whole process and the decision to buy led you to feel better? Client:

Yes.

Table  4.1 outlines these thoughts in a general way. For this client the thoughts had to do with control and validation. Other common thoughts associated with acquiring include opportunity, uniqueness, availability, low cost, and so forth. People who hoard often work hard to control their acquiring, but strong emotions and beliefs allow free reign to the impulse to acquire. The immediate consequences of acquiring are usually a positive mood and even a sense of euphoria. After identifying these immediate reactions, keep going to ask about the long-term consequences.

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Clinician:

Client:

You liked what you bought at the time. Did your feelings about them change later? Yeah. I was really feeling good as I left the store. But as soon as I turned out of the parking lot, I started to regret buying all this stuff. I knew we’d have another argument, and I wished I had gone the other way to the supermarket so I wouldn’t have seen the store.

Clinician: What other thoughts did you have? Client:

Well, later I really got down on myself. I’m such a weak person for buying all this unnecessary stuff. Our house is crammed full, and here I am out spending money we don’t have for more stuff I will probably never wear! I just felt totally worthless.

At this point, summarize what you and the client have learned about the episode and review all of the sequences. Clinician: Let’s see if we can put this together to help us understand how this episode happened. You left the house angry with your husband and upset. Then you passed your favorite store and stopped. You thought to yourself, “I deserve to have nice things” and “No one has the right to tell me what I can and can’t have.” Then you made the decision to buy something and began feeling better. Pretty soon you were in a good mood and enjoying yourself. I’m not sure but I think this led you to buy even more things. However, later you regretted your purchases and began to feel pretty bad, not only about buying things but also about yourself as a person. Does that about sum it up? Client:

Yeah, that about does it.

Clinician: It sounds like you are most vulnerable for buying episodes when you are experiencing either strong positive or strong negative emotions. Have you bought excessively when you weren’t in one of these moods? Client:

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Not usually. Normally I stop myself when I think about all our bills and what else we could use the money for.

Clinician: Okay. Now as you described this episode, it sounds like your shopping helped you cope with and get rid of your bad mood. Is that right? Client:

Yes.

Clinician: So shopping works in the short run to make you feel better, but soon you feel worse because you have spent too much money and your shopping will make the clutter at home worse. So the short-term benefits of feeling better are quickly followed by the longer term costs of feeling worse. Is that right? Client:

Yeah.

Clinician: So if we diagram this episode, we can start with a box at the top that says “angry and upset” followed by a trigger which was the sight of the dress shop. Then we have the thoughts you were telling yourself in the car and then in store, that you deserve to have nice things and that no one has the right to tell you what to do. These thoughts take over and crowd out your more rational thinking and you buy. Does this make sense so far? Client:

Yes, it does.

Clinician: The actual buying of the clothes and the immediate aftermath is pleasurable, a sort of a high, but soon it is followed by frustration with your own behavior, conflict with your husband, more clutter at home, and some pretty bad feelings about yourself. Right? Client:

Right.

Clinician: Do you think the negative moods and conflict this creates increase the chances that you will be in a bad mood and engage in other buying episodes? Client:

Probably.

Clinician: So this is a vicious cycle that perpetuates itself to some extent. Client:

Yes, I see that it probably does.

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Figure 4.4 displays this functional analysis model sketched out during the therapy session. You can point out places in the model where the behavior is positively reinforced (i.e., immediate enjoyment) and negatively reinforced (i.e., relief from anger and upset). It is also important to highlight how this process actually increases the likelihood of the episode happening again. Once you’ve laid out the functional analysis, ask the client about events and thoughts that typically lead to decisions to buy. Ask whether they can think of any alternative ways of coping with the emotions that triggered the episode. Avoiding the triggering stimuli can help in the short term, but eventually clients will need to find other ways to manage their strong emotions. Once you and the client have a working knowledge of how the saving and acquiring behaviors are maintained, the next step is to plan the treatment as described in Chapter 6.

Negative feelings: Angry, Upset

Negative thoughts about self: “I am totally worthless.”

Shopping trigger: Driving by the store

Feelings: Regret, worry

Thoughts: “My husband will be mad” “I spent too much money”

Problematic Thoughts: “I deserve nice things.” “No one has the right to tell me what to do.”

Feelings: Pleasure, Enjoyment

Decision to Buy

Figure 4.4

Functional analysis of a compulsive buying episode

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Homework Homework assignments that may be useful between sessions for developing the model and advancing treatment planning include asking the client to: ■

Work on the model (Fig. 3.1 in the Workbook) at home to identify additional components that contribute to hoarding or acquiring.

■

Monitor thoughts and feelings using the Brief Thought Record form (in the Workbook) while sorting at home or when acquiring.

■

Complete the Acquiring Form (in the Workbook) to obtain a full list of the types of items accumulated in recent weeks and months.

■

Work on a functional analysis (in the Workbook) after an incident of acquiring or inability to discard to capture the sequence of triggering events, thoughts, feelings, and actions.

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Chapter 5

Enhancing Motivation

Outline ■

Employ motivation-enhancing strategies with clients who exhibit ambivalence about treatment

Two major impediments to successful intervention for hoarding disorder (HD) are the lack of insight into the severity of the problem and low motivation to resolve it. In Chapter  6 on treatment planning, we describe visualization exercises that are useful for identifying low insight and ambivalence about reducing clutter. Here we provide ways to recognize motivational problems and outline a variety of strategies for resolving them. Some of these intervention techniques are based on well-researched motivational interviewing (MI) methods developed by William Miller and Stephen Rollnick and described in their 2013 book, Motivational Interviewing:  Helping People Change. We strongly urge clinicians to read this volume and to view the accompanying training videotapes. In this chapter, we also describe other motivation enhancing strategies we have found useful, such as problem-solving skills, visits to the home by other people, and behavioral experiments. The methods described here should be used whenever clients exhibit ambivalence about the work that interferes with progress. Clinicians may elect to spend entire sessions using motivational methods or simply apply one or more strategies briefly until the client expresses an interest in change and is willing to proceed with planned interventions. If clients do not express a clear wish to resolve their hoarding problem after two or three sessions using motivational methods, then seek alternative strategies to address the hoarding problem (e.g., recommend that

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family members consult with agencies that may help motivate clients by enforcing health and safety regulations regarding public health, housing, elder abuse and neglect, etc).

Insight and Motivation Clinicians often describe HD clients as lacking insight (Tolin, Frost, & Steketee, 2012), and some studies have supported this conclusion. In a survey of elder service caseworkers, Kim et al. (2001) reported that only 15% of clients acknowledged the irrationality of their hoarding behavior. In a survey of family members, Tolin et  al. (2010a) found that more than half of the family members described their loved one with hoarding as having “poor insight” or “lacks insight/delusional.” But are these reports accurate? In a recent study, we found that family members’ and clinicians’ reports of hoarding severity are heavily colored by their level of frustration with the lack of progress in clearing clutter. Further, we found evidence that HD individuals may over-report the severity of their hoarding compared to independent observers (DiMauro, Tolin, Frost, & Steketee, 2013). The problem with understanding insight in HD has to do with how it is defined. The classic definition of insight is an absence of awareness of the severity and consequences of a problem and is called “anosognosia” (Frost et al., 2010). Anosognosia is typically associated with schizophrenia and other psychotic disorders. Hoarding disorder clients with anosognosia do not consider their hoarding to be problematic and are unlikely to seek treatment voluntarily, although they may be sent by authorities or family members. The percentage of HD cases suffering from anosognosia is unknown, but given the frequency with which we see people seeking help for hoarding, it is probably fairly small. In fact, the field trial for HD found 86% of HD cases had “good” or “fair” insight and only 3% were classified as having “absent insight” or “delusional” (Mataix-Cols et al., 2013). A related phenomenon that is sometimes mistaken for lack of insight is overvalued ideation (OVI), a persistent or unreasonable belief—in this case, about the potential value of an object. Overvalued ideation is

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typically seen in disorders such as hypochondriasis and body dysmorphic disorder, and, less often, OCD. In HD, the belief that a decades old newspaper contains information so valuable that it can’t be discarded despite a house full of newspapers may appear to some as a lack of insight. However, such beliefs are part of the symptom pattern in hoarding and must be treated accordingly. Another phenomenon sometimes mistaken for a lack of insight is defensiveness. For most HD clients the hoarding behavior is wrapped in years, even decades, of profound interpersonal conflict with family members, friends, and often authorities who exhibit frustrated or rejecting attitudes. The consequence of these patterns of interaction is defensiveness and knee-jerk arguments against change. These patterns play out in the therapist’s office and can appear as an insight problem. Related to this pattern is an apparent tendency among HD clients to react strongly to any hint that other people are controlling or constraining their freedom, a phenomena called “therapeutic reactance” (Buboltz, Thomas, & Donnell, 2002). This appears most frequently around instructions or “homework” assignments. One of the clients in our first treatment study put it quite clearly in her first session. She said, “I know myself, and I want you to know something important about me. If you tell me what to do, I won’t do it.” It is important to keep this lesson in mind and to make sure the therapy is truly collaborative. Understanding the differences among these manifestations of insight and motivation problems will help determine how you approach the hoarding behavior. Clients who truly lack insight (anosognosia) will require you to begin at a different place. The best rule of thumb is to begin with the client’s concern. In anosognosia this will typically be something like, “How can I get the health department to leave me alone?” For these clients, begin there (“Okay, let’s work on how to get them off your back”) and plan to use mainly motivational interviewing methods and practical ways to reduce danger in the home before directly addressing the sources of the hoarding problem. Similarly, clients who are defensive about their behavior may need several sessions of MI before signing on for hoarding treatment; be careful not to come across as taking the side of family members or authorities.

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Motivation to Change Sustaining motivation over the full course of CBT is difficult for many people with HD. Midway through treatment, after the novelty of being in treatment has worn off, motivation can wane, especially when faced with difficult decisions. Motivational interviewing theory (Miller & Rollnick, 2013) provides a useful framework for conceptualizing these problems. Motivation to change depends on two things:  importance of the change and confidence that change is possible. Importance of change refers to the discrepancy between what life is like now and what we want our life to be. This discrepancy is easy to see in many hoarding cases using the visualization exercises in Chapter 6. But the motivation to change created by this discrepancy will be short-lived if the client lacks confidence that change is possible. Without that confidence, clients will seek to reduce the discrepancy by changing their perception of the problem rather than by changing their behavior. Expect comments like, “Well, the clutter is really not so bad,” “I don’t really mind the clutter,” or “This is really my wife’s problem, not mine.” These statements sound a lot like lack of insight, but in fact, they reflect a motivation problem that can be corrected. The job of the clinician using MI is to develop the discrepancy (importance of change) while also providing the client with confidence about change.

Tips for Developing Discrepancy (Importance of Change) There are a variety of ways to heighten discrepancy between the current state of affairs and how the client wants to live. One of the simplest is to ask who visits the home. Almost all HD clients experience shame when others see the condition of their home. A discussion about how the client feels when someone rings the doorbell or asks to stop by or asks for a ride in their car can be a good starting point for developing discrepancy. Consider incorporating visualization exercises by asking your client to visualize someone coming to the door now, followed by imagining someone coming when the front room is cleared of clutter. A general rule of thumb is to focus on function. What would the client like to do that they can’t do now because of the condition of the home?

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Then ask them to visualize being able to do that activity (e.g., having friends over) once their home is ready. Another way to develop discrepancy is to use the client’s values and goals established during treatment planning (Chapter  6). For example, the discrepancy will become apparent to a grandparent who values family relationships but whose son or daughter will not allow the grandchildren to visit because of the condition of the home. Draw these discrepancies out during discussions, but avoid coming across as trying to convince your client of some conclusion. This is a delicate balance that requires practice. In MI terms, only the client can explore and resolve ambivalence. They cannot be “convinced” by persuasion.

Addressing External and Internal Impediments to Motivation Among the several variables that influence clients’ motivation to engage in therapy are lack of appropriate pressure and support from others who care (especially among those who live alone), the absence of visitors to the home, toxic levels of criticism from family members, and significant depression. As evident from this list, family and friends can be both a help and a hindrance. As we noted in Chapter 1, people with HD tend to live alone and their attachment to others may be tenuous; some suffer from social phobia and may have dependent interpersonal styles, relying on others to make many decisions. Although these characteristics are not necessarily problematic for treatment, the lack of contact with others who provide feedback about living conditions may reduce their insight into the problem and motivation to fix it. Related to this is the “visitor effect,” the tendency to tidy up one’s home when visitors are coming. Because this is such a strong motivating factor for many people, we recommend arranging regular home visits, initially by the clinician and/or coach, and as soon as possible by supportive family members and friends. These visits by family and friends need not be to work on clutter but merely to provide clients with new perspectives on their homes. Some clients enter treatment at the behest of a partner or family member frustrated by the hoarding, sometimes because spouses have threatened to leave, and clutter and compulsive buying have become weapons in an interpersonal conflict. Explore these issues using motivational strategies

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to ensure that clients can articulate personal (not merely family) goals before active treatment begins. Many hoarding clients find being at home an unpleasant experience and structure their lives to spend as little time there as possible. Help these clients develop strategies to spend more time at home, especially doing things that are enjoyable. Hoarding clients may complain about fatigue and health problems as impediments to starting or completing homework. The aversiveness and enormity of the decluttering task contributes to these experiences. Incorporate these problems into the case formulation (Chapter 4) as vulnerabilities and avoidance behaviors. Treat them as you might approach a physical fitness problem. For example, one of our clients could work for only 15 minutes before he became exhausted at the beginning of treatment (Frost, Steketee, & Greene, 2003), but after 2 months of gradually increased practice, he was able to work for more than an hour without a break. Depressed clients may lack energy for homework or tolerance for the discomfort of making decisions about clutter. If mood interferes, then consider immediate treatment for the depression (e.g., medications, cognitive therapy) while assessing the hoarding problem and establishing a treatment plan, waiting until mood is improved before working on sorting and removing clutter or assigning significant homework.

Understanding Their Experience Most hoarding clients feel ambivalent about changing their behavior. On the one hand, they recognize the problems hoarding has generated for them, but on the other, they have compelling reasons not to get rid of their collection of newspapers. More than likely, your client will have negative experiences from other’s attempts to help them. These will have taken the form of arguing for getting rid of stuff—“Just throw it out.” But this view does not take into account clients’ ambivalence, and an argument will ensue in which helpers present reasons for getting rid of things and clients dig in their heels and give reasons for keeping them. Progress stalls quickly in this scenario. The motivational interviewing strategies outlined here are designed to prevent these arguments and

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disarm defensiveness by helping clients first articulate and then resolve their ambivalence.

Identifying Ambivalence You must first recognize ambivalence before you can apply motivational techniques. Be alert for the below-mentioned verbal and motor behaviors that signal ambivalence.

Relentless Complaining and Diverting Discussion to Other Topics Clients complain repeatedly about others or about rules or regulations— for example, “I don’t see why I  can’t just live like this; I’m really not bothering anybody” or “The city has no right to do this.” One woman digressed regularly, using treatment sessions mainly to complain about the people in her life (her landlord, her daughter, her coworkers). When questioned about her interest in working on the hoarding problem, she agreed that she was more interested in solving other problems, necessitating motivational interviewing to determine whether treatment for hoarding was appropriate at this time. A variant of this problem is evident in clients who try to engage clinicians in understanding, rather than working on the problem. Although it is important to help clients understand why their hoarding developed, spending a lot of time on this issue will impede progress on treatable aspects of the symptoms. An analogy to a broken leg is useful: Repairing the leg is the first priority and then clients can determine why it happened to prevent a recurrence. After giving this explanation, treat repeated “why” questions as diversions from the central goal of improving hoarding symptoms and use motivational strategies as needed.

Arguing Clients may challenge clinicians’ statements or homework recommendations—for example, “That doesn’t really make sense, how am I going

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to remember what I want to get if I don’t get it right then?” Occasionally, such behaviors reflect perfectionistic, controlling, or narcissistic traits in clients who are not yet committed to working on decluttering or reducing acquiring. Arguing signals an absence of collaborative work and is grounds for examining motivation. Keep in mind that clients naturally react negatively to perceived constraints to their freedom, so a reminder that they will make all decisions about possessions may be helpful.

Nonverbal Signals of Ambivalence Sighing, not paying attention, and turning sideways are examples of nonverbal behaviors indicative of ambivalence about treatment or discomfort with what the clinician has just said. When one man sighed audibly as his clinician suggested a problem solving strategy, it was clear that he had dismissed her recommendations and would not follow through. In such instances, stop the action and inquire what the sigh meant or offer the hypothesis that the client was unhappy with the exchange.

Arriving Late, Canceling, and “Forgetting” Appointments These therapy-interfering behaviors often, but not always, reflect motivational problems that indicate the need to help clients articulate their ambivalence before strengthening their commitment and confidence in their ability to change (see below). In probing why the pattern is occurring, be aware of other possible explanations. Sometimes clients miss appointments because of other problems such as OCD rituals or ineffective planning. This would be evident in their missing not only therapy appointments, but other meetings as well (e.g., medical appointments, work-related meetings, etc.). Consider using a problem-solving strategy (Chapter  8). Sometimes other more pressing problems interfere with clients’ energy and time to devote to work on hoarding. If so, reschedule therapy for a later date to avoid irregular sessions, wasted efforts, and unsteady progress. Occasionally, clients are uncomfortable with the therapy or the clinician. Help clients express their concerns at the end of each session with a routine request for feedback. Of course, accept these criticisms and work to resolve them.

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Not Doing Homework One of the most common problems is doing too little homework to make progress. “I haven’t had time to go to any stores to practice.” “I have a hard time finding time to sort. I have things I need to do to get ready for the next day.” “I don’t want to get depressed or anxious so I keep busy with friends; I really don’t have time to sort.” (See the earlier section on impediments to motivation.) Resolve this therapy-interfering behavior using motivational methods and problem-solving strategies before trying to move forward in treatment.

Discouraged Despite Progress Some clients discount progress (especially when depressed), hold perfectionistic standards, or have so much clutter that small improvements are difficult to see. This can undermine the client’s confidence in the capacity to succeed. Consider using updated photographs for comparison to recognize even small changes.

Assumptions Behind Motivation Enhancement Methods Miller and Rollnick (2013) have defined motivational interviewing as “a  collaborative conversation style for strengthening a person’s own motivation and commitment to change” (p. 12). Motivational interviewing draws on client strengths and assumes that clients have the right and capacity to make informed choices. It is a person-centered intervention style aimed at resolving ambivalence about change. Miller and Rollnick have noted that MI “is done for or with someone, not on or to them,” and that “partnership, acceptance, compassion and evocation” are key aspects of this method (p. 24). Here are some basic assumptions: ■

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Motivation to change cannot be imposed by others. Clients who enter treatment because they are pressured by friends and family are unlikely to change their behavior unless they first decide they would benefit personally.

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If ambivalence about change is not addressed, then non-compliance and a lack of common goals will undermine treatment.

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Clients must articulate the ambivalence, whereas clinicians helps them express and explore all sides of it. Many hoarding clients recognize the problems and express a desire to change, but when faced with the task of actually discarding a cherished possession, their motivation evaporates. Helping them discuss their ambivalence sets the stage for leveraging their goals and values to overcome fears about losing possessions. It also helps clarify beliefs that are interfering with recovery.

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Avoid direct persuasion, as authoritative styles do not work well. Beware of slipping into a “persuasive” mode when clients are agonizing over seemingly worthless objects. Rather, express curiosity to elicit ambivalence, consistent with the Socratic style of cognitive therapy (see Chapter 10).

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Clients whose family and friends have trampled on their freedom of choice will be suspicious of the intentions of helpers. Developing a trusting relationship may take longer, but it is absolutely essential.

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Therapy is a partnership, not a relationship between expert and recipient. Work side by side to understand the impediments and help clients learn to make wise decisions.

Four key processes for enhancing motivation (Miller & Rollnick, 2013, p. 36) include: ■

Engagement to establish a connection and helpful working relationship

■

Focusing to develop and maintain a specific direction in the conversation about change

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Evoking to elicit clients’ own motivations to change (this is the heart of MI)

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Planning to develop a commitment to change and an action plan to get there

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In conjunction with evoking clients’ own motivations to change, two strategies are especially useful: 1.

Developing discrepancy. Because motivation to change arises from clients’ perception of a discrepancy between their current circumstance and their personal goals and values, strategic comments or questions (e.g., “How does this fit your goal of having your granddaughter visit you?”) can help heighten awareness.

2.

Rolling with resistance. Resistance reflects clients’ personal beliefs and best attempts to cope with their circumstances and becomes a signal to respond differently. Invite new perspectives and consider your client the primary resource in identifying solutions.

Five main MI skills are:  (1)  asking open-ended questions, (2)  affirming, (3) reflecting, (4) summarizing, and (5) giving information and/or advice (with permission).

Strategies to Enhance Motivation In Chapter 6 we recommend strategies to enhance motivation such as the imagery exercises and establishing goals and values. The practical strategies described below for building motivation are intended mainly for clients with limited awareness of hoarding as a problem; they are also useful for insightful clients whose motivation wanes periodically. These methods are intended to help clients recognize and express concern about their hoarding, decide to change their behavior, and feel optimistic about making those changes. These goals are pursued using five main strategies described briefly below. Keep in mind the need to emphasize clients’ personal choice and control above all.

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1.

Open ended questions (“what,” “why,” “how”) encourage clients to provide information about themselves. Examples are, “What led you to decide to come for treatment?” “Why do you think the clutter got out of hand?”

2.

Affirming requires clinicians to make general statements about clients’ strengths and resources, as well as specific ones about strengths and positive steps toward articulated goals. Supportive and

appreciative statements based on your actual feelings convey respect for clients’ feelings, struggles, and accomplishments. Examples are “You understand peoples’ needs and are very thoughtful” and “You are pretty organized and a pretty good problem solver at work. It seems likely you will learn to do this at home too.” 3.

Reflective listening statements (not questions) indicate you heard the client or noticed his or her reactions; they help clients feel understood. Reflections include repeating, rephrasing, and paraphrasing, especially feelings (“you didn’t like that,” “these things are important to you”) and thoughts (“you don’t want your daughter to interfere”). They can be followed with open-ended questions as in the following sequence:

Client [AVOIDING I clear it and stuff just ends up there. I don’t understand ACCEPTING how it got this way. RESPONSIBILITY]: Clinician: You put things on the table and didn’t realize you were doing this. When does that happen? Reflections also include educated guesses about clients’ thoughts and feelings and direct comments about ambivalence: “On the one hand you feel. . ., on the other hand you. . . .” Make direct statements that concisely reflect the client’s thoughts, feelings, and behaviors without adding unnecessary phrases (“it seems like. . .”). This takes a bit of practice but produces a more compelling comment that engages clients in evaluating their experience. 4. Summarizing what clients have said over the past few minutes helps them hear themselves with a little more perspective. Keep them brief and without qualifications or unnecessary modifiers. Summaries can reinforce some points more than others. Here’s an example: “You are very angry with your landlord for making the complaint and think he exaggerates your problem. You have worked hard to clean up the hallway and living room, but this has taken more time than you expected or he allowed. You’d like him and your family to get off your back, and you are sure you can solve the clutter problem by yourself.” Then ask an open ended question, “What do you think of all this?”

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5.

Informing and advising can be very helpful for clients who ask for this. Ask permission before offering this. Before offering it, you might want to acknowledge that your client may not agree or heed the advice—this indicates your respect for their right to make their own decision.

The following additional open-ended questioning and reflexive listening strategies can help clients air and resolve their ambivalence: Evocative questions go beyond open-ended ones by directing clients to discuss the effects of their hoarding. These can provoke statements of recognition or concern about the problem, or denote an intention and optimism about making changes. Examples are: “How has this affected your husband?” “How does the clutter fit with the things you value in life?” “What are the successes you’ve had that make you think you could do this?” Taking the negative side of an argument helps disarm someone who is used to defending their hoarding:  “Why would you want to change this? You really enjoy having [buying] all these things.” In the same vein, tentative motivational statements can be strengthened by asking almost paradoxically: “Why would you want to change this, especially when it would feel like giving up part of yourself?” Exploring pros and cons of hoarding elucidates both the positive and negative elements of the problem. Consider the following series of questions: “What do you like about tag sales?” “Are there things you don’t like about them?” “What do you enjoy most about having these things?” “What are your least favorite parts of owning all these things?” It may help to inquire about pros and cons that clients have already alluded to: “You mentioned that you spent more money than you wanted. Is that a disadvantage? Maybe you don’t really overspend.” Another sequence might be: “I got the idea from your comments that your self-esteem has suffered. Is that true? How big a deal is that for you?” Asking for elaboration encourages clients to expand on the negative consequences of problematic behaviors. For example, “You mentioned that sometimes you waste time looking for things. Has this happened recently?” When clients are reporting complaints by others that seem to avoid the main issue, consider asking: “Was that her main concern?”

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Requests for elaboration of statements about changing hoarding behavior are especially useful to enhance commitment to change. Using extreme contrasts can help amplify reluctance to change hoarding behavior, as well as the benefits of working on the problem. “What is the worst thing that can happen if you go along as you have been?” “If you were to decide to work on this problem seriously with me, what do you think would happen?” “What are the best things that could come out of change?” Looking forward and looking back also help amplify concerns by asking clients to project themselves into the future or into the past. “If you think ahead 5  years, what would you like your life to be like?” “Suppose you were planning to commit time to working on this problem, what would that mean for your marriage?” This method can be especially useful for clients who tend to blame others for their problem. Looking back will only be useful for clients whose history contains a period in which hoarding was not a significant problem:  “Contrast now with how you felt before these problems began. What was your life like then?” Reframing statements are intended to clarify ambivalence and help clients’ alter their interpretation of events by emphasizing the positive aspects of the situation. For example, “You think that behind your wife’s nagging about your collecting things is a real concern for you, although you still find it annoying.” Change talk refers to clients’ statements about the desire, ability, reasons, need, and commitment to change. As Miller and Rollnick have suggested, readiness to change is often evident when clients stop arguing, quiet down, appear calmer, and perhaps express sadness. They may ask questions about what to expect in treatment. You can strengthen their commitment and confidence by asking simple questions after your client has made tentative statements about making changes: “What would you like to do next?” “What might be your first goal?” Emphasizing personal choice is a critical component of motivational enhancement. Be clear that all choices and decisions about organizing, acquiring, and getting rid of things are made by your client; you are only a sounding board.

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Rating importance and confidence in change is another strategy for enhancing change talk. Ask clients to indicate how important it is to change their hoarding problem on a scale from 0  =  not at all to 10  =  extremely important. To encourage more change talk, ask why they chose that number. If it is a high number, then simply ask why it is important. If it is a moderately low score (a “3 or 4”), then ask why the person didn’t pick a lower number. Alternatively, ask what would need to happen for the client to move from a 4 to an 8 on the scale. A similar procedure can be followed in asking how confident clients are about being able to change. Then summarize the clients’ statements. And ask about next steps: “Where does that leave you now?” “What are you thinking about your hoarding at this point?” “What’s the next step?” “Where does hoarding fit into your future?” Throughout these conversations, comment positively on clients’ willingness to talk with you about their situation, and express confidence in their ability to accomplish their goals. To encourage decision making about treatment, ask clients’ for their own wisdom to help them determine what they want to do (e.g., “Tell me what you think will happen based on your own experience”). When you are concerned about your clients’ preferences to keep something that seems inconsistent with previous choices, ask permission to offer an opinion before doing so.

Methods to Avoid in Motivating Clients to Change

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Avoid presuming that hoarding symptoms are the main reason clients have agreed to seek help; begin with a broad focus and narrow it later.

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Avoid arguing at all costs as arguments that champion change only make patients dig in their heels harder.

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Avoid labeling the problem; clients do not need to admit or declare that they have a problem, only that they are interested in change. Using the term “hoarding” is not required for motivation or success. Some clients find it helpful to have a formal diagnosis, but use the label hoarding disorder only when the client asks.

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Avoid blame. No one is at fault for the development of this problem and many factors have contributed. Don’t side with clients against someone (parent, sibling, others), as this can force clients to defend the person. It is best to simply listen closely and use the MI strategies described earlier. Avoid asking too many questions. As a general rule, try not to ask three questions in a row; after two, summarize or comment.

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Avoid adopting the role of expert. The relationship should feel like a partnership in which clients are experts about themselves and clinicians are expert about the problem and its characteristics.

Other Motivation-Enhancing Methods Problem Solving We have already noted that many clients feel overwhelmed; have limited time to work on hoarding; experience medical problems, depression, fatigue, distractibility, or other personal mental and physical conditions; or lack help to manage clutter removal. These are all concrete problems that may lend themselves to a problem-solving strategy. Because this method is described in Chapter 8, we will not detail it here, except to list the basic components that include: (1) define the problem, (2) generate solutions, (3) select a solution, (4) implement it, and (5) evaluate the outcome. Whenever a concrete personal, interpersonal, or practical barrier presents itself, consider engaging clients in deliberate problem-solving efforts and work out a homework assignment consistent with those efforts to solve the problem.

Behavioral Experiments When clients express reluctance to proceed because they fear intense anxiety will overwhelm them or are concerned they will be unable to perform some task, you can recommend a behavioral experiment to test their concern by framing it as a hypothesis. This emphasizes their

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scientist role (see Chapter 10 on cognitive strategies) and helps them step back a little to evaluate the situation more objectively.

Using Metaphors Sometimes metaphors are useful for clients who are reluctant to actively engage in change behavior. Describe therapy as like using a life preserver when a person is afraid of drowning—clients must let go of the sinking boat to try a better option, but there is no way to know whether the life preserver will really work until we try it. This metaphor acknowledges the emotional strain of letting go of usual methods of coping in favor of trying new methods.

Speaking to Successful Clients Reluctant clients may gain confidence about change by speaking to someone who has completed treatment successfully, preferably someone of the same gender and/or age. A  successful model, especially someone who also struggled to succeed, can be a strong motivating factor to continue. Broker the connection by checking with each person and determining how they would like to communicate with each other.

Enhancing Homework Compliance Lack of homework compliance usually reflects client ambivalence and is probably the single most common problem for clinicians. Table 5.1 lists some possible solutions.

Homework for Motivational Interviewing Working on motivation may not always lend itself to homework assignments, especially when clients have not yet committed to treatment. As

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Table 5.1 Ways to Enhance Homework Compliance Schedule particular times for work Link homework times to other routine activities that serve as reminders Ask someone to be present at home or in acquiring settings during practice Play pleasant music or the radio during homework sessions Find ways to interrupt self-defeating thoughts Monitor homework (when, where, number of hours, etc.) Provide reminder calls Plan brief phone contacts before and after homework

motivation increases, however, homework assignments may be appropriate. Possible assignments include: ■

Make a list of the pros and cons of hoarding (e.g., the good and bad parts of acquiring or of having clutter in the home)

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List in order of importance the things he or she values most in life

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Think about how hoarding fits with personal values (e.g., what personal goal or value will be gained if the home were uncluttered)

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Chapter 6

Planning Treatment

(Corresponds to Chapter 4 of the Workbook)

Materials Needed ■

Photos from home visit

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Client’s Model of Hoarding from Chapter 4 (Chapter 3 of the Workbook)

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Goals Form

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Clutter Visualization Form

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Unclutter Visualization Form

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Acquiring Visualization Form

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Practice Form

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Personal Session Form (from Workbook)

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Establish treatment goals and set rules for treatment

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Complete visualization exercises

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Use problem solving to troubleshoot barriers to progress

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If applicable, include the coach in the planning session(s)

Outline

This chapter outlines the steps for planning treatment. With the assessment and model building completed, it is time to help your

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client establish treatment goals and to describe the rules you’ll follow during the therapy. We suggest several visualization exercises to help your client clarify his or her thoughts and feelings about organizing, reducing clutter, and limiting acquiring. Following this, you can clarify how you’ll address the hoarding problems and in approximately what order. Non-acquiring and sorting practice is the basis for applying most treatment components. “Sorting,” as we refer to it here and throughout this guide, means the consideration and decision making regarding what to do with possessions. This includes not only the decision about whether to keep or discard a possession, but also what to do with the item next. Kept items must go where they belong and removed items should be recycled, sold, donated or placed in the trash. The treatment components used to develop non-acquiring and sorting include (1) skills training, (2) cognitive therapy methods, and (3) behavioral methods. Homework between sessions is based on the work done in sessions. Because insight and motivation can wax and wane for most people who hoard, this planning session is intended to decrease clients’ fears about treatment and increase motivation and confidence in the therapy. If clients plan to work with a coach who will need training in doing the therapy, this is a good time to arrange for the coach to be present for part or all of the session, depending on the client’s wishes and the extent of the coach’s involvement in the intervention process. You will be a model for coach behaviors. The role of coaches is to help clients remain focused on their task, provide emotional support, facilitate decision-making by asking open-ended questions and expressing curiosity, help with hauling to remove unwanted items, and accompany clients on non-acquiring trips as needed. Rules for coaches are similar to those for clinicians described below. A handout of instructions for coaches is provided in the Appendix.

Treatment Goals Help your client develop his or her own personal treatment goals by asking directly, “What would you like to accomplish in working with me

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on your hoarding problem?” or “When we are done working together, what do you hope will happen? What are your goals?” Below we list some common treatment goals that might be relevant, but even more important are your client’s own personal goals. 1.

Understand why I hoard. A better understanding will help clients make progress and can enhance awareness of early warning signs to prevent setbacks after treatment ends.

2.

Create living space I can use. This goal is almost universal and suggests that early efforts should be devoted to clearing the most desired living spaces. Help clients decide what they want to do most (cooking, dining, working on art projects, etc.) and work toward those ends.

3.

Reduce compulsive buying or acquiring. The motivation behind this goal may be to reduce debt or save money, as well as to limit the amount of clutter. Because acquiring is usually associated with strong positive emotions like comfort and joy, developing alternative pleasurable activities is also an important goal of treatment (see Chapter 7).

4. Get organized to find things more easily and make them more accessible. Strategies for learning these skills are the focus of Chapter 8. 5.

Improve my decision making. Most HD clients struggle with decision making, also a focus of Chapter 8.

6. Reduce clutter. Although this is a main goal for family members, it may not be a primary one for clients because this implies getting rid of things—an anxiety-provoking prospect. Do not add this to the list unless the client specifically states it. In fact, clutter will reduce as other goals are achieved. Below are some of the personal goals listed by some of our clients:

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To enjoy my instruments again

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To create breathing space, order, and beauty in my bedroom (especially in front of the closet

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To have a living room that a friend or family could enter

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To have a safe kitchen with working surfaces

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To take a bath

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To remove bagged items

Ask clients to complete the Personal Goals section of the Goals form (page 42 of the Workbook) to identify their own goals for the coming weeks and months. This can be started during the office session and completed as a homework assignment.

Treatment Rules The following rules (contained in the Workbook) are intended to ensure that treatment progresses in a way that is manageable for clients. These rules are specifically intended to increase clients’ confidence (selfefficacy) about managing their own hoarding symptoms. 1.

Do not touch or remove any item without explicit permission. Most people with hoarding disorder are extremely concerned about other people discarding their possessions without consulting them. Misguided efforts to declutter by family members have heightened their sensitivity. Thus, an important aim of treatment is for clients to develop trust that their relationship with you is truly collaborative. This rule is not an easy one to follow because the impulse to pick up things to help is powerful. You can remove items at your clients’ request, especially to help remove them for trash or recycling. Later in treatment, your client may ask you to help sort items, once the rules for doing so are very clear to both of you. Clients’ initial fears often ease considerably as the therapy progresses.

2.

Clients make all decisions about possessions. Treatment is designed to help clients learn to make reasonable decisions about saving and organizing their possessions. You can occasionally offer advice when asked, but you cannot make decisions for clients without interfering with an important goal of therapy. It is likely that past

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attempts to help by friends and family members have violated this rule and caused clients to be overly sensitive to other people’s involvement. 3.

Treatment proceeds systematically. Determine the plan for where, when, and how to sort cluttered areas. Most clients decide to work room-by-room because this produces highly visible progress that enhances motivation. You can blend this plan with sorting by types of items (e.g., all the books) from different rooms when this makes sense. Generally, work from easier to harder situations. Choose a method according to your client’s preference and tolerance, the likelihood of immediately observable progress, and rapid learning of organizational skills. If clients insist on methods clinicians consider problematic, try an experiment to see if their preferred method works and, if not, consider alternatives.

4. Establish an organizing plan before beginning the sorting process. Develop a detailed plan for where to store kept items. Many clients tend to generate too many categories, becoming confused by the process. Establishing a limited number of categories at the outset of sorting will reduce this problem. For this reason, we suggest sorting objects before paper, which requires many categories. Chapter 8 focuses on this topic. 5.

Clients think aloud while sorting (especially early in treatment). This helps clinicians and clients understand the thoughts and emotions that determine acquiring, organizing, and saving (or removing) behavior. Speaking aloud helps clients become consciously aware of their reasons for saving and will be useful in learning how to alter problematic beliefs.

6. Only handle it once (OHIO)—or at most twice. The goal here is to prevent the churning of possessions that are merely recycled from one disorganized pile to another. Clients learn to make decisions quickly and firmly by handling objects minimally, although “once” may not be possible as items often must go to an interim location before space is cleared for the final destination. Allow some flexibility when clients are unable to make a final decision but are making clear progress.

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7. Treatment proceeds in a flexible manner. Flexibility and creativity will help solve logistical problems associated with organizing a too-full home. When clients become stalled because organizing one area depends on having another space ready for storage, problem solving may be needed.

Visualization and Practice Exercises The exercises described below are intended to help understand your client’s motivation for treatment. These tasks can be employed any time during the assessment and model development phase and may be especially useful in developing goals and preparing for treatment. We recommend doing the clutter visualization task first, followed by unclutter visualization and imagining the ideal home. Examples of completed visualization forms are given below, with blank copies in the Appendix and in the client’s Workbook. You may photocopy the forms from the book or download multiple copies from the TreatmentsThatWork™ website at www.oup.com/us/ttw.

Clutter Visualization For this task ask clients to visualize a cluttered target room in their home (e.g., kitchen, dining room, living room, bedroom) to determine how much discomfort they experience because of clutter and the nature of their thoughts. Use the Clutter Visualization Form in the Appendix for this purpose. An example of a completed form is provided below. Ask clients to close their eyes and imagine standing in the middle of the room, slowly turning around to see everything in it. Ask them to describe what they see, and after about a minute ask about how much discomfort they experienced on a scale from 0 (no discomfort) to 100 (the most discomfort you can imagine). This 0 to 100 scale (also used in Case Formulation for the acquiring situation list) will be useful later in treatment for other self-ratings of emotions and strength of beliefs.

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Example of Completed Clutter Visualization Form Room: Kitchen

A. Visualize this room with all of its present clutter. Imagine standing in the middle of the room slowly turning to see all of the clutter. B. How uncomfortable did you feel while imagining this room with all the clutter? Use a scale from 0 to 100, where 0 = no discomfort and 100 = the most discomfort you have ever felt. Initial Discomfort Rating:  90 C. What feelings were you having while visualizing this room? 1. Overwhelmed - Oh my God! 2. Anxious 3. Depressed D. What thoughts (beliefs, attitudes) were you having while visualizing this room? 1. How am I going to clean this mess up? I don’t know if I can deal with all of this stuff. I have no place to put it

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2. I don’t know what to do. My husband is so upset with me. He’s going to leave me if I can’t do this. My kids just make it worse. If I clean it up, they’ll just mess it up. How can I stop that? 3. I’ll never get it all done. I shouldn’t have let this happen.

If clients have difficulty visualizing, then consider using the photographs of this room taken during the home visit to cue their reactions. Next, ask clients how they felt (emotion) and what they thought during their visualizing. Feelings might be negative (anxious, fearful, embarrassed, ashamed, guilty, disgusted, confused, overwhelmed, pressured, disoriented, hopeless, depressed, frustrated, discouraged) and also positive (happy, pleased, relieved, comforted, hopeful, proud). Record these on the form. Next ask about thoughts, helping clients formulate these in short sentences and distinguish them from feelings. Record

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these  thoughts on the form. Examples might be:  “This is ugly,” “I’ll never find anything in this mess,” “There must be buried treasures here,” and “It’ll only take me a little while to clean this up.” If clients have trouble identifying their thoughts, then suggest ones that seem likely based on your formulation, as well as others that are quite unlikely (“Were you thinking that this is a really pleasant room?”); these contrary ideas offer a springboard to clarify thinking. As in the model development phase, recording these feelings and thoughts during the visualizing facilitates self-observation and reporting needed for upcoming homework. Finally, summarize information from the visualization exercise about the link between thoughts and feelings and motivators for change. For example: “When you imagined the living room with its clutter, you thought that other people who saw it would think you were inadequate, and you wondered why you can’t clean it up. Those thoughts left you feeling embarrassed and ashamed. You also felt overwhelmed at the idea of cleaning up. It seems like learning to clear the clutter would probably enable you to feel better about yourself, but also that you are likely to feel overwhelmed and perhaps wanting to avoid dealing with the clutter. Does that sound right to you?” This might lead to further discussion of aspects of the client’s model for hoarding behavior and also of how to resolve potential barriers to working on clutter during treatment. If clients report little discomfort and strong positive feelings during the visualizing, then explore their interest in treatment using motivational interviewing techniques from the previous chapter (e.g., “Having these things around pleases you. Why would you want to change this?” or “You can see the benefits of keeping your home like this. Are there any costs?”). Some clients do prefer cluttered living spaces and these preferences must be honored while helping clients generate realistic goals for treatment.

Unclutter Visualization This task is designed to help clients examine their feelings about possessions and the likely impact of removing clutter during treatment.

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Use the Unclutter Visualization Form in the Appendix to ask clients to visualize the same room used for the previous task, but this time without any clutter. An example of a completed form is provided below. To assuage fears about what might have happened to their things (e.g., “Where did it all go?”), ask them to imagine that everything they wanted to keep is still there but put in a place where they can find it. To make this image vivid, ask clients to describe the appearance of the room in some detail, including uncluttered furniture and a floor without clutter. It may be difficult for clients to imagine at first, but give them some time to develop the image and ask them to narrate as they do. If necessary, the photographs of the cluttered room could be used to help clients imagine what is underneath the clutter. As they visualize the uncluttered space, ask them to consider what they can do with this room, including activities, ways to decorate the room, having visitors over, and so forth. Allow approximately 1 to 2 minutes for visualization (more if this seems helpful), and then ask for a rating of discomfort (0–100). Ask clients to describe both negative and positive emotions and identify thoughts during the experience. Record these on the form. A Socratic questioning style (“That’s interesting, I wonder . . .”) and reflective listening strategies (“It sounds like. . .”) are often useful. Help clients connect their thoughts (e.g., about being wasteful) to their emotions (e.g., guilt, satisfaction). Do not challenge thoughts at this stage, although you can ask about thoughts and feelings previously reported during assessment and model building. Your questions should be genuinely curious so the client does not become defensive (e.g., “Previously you mentioned. . ., is that what you mean here?”). To enhance motivation, ask, “Are there ways your life would improve if this room were uncluttered?” If needed, prompt with open questions such as, “How would it help you if your kitchen counter were cleared of stuff?”

Ideal Home Visualization Clients can also clarify their goals for therapy by imagining their ideal (but not perfect) home, room by room. This should be the home in which they currently live, with rooms decorated in the manner they

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Example of Completed Unclutter Visualization Form Room:

kitchen

A. Visualize this room with the clutter gone. Imagine that all the items are in a place where you can find them, and picture cleared surfaces and floors, tabletops without piles, and uncluttered floors with only rugs and furniture. B. How uncomfortable did you feel while imagining this room without all the clutter? Use a scale from 0 to 100, where 0 = no discomfort and 100 = the most discomfort you have ever felt. Initial Discomfort Rating:  50 C. What thoughts and feelings you were having while visualizing this room? 1. It looks empty - hard not to worry about where things went. 2. My kids will probably just mess it up again. 3. My husband will like it. D. Imagine what you can do in this room now that it is not cluttered. Describe your thoughts and feelings. 1. I have always hated the color in here. We could paint it yellow like I always wanted. Now it needs curtains. I bought some a long time ago and they are probably still around somewhere. 2. The whole family could eat breakfast at the table in the morning. Without a huge mound of clutter in the way! 3. I could cook again and use my cookbooks

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E. How uncomfortable did you feel while imagining the room this way? (0 = no discomfort and 100 = the most discomfort you have ever felt) Final Discomfort Rating:  25 I sort of got excited!

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would find most satisfying. This is especially useful if the unclutter visualization exercise was somewhat disturbing. This task can be done in the office or during the home visit. In visualizing the ideal home, ask clients to provide details such as where furniture would go, what items would be visible, where things are stored for easy access, and so forth. Some clients benefit from a homework assignment to draw out a floor plan for each room that illustrates the placement of furniture and other items. Many clients have not considered how they would like to decorate their rooms because the clutter has prevented this option. Later in treatment when significant clutter has been cleared, expand this exercise to actual decorating of spaces.

Visualizing Acquiring Ask clients to imagine a typical situation in which acquiring contributes to their hoarding problem. Select one they will encounter soon and expect to have trouble resisting, such as a yard sale, a store bargain, an item that looks pretty, or a free offer. See below for an example, and the Appendix for a blank Acquiring Visualization Form. In the image, ask the client to imagine just looking at the item without picking it up. Allow about a minute of silence and then ask, “How strong is your urge to get this?,” using a scale from 0 (no urge) to 100 (irresistible), and “What thoughts do you have as you look at the item?” Record these on the Acquiring Visualization Form, along with a brief description of the scene they imagined. Now ask clients to imagine leaving without acquiring the item that they will be unable to get again (lost opportunity). Allow about a minute of silence for visualizing and again ask for a rating of distress to this new image and what thoughts they have about leaving the scene. You can use examples to prompt the thoughts, such as “Were you thinking that you’d miss a really good buy?” Other examples might be, “I’ll miss out on important opportunities” or “I won’t feel complete if I  don’t get this.” Comment on any aspects that seem especially important motivators for acquiring or important links to components of hoarding in the client’s model. If they have trouble generating a distressing image, then you can add components that might prompt a more realistic image (e.g., seeing another shopper considering the item they’ve identified).

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Example of Completed Acquiring Visualization Form Visualize a typical situation in which you have a strong urge to acquire something. In your image, don’t actually pick up the item, just look at it. Please describe the location and item you imagined. Inside my favorite consignment shop. Seeing a nice pair of high-heeled shoes that would fit me. Rate how strong was your urge to acquire the item (0 = no urge to acquire, 100 = irresistible urge). Acquiring Urge 100 What thoughts did you have while you imagined this scene?

1. These are really pretty and they fit and they are a great bargain. I need to get these . 2. I shouldn’t be spending money on me, but I should get these now or they’ll be gone next time I come in. 3. I could wear these to church with my black and white suit. Visualize this scene again, but this time, imagine leaving without the item. How much discomfort did you experience while imagining (0 to 100). Discomfort Rating 90 Please list any thoughts you think would help you to not acquire an object.

1. I don’t have any money right now. 2. I already have a lot of shoes and I have ones that are this color. 3. I should leave these for someone else who needs them more than I do. Now rate how uncomfortable you feel about leaving without the item(s) from 0 to 100. Discomfort Rating 70

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Photo Exercise Many people who hoard have grown so accustomed to living in a cluttered home that they no longer notice the clutter. This may be a form of avoidance or possibly just habituation. Some clients react with shock to the photographs of their own rooms, suggesting that this external vantage point enables them to see the clutter in a different light. For some clients, viewing the photos of their home helps them recognize the problem and stay motivated to work on the clutter. Following the first home visit, ask clients to review pictures of each room and indicate their reactions on seeing the photos. Explore their thoughts and emotions as appropriate to enhance recognition of the severity of the problem and motivation for change.

Experiments or Exercises At the beginning of treatment, clients often want to get started quickly. Plan some specific tasks—call them “experiments” or “exercises”—to get them started and help them understand the challenges of sorting, discarding, and resisting acquiring. Design assignments collaboratively with the client to provide a valid test of their beliefs and their need for help with the problem. Frame this as an experiment with no expectations regarding the client’s ability to part with items (or resist the impulse to acquire). The most important outcome is what clients learn, not their success in discarding or avoiding acquiring. Clients who believe they can sort and get rid of unwanted items but just haven’t had time to do so can see whether this is true. Ask them to get rid of (discard, recycle) something that provokes moderate discomfort and record how they feel for the next few hours and days using the Practice Form in the Workbook. First, ask clients how distressed they feel (0 = no discomfort, 100 = most uncomfortable they have ever felt) at the outset and then again after they try the task. Continue to ask for ratings every 10 minutes or so as your conversation during the session moves on to other treatment planning topics. If discomfort declines, then call this to clients’ attention and at the end of the experiment (in this session or

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Example of Completed Practice Form A. What was the item (to remove or not acquire)? get rid of 2 old news magazines Initial discomfort (0 = none to 100 = max) 50 B. What did you do (not acquire, trash, recycle, give away, other put both magazines in the recycle bin Discomfort rating (0 to 100)

after 10 mins

45

after 20 mins

30

after 30 mins

20

after 40 mins

5

after 50 mins

0

after 1 hour

0

the next day

0

C. Conclusion regarding experiment:  That wasn’t so bad. At first I was afraid I might need something from the magazines, but after a while, I decided the news was old anyway and it probably wouldn’t make a difference to me now. Then I felt o.k. about getting rid of something.

the next), ask what they have concluded about the experience. If discomfort declines slowly or not at all, then extend the experiment into a second or third day to help clients draw conclusions about habituation of their discomfort. An example of the Practice Form is given above. The Appendix contains a blank form. This brief exposure provides some indication of how clients will react to direct practice later during sorting, discarding, and non-acquisition. Some will habituate quickly to the loss, whereas others may require more time and more direct interventions to reduce discomfort. These probes also provide a context for later behavioral experiments that test clients’ specific hypotheses. Even if clients are unable to get rid of anything, the experience helps you plan next steps. Following the experiment in the session, ask clients to do a similar behavior experiment on their own at home using the Practice Form.

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Connecting Methods to the Model After using the above visualization exercises, help clients connect treatment strategies to their hoarding model. Throughout treatment, sorting clutter in the office and at home serves as the basis for most treatment methods. These methods are (1) learning skills for attention focusing, organizing, decision-making, and problem solving; (2) cognitive therapy to examine and correct faulty thinking; and (3) exposure to reduce strong emotions and avoidance behavior. We usually begin with skills training for organizing and apply these skills during the sorting process. Following this, cognitive therapy methods can be used during practice sessions. The need for other skills training depends on the client’s symptoms and progress in treatment. Figure 6.1 illustrates methods to address the vulnerabilities, information processing problems, meanings of possessions, and behaviors for the client described in Chapter 4. All of these methods rely on homework between sessions and presume that clinicians (or coaches) will help clients in their homes or at acquiring sites to facilitate exposures until they can undertake these on their own as homework assignments. Dialogue illustrating how to connect clients’ problems to therapy methods follows:

Case Vignette

Clinician: Let’s talk about our treatment plan for you and what this will involve. Client:

I’ve been wondering how we were going to fix all this stuff. It seems like I’ve got a lot of problems, sort of overwhelming.

Clinician: I realize it may seem that way to you, but actually, your situation is very typical of most people with hoarding, and we have several treatment methods that work very well for these problems. Let’s look at your model so we can decide what to do for each of the things that contribute to hoarding. Client:

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Okay. I’m glad to hear there’s a plan at least.

Information Processing Problems:

Vulnerability Factors:

Skills training for problem solving, organizing, attention focusing, and decision-making

Review early beliefs about mother and burglary reactions Cognitive therapy and activity scheduling to address depressed mood

Meaning of Possessions: Cognitive therapy to examine and challenge beliefs that support hoarding and acquiring

Emotional Responses: Exposure to sorting and removing clutter; exposure to acquiring cues without acquiring

Positive Reinforcement:

Negative Reinforcement:

Review costs of acquiring and clutter Find other sources of pleasure

Exposure inhibits this process

Behavioral Change: Increase discarding Increase sorting & organizing Reduce acquiring Reduce clutter Figure 6.1

Hoarding Model with Treatment Strategies

Clinician: Let’s start with the information processing we’ve talked about—focusing attention, making decisions, and organizing. These are probably interconnected, and it’s usually easiest to work on skills for organizing first and then on methods to keep focused on the task at hand when you are sorting your things. So we’ll develop a pretty comprehensive organizing plan and get fairly detailed about where things should go and what goes with what.

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Client:

Yeah, I sure do need to do that, but how can we do it with no space to put stuff?

Clinician: I agree, that’s a challenge—let’s call it “a problem to be solved.” For this we’ll first do some straightforward problem solving together to come up with ideas for how to get things to where they go, once we know where they belong. I’ll teach you some problem-solving skills because we’ll probably need these periodically during treatment. [Reinforcing client for participating actively in posing this challenge] You’re absolutely right, that will be a first priority to figure that out before we can do much sorting of clutter. Client:

So, then what next?

Clinician: We need to develop an organizing plan so you decide ahead of time where you want to keep things. Then we can start sorting and move items to interim and final destinations. As we do this, we might need to modify the plan a bit. If you have problems staying on task as we have discussed, we can try out some strategies to keep you focused. I have some ideas I can suggest when we get to that point. Client:

How long will that be?

Clinician: Probably within the next couple of sessions, depending on how long it takes us to figure out the organizing plan. Client:

Okay. that seems reasonable.

Clinician: Once that’s in place, you’ll be doing a lot of sorting, and in fact that is the main activity of treatment. When you are sorting in the office and at home, I’ll work closely with you to examine what you are thinking and whether it makes sense to you. So if we look at the vulnerabilities you listed on your model, then we already know these are linked to the beliefs that maintain clutter and acquiring. You and I will work on these, using cognitive therapy. Client:

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What’s that?

Clinician: Cognitive therapy is a method we’ve already started to use by identifying your thoughts that affect your feelings when you are trying to sort and when you acquire something. Our next steps will be for me to ask questions that help you decide when your thoughts make sense to you and when they don’t. We’ll look for alternative thoughts and see if these make more sense to you under some circumstances. For example, we’ll talk about your ideas about needing to know and about waste when these come up during sorting. We can also use cognitive therapy to help with your depression that sometimes gets in the way of sorting. Client:

What about my emotions? It makes me anxious to sort stuff and guilty too.

Clinician: Right. When you start to think differently about things, you will also feel differently about them as well. Remember that most of your feelings follow directly from thoughts about your possessions or about buying something. We can help reduce your fears by testing them out in experiments, like the one we did today to see how you felt after you got rid of something. You started out feeling uncomfortable and half an hour later, you were less anxious. That’s what usually happens when people practice something difficult over and over again. Client:

I’m not sure I’m ready for a lot of that right now. [Avoid discussing practice discarding at this stage because it will make little sense to clients who don’t yet see why they might need to get rid of items.]

Clinician: I understand. That’s why we start with organizing skills and cognitive therapy, and then do more sorting and removing clutter as we go. It takes a while to build up to this but you’ll find it gets easier and easier, and in fact, you’ll sort more quickly as your decision making gets quicker because you’ll be less worried about what you are doing. Client:

Okay, I think I get it. We start with organizing and work on my thoughts and other things as we go along.

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[Encourage clients to describe their understanding about how treatment will work so you can confirm the plan and correct any mistaken ideas.] Clinician: Exactly. It’s hard to say exactly how long this will take, but you do have quite a bit of clutter so my guess is we’ll need about 6 months and maybe more. Client:

Well, it’s not like I haven’t had the problem for years now. It’s at least 20 years so a few months is no big deal I suppose.

Troubleshooting Barriers to Progress Even the most highly motivated people experience barriers to making progress. A  number of factors can make dealing with hoarding especially difficult. Some of these are personal, such as depression, attention focusing problems, OCD symptoms, health problems, and feelings of being overwhelmed. Others are external, such as lack of social support, pressure from family members or authorities to fix the problem, and lack of time to sort because of a very busy lifestyle. Explore these problems with clients using problem-solving methods from Chapter  8. In our experience, solutions are often possible. Chapter 11 discusses strategies for working with clients who have various concurrent psychological problems, including comorbid depression, OCD symptoms, attention deficit, and stealing. Below are strategies for addressing other potential barriers that can impede progress.

Sensitivity to Criticism Many hoarding clients have a lifelong history of criticism from others for their behavior and have become highly sensitive to it. This may be especially evident in clients with social anxiety and depression who too easily jump to conclusions about clinicians’ (and others’) views of them. Be especially alert to your client’s perceptions of your comments. If you suspect an unstated problem, ask for feedback:

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Clinician: Sometimes people get angry or hurt by things I say. It is very important to tell me whenever this happens so I can fix the problem. Did this happen during our session today? The ensuing discussion can provide an opportunity to examine erroneous thinking and the actual evidence for perceived criticism to correct misimpressions. Hoarding clients can be particularly sensitive to criticism during the first home visit, especially when you are the first person in years to cross their threshold. Delays in getting into the homes of these clients probably reflect intense fear of criticism, even from someone they have asked to help them with the problem. Everything from your posture to your facial expression may be interpreted as criticism or disapproval. During this first visit, treat the condition of the home in a matter-of-fact manner and avoid any kind of negative statement, regardless of severity. Be sure to train a coach to respond in the same vein.

Anger Anticipate that at some point during treatment, your client may become angry with you because you have become associated with repugnant tasks they have avoided for years. This may happen during sorting sessions or when they are working alone and feeling very uncomfortable. Anger can be a defensive reaction for clients who are easily offended by criticism, or it may signal suspicion and paranoid thinking for some clients with these personality features. Below are potential steps for dealing with anger, regardless of whether it seems justified: 1.

Ask questions to clarify exactly how clients feel and whether they think the perceived attack was intentional or mean-spirited. ■

■ ■ ■

“I can hear that you are upset. Say more about what led you to feel this way?” “Did this bother you a lot this week?” “Are you angry with me for putting you in that position?” “Did you feel I was purposefully being mean?”

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2.

Reflect and summarize clients’ statements and ask if that is accurate: “Okay, if I understand you correctly, you are angry because you felt attacked and criticized by me at the end of the last session. Is that right?” Admit mistakes and apologize briefly. Do not blame clients, interpret their feelings, or imply they are inappropriate, as this would be invalidating and create further distance. ■

3.

■

“I’m sorry my actions led you to feel upset. I think I made a mistake when I challenged your thinking. I should have asked you more questions to understand it better. This was my mistake.”

4. Explore the source of the anger or frustration when clients are ready, including cognitive biases. For example, one woman had cognitive errors (see Chapter 10) of all-or-nothing thinking and overgeneralization. A hint of criticism or her own minor mistake led her to conclude she was not only inadequate, but a total failure. She discounted statements about her good qualities, and jumped to conclusions that the clinician disapproved of her. The clinician used Socratic questioning (described in Chapter 10): ■

■

■

■

5.

Formulate hypotheses and test these (see Behavioral Experiments in Chapter 10). For example, clients with perfectionistic standards who perceived negative evaluations from others might be asked: ■

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“You thought I was criticizing you. I also said some nice things about you. Did you hear those?” “That’s interesting; why do you think you discounted them? How do positive comments make you feel?” “Do you do this with other good things too? When you are successful at something?” “Sounds like your standard for what is “acceptable” is very high. How often are you able to meet it?”

“The next time you think I am being critical of you and you start to feel angry, would you be willing to try an experiment? Would you be able to ask me whether I meant to criticize you? Then I can tell you what I was actually thinking, and I promise to be honest. This will tell us how often your fears

■

of criticism are justified and whether you are being hard on yourself. You’ve said this also happens with other people, and you can also ask them the same question if you believe they would be honest with you.” “You could try an experiment to test whether one mistake means you are a failure. Is there something you can schedule for yourself this week where you can make small mistakes and see if you can still feel good about the parts you did well?”

Feeling Overwhelmed Clients facing extremely extensive clutter piled to the ceiling in many rooms are likely to feel overwhelmed at the prospect of working on it. The problem seems so huge that it difficult to know how or where to start or whether progress is even possible. This can lead to procrastination and avoidance of homework assignments. Help clients by discussing their powerful feelings and structure tasks in a simple and stepwise manner. Ask clients to help by indicating whenever an assignment seems too hard and reporting negative feelings as soon as they arise.

Need for Social Support or Coaching A potential barrier to making progress is the lack of support from others for their efforts. In our experience, many people with hoarding problems have great difficulty making progress on their own. The presence of someone else in the room (even if interaction is minimal) can provide emotional support that reduces uncomfortable feelings and help distractible clients stay focused. Supportive others can also provide positive reinforcement, and just knowing that someone will visit can be a powerful motivator. Ask clients who might provide a calming presence while they work, without interfering with their efforts. If such supportive family members or friends can assist as coaches, arrange a conversation with them and the client to provide information about hoarding and guidelines for what to do and what not to do. Ideally, the person can be

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present during a home session to observe you working with the client. Instructions for coaches are provided in the Appendix. A word of caution is in order here. Many family members do not make good coaches or helpers. Longstanding patterns of criticism and “taking control” are difficult for family members to break. Even with explicit instructions and modeling of appropriate behavior, some family members just can’t refrain from clandestine discarding of the client’s possessions or critical comments that undermine progress. Be sure to anticipate such problems if family members or others are involved in treatment.

Avoidance of Feelings Some clients try to avoid negative emotions and prematurely draw conclusions about the meaning of possessions without actually processing their thoughts and feelings about them. That is, they make an immediate decision to save something rather than actually considering the true value of the object. One way around this problem is to ask them to verbalize their thoughts and feelings about an object before they make a decision about discarding it. This “processing time” allows them to more fully experience the meaning of the possession and prevents them from avoiding uncomfortable feelings associated with making decisions about keeping or getting rid of it.

Unusual Beliefs We have occasionally encountered unusual beliefs associated with hoarding problems, such as a fear of death. One elderly woman stated, “God would not allow me to die in a place that was so cluttered and dirty.” She concluded that if she cleaned and removed the clutter, it would be time for her to die. Another elderly client reported that cleaning up her home meant it was time for her to move to a nursing home. In a related vein, some clients who began removing clutter after having not done so for years reported a fear that they would lose interest in everything, including life. These fears were reflected in sudden refusal to work on de-cluttering after a period of relative success.

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In such situations, clinicians can investigate the source of the problem and use cognitive strategies to work on faulty beliefs. We advise against directly challenging such a belief until your client is ready to examine it. For example, beliefs that it is wasteful to discard something of potential use may reflect part of the clients’ identity as a responsible and good person. Challenging these ideas is likely to provoke distrust in a clinician who does not appear to respect their views. Ask clients to clarify what they believe and how they came to this conclusion, but focus this line of questioning on how to incorporate their belief into a lifestyle that is functional.

Special Issues Sometimes clients face imminent deadlines to remove most or all of the clutter because of deadlines or ultimatums from law enforcement or community agencies or family members who threaten to leave or are planning drastic measures to remove clutter. In these cases, intensive methods may be needed that require figuring out how to engage others in the sorting sessions. In such cases, clients might hire a professional organizer or cleaning company to help. Many of these professionals have experience with hoarding and have learned to be sensitive to clients’ problems. Another option is to train friends, family members, paraprofessionals, or student assistants to assist clients with sorting and hauling. A cleaning agency may be essential if clutter includes significant amounts of human or animal waste that pose health risks to in-home workers. We caution that working on hoarding problems can cause considerable frustration for clinicians. Progress on clutter is likely to be slow at first; patience and optimism are important traits for clinicians. Keep in mind that much of the work early in treatment is to help clients learn skills and change their thinking about possessions, not merely to reduce clutter. Focusing too much on clutter, which is only a manifestation of the hoarding problem, can stall therapy.

Homework Homework assignments for this segment can be self-education tasks as well as those that help clients gather information to

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encourage self-observational skills that will be useful throughout treatment. Emphasize the importance of homework as follows: “I’ll ask you to do homework every week. We will agree together on what makes sense for you to do. But once you agree, I’ll expect you to do it or tell me what happened. This is very important because we are only meeting once a week and we can’t possible work effectively on the hoarding without a lot of work between sessions. This is not going to be easy for you. Are you sure you want to do this?” This final question is intended to help address the common problem of early enthusiasm for treatment followed by waning of motivation and effort. The following are recommended homework assignments for this phase of goal setting and treatment planning:

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■

Complete the Personal Goals section of the Goals Form (page 42 of the Workbook).

■

Monitor thoughts and feelings during sorting, discarding and acquiring to help develop the hoarding model further.

■

Use visualization exercises at home.

■

Have client focus on their thinking while discarding using the Practice Form from the Workbook.

Chapter 7

Reducing Acquiring

(Corresponds to Chapter 5 of the Workbook)

Materials Needed ■

Client’s Hoarding Model (from Chapter 4)

■

Acquiring Questions Form

■

Practice Hierarchy Form

■

Problematic Thinking Styles list

■

Downward Arrow Form

■

Need to Acquire Scale

■

Want to Acquire Scale

■

Help the client generate acquiring questions

■

Work with the client to develop a graduated hierarchy to reduce acquiring

■

Help the client identify and engage in pleasurable, alternative activities

■

Incorporate cognitive strategies during non-acquiring practice

Outline

We have already noted that the vast majority of HD clients have excessive levels of acquisition. Most of these involve compulsive buying, but a significant number have problems with acquiring free things. In Chapter 4, we noted that excessive acquiring often results from difficulty

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inhibiting urges to acquire that have been reinforced by positive emotions (pleasure, enjoyment). This is akin to the “high” people experience when they gamble or engage in other addictive-like activities and warrants considering acquiring an impulse control disorder. Sometimes acquiring occurs as an attempt to alleviate bad feelings like depression, distress, loneliness, and other unpleasant experiences. In these contexts it represents an attempt at self-regulation of emotion. Like interventions for sorting and discarding, treatment for this problem requires practice in situations that provoke acquiring and modifying acquiring beliefs. The goal is to increase tolerance for these urges. These practice exercises focus especially on cues that trigger strong urges to shop or pick up free things so clients can effectively resist these urges. We recommend working on acquiring as soon as clients are able to avoid exacerbating the clutter problem. However, if acquiring is a mild contributor to clutter, then work on acquiring can be concurrent with sorting, organizing, and getting rid of items or can begin after skills in these areas are well trained. The decision on the order of treatment depends on the magnitude of the problem in any of these areas. Some HD clients do not recognize an acquiring problem that becomes apparent over the course of treatment. Some have controlled their acquiring by avoiding places where they can’t control the urge. As noted below, avoidance rarely works in the long run. Keep these possibilities in mind when asking clients about the volume of possessions entering their home.

Reviewing the Model of Acquiring and Planning Treatment Of course, intervention for acquiring should be based on the information collected during assessment (see Chapter 3) and on the client’s model (Chapter 4) for how and when the acquiring occurs and is reinforced. The assessment will have clarified whether clients collect free things or accept items from others; have subscriptions; order from catalogs, on TV, or on the web; pick things out of the trash; buy in stores, yard sales, or flea markets; buy extras; or steal items. Practice settings must be designed to fit the typical acquiring places and items clients have difficulty resisting. Cognitive methods will focus on thoughts and beliefs identified in the model that make resisting urges to acquire difficult.

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In Chapter 6, we recommended having clients visualize one or more of their most common acquiring situations to clarify what provokes and reinforces acquiring. Because acquiring is accompanied by pleasurable feelings, helping clients resist their urges will also require finding alternative sources of enjoyment. This is like helping people with alcohol problems find other places, activities, and companions besides going to the local bar to join their drinking buddies. Similarly, because acquiring sometimes serves as a coping or mood regulation strategy, alternative methods of dealing with unpleasant emotions must be sought. Be sure to spend sufficient time identifying replacements for the pleasure and distress-relief associated with acquiring. Failing to do so is an invitation for failure and relapse.

Avoiding Triggers for Acquiring Sometimes clients can control their excessive acquisition by simply avoiding the triggers that begin their acquiring episodes. For example, they don’t go out on Saturday morning so they won’t see ongoing tag/garage sales. This strategy may prove effective in the short term as long as clients’ motivation remains high, but avoidance of acquiring cues is not likely to work over the longer term. Evaluate this carefully to determine when avoidance is a wise decision and when it is no longer effective and the time is ripe for them to learn to control urges in the presence of routine triggers for acquiring. This will require practice in acquiring situations as discussed below.

Focus of Attention One thing we have noticed about acquiring episodes in HD is that clients’ focus of attention may narrow so they are not aware of what they are doing when they acquire. They focus so exclusively on the desired item and its attractive features that they don’t think about the fact that they don’t have money, room, or need for the item or that they already have a dozen similar items. A very simple yet effective strategy is to ask clients to generate a set of questions they consider reasonable to ask themselves before acquiring something (see Acquiring Questions Form). We ask them to carry this form with them wherever they go and pull it out when faced with an acquiring situation. If, after answering the questions, they

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still want to acquire the object, then they are free to do so. This procedure brings the broader picture of the acquiring process into play to reduce impulsive acquiring. Common questions can be found below; encourage clients to use questions from this list and others they find helpful. Questions for Acquiring ■

Does it fit with my own personal values and needs?

■

Do I already own something similar?

■

Am I only buying this because I feel bad (angry, depressed, etc.) right now?

■

In a week, will I regret getting this?

■

Could I manage without it?

■

If it needs fixing, do I have enough time to do this or is my time better spent on other activities?

■

Will I actually use this item in the near future?

■

Do I have a specific place to put this?

■

Is this truly valuable or useful or does it just seem so because I’m looking at it now?

■

Is it good quality (accurate, reliable, attractive)?

■

Will not getting this help me solve my hoarding problem?

Advantages and Disadvantages As for other components of hoarding, the case formulation (Chapter 4) helps clarify how compulsive acquiring benefits the client, as well as what they are avoiding by giving in to their urges. Often clients recognize that acquiring makes them feel better when they are distressed or depressed, but they don’t always notice that this effect is short-lived and that the long-term effects contribute to their unhappiness. Exploring the advantages and disadvantages of acquiring (using

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Table 7.1 Advantages and Disadvantages of Acquiring Advantages of Acquiring ■ ■ ■ ■

Disadvantages of Acquiring

Feels good (kind of a “high”) Don’t feel guilty about leaving object behind Reduces frustration about my spouse Might lose an important opportunity if I don’t get this

■ ■ ■ ■

Incur more financial debt Feel anxious about the debt Criticism from my spouse about finances Adds to the clutter because there isn’t enough room for items

Advantages of not Acquiring ■ ■ ■ ■

Have more money for other things I want even more Have more space to display pretty things Have more space to do my projects Feel more in control of my life (I can choose instead of feeling compelled to buy)

the Advantages/Disadvantages Worksheet in Chapter  5 of the client Workbook) can strengthen clients’ desire to change. Typical reasons for (advantages of) acquiring and examples of the disadvantages of acquiring and the advantages of not acquiring are shown in Table 7.1. Help clients consider the weight of the evidence for the advantages and disadvantages they list to draw conclusions about their behavior.

Establish Rules for Acquiring Once clients agree they need to acquire fewer things, help them establish rules to accomplish this goal, especially for items or activities (e.g., going to tag sales) that contribute heavily to the problem. For example, clients might decide not to acquire unless they: ■

Plan to use the item in the next month.

■

Have sufficient money (not credit) to pay for the item.

■

Have an uncluttered place to put the item.

Some rules may be temporary. For example, clients could eliminate all magazine and newspaper subscriptions for the short term and place a limit on how many of these they will purchase until the clutter is reduced below a certain level. The advantage of this strategy is that it feels less intense for the client while also giving them practice in curtailing acquiring.

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Practice Exercises Treating acquiring problems requires practice in situations that expose clients to their urges to acquire. Repeated practice without acquiring trains clients to tolerate discomfort about not getting desired items and bring about changes in the meanings associated with this (e.g., making mistakes, not having extras in case of need, etc.). Arrange non-acquiring practices hierarchically, beginning with easier experiences and progressing to more difficult ones. Usually this means increasing proximity to favorite acquiring locations and items. To encourage clients in facing their fears and discomfort about not acquiring things they see that they want, the graph in Figure 7.1 may be helpful. This figure reflects the reduction in urges to acquire and in discomfort on a scale from 0 = none to 100 = maximum of a group of eight people with hoarding and acquiring who volunteered to participate in small groups in a non-shopping practice session with a clinician after one of our workshops. These individuals noticed substantial reductions in discomfort within a few minutes after leaving the store where they resisted buying something they typically would have acquired; approximately 20 to 30 minutes later, when leaving the mall, their urges and discomfort were only mild to moderate (showing a 50% reduction in intensity). Many were surprised by how rapidly their discomfort declined. Habituation of Buying Urge and Nonbuying Discomfort 80 Urge Intensity

70 60 50 40

Discomfort Rating

30 20

0 = No Urge or Discomfort 100 = Maximum Urge or Discomfort

10 0 Initial Exposure

Exiting Store

Exiting Mall

Figure 7.1

Reduction in urges to acquire and discomfort ratings for eight people with acquiring problems during a non-shopping exercise at an International OCD Foundation workshop.

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Clients who accumulate by buying in stores can begin their practice with what we call “drive-by non-shopping,” followed by walking through shops without touching things, and then handling objects without buying anything. Base these situations on information from the Acquiring Form (see Chapter 4) and from the Acquiring Visualization Task used in Chapter 6. After developing a list of possible practice situations with clients, help them order items from least to most distressing, or this can be assigned as homework. An example of a practice hierarchy is given in Table 7.2 below.

Table 7.2 Example of Completed Practice Hierarchy Situation

Discomfort (0–100)

1. Driving past a store in which I’ve bought things

10

2. Driving past a tag sale or flea market

20

3. Standing outside a store with a good sale on

20

4. Standing near a store in which I’ve bought things

30

5. Walking around at a rummage sale without buying anything

40

6. Walking into a store I like and not buying anything

50

7. Walking into a store with a sale and not buying anything

60

8. Seeing a CD I’ve wanted on sale in a record shop and not buying it

70

9. Returning an item I spent too much money on

80

10. Finding something my size on sale in one of my regular shops

80

11. Trying on sale clothing in my favorite store and not buying it

90

12. Finding something I’ve wanted for a long time at a terrific price and not buying it

100

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Once the hierarchy is developed, decide which exercises the client can do alone or with help from coaches (family, friend, etc.) and which ones should be done with your help because the urge to purchase or acquire may be too difficult to resist. For example, driving by and standing outside shops may be relatively easy for clients to accomplish alone or with others, but going into shops is likely to be harder. We suggest you accompany your client at least once to ensure he or she is fully exposed to the situation and able to learn effective coping skills (e.g., using questions, advantages/disadvantages, other cognitive strategies described below). To arrange non-shopping with a partner, identify a coach (see Chapter 6), such as a willing and helpful family member or friend, and decide whether you should speak to the helper first before agreeing on the task. This depends on your client’s confidence in the person’s ability to follow instructions for the task and your own confidence that the client can explain the task accurately. When in doubt about either of these, arrange to speak directly to the task partner and the client together (in person or by phone). Ask clients to record their discomfort level on a 0-to-100 scale about every 10 minutes or whenever they notice a change in discomfort. This can be done on a small card carried by the client or task partner. Work out how long to remain in the setting, depending on how quickly discomfort abates. The goal is to have clients experience a noticeable reduction in their discomfort and their urges to acquire items while still in the shop. However, this may not be possible early on when visual cues provokes strong urges clients resist only because of the presence of the accompanying partner. Urges will decline with increasing practice (not acquiring despite cues) and the use of effective coping strategies for managing discomfort. Ask clients to record not only the level of discomfort during practice but also their coping methods to discuss how well these worked. Plan repeated practices for clients who have serious acquisition problems, and intermix these with organizing, sorting, and discarding once clients can engage in non-acquiring with minimal planning and discussion. Practice on all non-acquiring hierarchy items should continue throughout treatment until clients’ can easily resist inappropriate acquiring in all problematic situations.

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Alternative Sources of Enjoyment and Coping For clients whose shopping or acquiring has become their main source of enjoyment, help them find replacement activities that become equally enjoyable and fulfilling. Ask clients to brainstorm a short list of likely alternatives, especially those that can be done spontaneously, alone and/ or in the company of friends, and inside and out of the home. See below for suggestions. List of Pleasurable, Alternative Activities ■

Visit a museum or other showplace of interest (historic home, local fair)

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Visit a library and check out books to read

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Read a book from library

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Watch a film in the theater or at home

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Go to a restaurant with friends

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Take a walk or hike with friends

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Attend a talk or lecture

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Take an adult education class at the local high school

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Attend a community meeting or gathering of interest

Then ask how pleasurable they expect each activity to be using a 0 (none) to 10 (maximum) scale. Select two or three activities that seem most feasible, enjoyable, and consistent with personal goals/interests and assign these as homework during the coming weeks, taking care to ensure clients plan the time for these and also keep a record of how much enjoyment (0–10) they expected to experience beforehand and how much they actually experienced during the activity. This behavioral experiment enables them to see if non-acquiring activities can provide enjoyable alternatives to acquiring. Equally important is providing clients with alternate ways to relieve distress or dysphoria. Some of the activities listed above may serve this function, and others can be generated and tested to determine how well they work to reduce negative mood.

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Changing Thinking About Acquiring Chapter  10 contains detailed instructions for using cognitive therapy methods to reduce problematic thinking and urges in acquiring situations. The basic methods below can be implemented in the office to plan exposures and during non-acquiring practice situations.

Faulty Thinking Identifying habitual (automatic) ways of thinking that reinforce acquiring helps clients learn to avoid mental traps. Refer to the Problematic Thinking Styles1 list in the Workbook to illustrate some of these patterns.

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All-or-nothing thinking: Black-and-white thinking exemplified by extreme words like “most,” “everything,” and “nothing” often reflect perfectionistic standards. Examples: “This is the most beautiful teapot I have ever seen”; “I won’t remember anything about this if I can’t bring home this reminder.”

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Overgeneralization: Generalization from a single event to all situations, using words like “always” or “never.” Examples: “I always regret not buying things like this”; “I’ll never have another opportunity if I don’t get this now.”

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Jumping to conclusions: Predicting negative outcomes without supporting facts. Example: “I’ll need something just as soon as I walk away without it.”

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Catastrophizing: Exaggerating the severity of possible outcomes. Example: “If I don’t buy it now, I’ll regret it forever.”

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Discounting the positive: Positive experiences are not counted. Example: “Yeah, I suppose I resisted the urge and saved some money, but what if I can’t stop thinking about it?”

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Emotional reasoning: Emotions are used instead of logic so feelings substitute for facts. Example: “I feel uncomfortable walking away without this, so I should just get it.”

List is adapted from Burns, D. (1989) Feeling Good Handbook (New York: Morrow).

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Moral reasoning: “Should” statements (“must,” “ought,” “have to”) accompanied by guilt and frustration; often driven by perfectionistic standards. Example: “I must get this magazine or I won’t know all the facts.”

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Labeling: Attaching a negative label to oneself or others. Example: “I’d be an idiot not to take advantage of this great sale.”

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Under- and overestimating: Underestimating the time to accomplish a task or one’s ability to cope or, conversely, overestimating one’s ability to complete a task or the emotional costs of doing so. Example: “I know I have a lot of magazines, but I’ll be able to read them all eventually”; “If I get don’t get this, I won’t be able to handle it.”

Ask clients to review the list for homework and discuss their own thinking styles the following week in session. Help clients become aware of thinking patterns during acquiring practice by asking about their thoughts and when errors are apparent, asking which one it might be, referring to the list. Once the error is identified, discuss alternative thoughts by asking, “What’s another way of thinking about this?” If clients have trouble coming up with a replacement, then suggest one (e.g., “Even if I feel uncomfortable about not acquiring this, I might get used to it.”) and discuss.

Downward Arrow The downward arrow method helps identify fears about not acquiring, as well as strong (core) beliefs about oneself and others. Label and describe this as a “cognitive technique that helps clarify thoughts and beliefs.” For example, during an acquiring practice ask clients to select an item that would provoke moderate discomfort if they didn’t acquire it and list this on the Downward Arrow Form. Ask how distressed (0–100) they feel about not acquiring this item and continue with a series of repetitive questions after each response: ■

“What would that mean?”

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“If that happened, what would that mean?”

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“What would be the worst part about that?”

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“Would anything else happen?”

If clients state thoughts that seem irrelevant to the acquiring task, then ask: “Do you have any other concerns about this?” Do not press it if clients have trouble identifying deeper meanings. After reaching the client’s bottom line (no further thoughts occur), connect the final belief or catastrophic fear to the original premise to help clients understand their own assumptions. Use this method to better understand clients’ reasons for strong urges to acquire when these are especially hard to resist in a practice situation. In the example below, one client had difficulty resisting a sale on DVDs in a discount store and wanted to purchase several of them.

Case Vignette

Clinician: Okay, it’s clear this bargain is hard to resist. What are your thoughts about not buying any of these? Client: Well, it’s a very good bargain. I’d save several dollars if I bought some of them. Clinician: If you didn’t buy them, what would happen? Client: I’ll be missing a good deal. It’s an opportunity. Clinician: You’d miss an opportunity. What would that mean? Client: I’ll miss the enjoyment. Clinician: What’s so bad about that? Client: I’ll feel bad, left out. Clinician: What’s the worst part about that? Client: I know this sounds silly, but it feels like I’ll never get to enjoy myself. I’ll never feel good. Clinician: So, I think you are saying that not getting this bargain means that you’ll never enjoy yourself? Does that make sense to you?

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Client: No, I guess not, but it seems so important at the moment. Like I’m missing out. Clinician: Missing out. Where do you think that comes from? From this point, the clinician and client can explore how not taking advantage of a sale or bargain became connected in the client’s mind to not enjoying herself. For example, this might derive from early experiences of deprivation, although this is certainly not always the case. Further exploration via Socratic questioning (see below and Chapter 10) can be used to explore an alternative approach to resisting bargains that makes more sense to the client. A video located at www.ocfoundation. org/hoarding/videos.aspx provides an example of the use of the downward arrow by Dr. Frost during a non-shopping trip.

Socratic Questioning To help examine the meaning and the evidence for the need to acquire, Socratic questioning can focus on whether clients actually think that not purchasing the item means that an unfortunate consequence will follow (e.g., “I’ll never feel good again,” “My life means nothing,” “I won’t be accepted by others”). For example, if the Downward Arrow questioning had led a client to say, “If I don’t buy this, I’ll feel stupid” (emotional reasoning), then consider the following types of Socratic questions to examine the evidence. Notice that some techniques are used more than once, with a slightly different focus. ■

Are other people who don’t acquire this also stupid? [double standard]

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Would you consider me stupid if I did not acquire this? [taking a different perspective by using the clinician as example] Why not?

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What would be the most accurate way to describe what it would really mean if you didn’t buy this?

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Do you usually feel stupid when you don’t buy something? [generalizing to other situations]

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Doesn’t everything you touch represent an opportunity? Shouldn’t you buy them all? [devil’s advocate] Why not?

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When we discussed the advantages and disadvantages of acquiring, I think you concluded that taking advantage of all the opportunities to acquire things would interfere with your ability to live your life the way you want to. [recalling incompatible information] If that is true, then how does that fit with the idea that you are stupid if you don’t get this?” [evaluating the logic]

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I am curious to know whether making any kind of mistake means that you are stupid? [generalizing to other situations]

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What about other people or me? Should we feel stupid if we made these same mistakes? [taking another perspective] Why not?

When clients begin to question their assumptions routinely and challenge the usefulness and accuracy of labeling of themselves as stupid (or “missing out” or other downward arrow conclusion), then ask where they think these ideas originated (e.g., influential past experiences). This helps consolidate a different perspective in which the original assumption (“I should buy this or I’m stupid”) has become questionable. Such changes typically occur gradually rather than all at once, so you will need to repeat these methods of questioning before a strongly held belief is relinquished.

Estimating Probability and Calculating Outcomes It is very common for clients to overestimate the value (attractiveness, usefulness, benefit) of items they could acquire and underestimate the time it will take to actually use them effectively (e.g., to fix something, create a handicraft; to read a newspaper or magazine). Help clients be realistic about how likely they are to actually benefit from the objects they want to acquire, but be sure the conversation does not degenerate into an argument. Consistent with motivational interviewing, avoid asking too many questions in a row, and if clients’ responses suggest resistance, then come back to the issue later or take another approach. Some questions might pertain to how long it will take them to use 20 bottles of shampoo weighed against the space required to store them and their wish to use the same product for that long a period of time. If clients habitually pick broken items from the trash, then ask how many have they actually repaired and used (not just made useful, but actually

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used them, sold them, or completed the original plan for the objects). What is the ratio of repaired items versus still broken ones? At this rate, what will be the outcome over a period of 5 more years? For clients with compulsive buying problems, at the current rate of spending, how much debt will they have accumulated in 1 or 2 more years?

Defining Importance: Need Versus Want Thinking styles often lead clients to magnify the importance of possessions to such a point that it seems crucial to acquire them. To help clients decide the true value of a possession based on their own goals and rational thinking requires them to distinguish what they truly need from what they merely want. The Defining Importance and Value Scales form from the Workbook will be useful for this purpose. Select an item your client recently acquired or wishes to acquire but appears to have no planned use or need for. Ask them to rate their need for it on a scale from 0 (don’t need at all) to 10 (need it very much). Then help them refine the scale by asking them to think of something they cannot live without like food or water. Draw out the scale (see below) and place these items under the heading “required for survival” at a value of 10. Next, ask clients to think of something they might like to have, but know they do not need or expect to acquire, like a Mercedes or a diamond necklace. Assign this a value of 0. Thus, the need scale is redefined as follows: Need to Acquire Scale 0 ------- 1 ------- 2 ------- 3 -------4 ------- 5 ------- 6 ------- 7 ------- 8 ------- 9 -------10 Not needed (for survival: diamonds)

Required (for survival: food/water)

It may be useful to specify different dimensions of need, such as safety, health, employment, financial affairs, and recreation. Also ask about items that might be designated as moderate need—spoons and forks, bed sheets, a suitcase, and so forth. Be careful that the level of need takes into account how many of the items are already available in the home (i.e., the value of the 10th set of bed sheets is considerably lower than the first

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set). Now ask clients to re-rate their need for the original item they want to acquire on this scale. The rating for the item is likely to go down, now that they have expanded their view of needed items and their purpose. Now, ask clients to create a Want Scale and rate the item on this scale as well. For example, a least favorite food (lima beans) and a most favorite food (chocolate cake) will not receive the same want rating, but they might receive a similar need rating depending on hunger. Want to Acquire Scale 0 ------- 1 ------- 2 ------- 3 ------- 4 ------- 5 ------- 6 ------- 7 ------- 8 ------- 9 ------- 10 Don’t want Desperate for

Ask the following questions to help clients re-evaluate their desire for the item: ■

How much do you need to get this item?

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Would you die without it?

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Would your safety be impaired without it?

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Would your health be jeopardized?

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Must you have this for your work?

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Do you need it for financial purposes? (e.g., tax or insurance records)

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Is there some other reason why you need the item?

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To what extent do you want the item more than you actually need it?

After discussing the true value of possessions in relation to other important goals in life, ask clients to re-rate their desire for the item. If this has reduced, discuss what aspect of this exercise was useful and how they might use this method during non-acquiring homework practice.

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Homework Select homework assignments that you and your clients collaborate on and clients are at least 75% confident they can do (high self-efficacy). ■

Carry Acquiring Questions Form during outings, and possibly laminate it.

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Develop a list of potential practice situations using the practice hierarchy form in the Workbook; order these from least to most difficult.

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Select non-acquiring situations clients will practice before the next session; keep a record of these for discussion in session. Record the context and items for each situation.

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Notice thoughts during practice outings to identify Thinking Errors.

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Use selected thinking strategies during non-acquiring practices (advantages/disadvantages, estimating probability and outcomes, need versus want scales, list of questions).

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Plan enjoyable activities as alternatives to acquiring during the week and record the expected and actual degree of pleasure experienced during these.

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Chapter 8

Training Skills

(Corresponds to Chapter 6 of the Workbook)

Materials Needed ■

Photos from home visit (strongly recommended)

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Task List

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Organizing Plan

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Personal Organizing Plan

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Preparing for Organizing Form

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How Long to Save Paper

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Filing Paper Form

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Questions About Possessions from Chapter 7

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Train client in using problem-solving skills

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Help client develop organizing skills

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Help client develop and implement a personal organization plan

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Teach strategies for organizing paper and creating a filing system

Outline

As described in Chapter 1, most clients with hoarding problems exhibit information processing deficits that interfere with their ability to engage in effective (1) problem solving, (2) categorizing and organizing objects, and (3) sustaining attention on overall goals and during sorting tasks.

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The chaotic nature of the clutter in their homes is a result of these skills deficits. Typically, clients’ past efforts to get organized took considerable time but accomplished little more than churning piles. Many hoarding clients are ineffective problem solvers. For example, they find it difficult to figure out how to move items around within the home, how to get unwanted items out of the house, and how to deal with everyday issues such as time management, paying bills on time, making and getting to appointments, and identifying people and organizations who can help with various needs. Because many hoarding clients are unable to sustain attention on repetitive chores like organizing and sorting (Hartl, Duffany, Allen, Steketee & Frost, 2005), clinicians must use strategies that help focus attention and limit the scope and duration of tasks. Many clients rely heavily on keeping objects in view to remember them, resulting in piles of things covering the furniture and floors. The short-term relief provided by setting items within sight is outweighed by the long-term costs of losing items in the clutter. In addition, hoarding clients tend to create too many categories while sorting their own things (Wincze et  al., 2007)  and have trouble conceptualizing how and where to store items. Learning to problem-solve and to categorize, file, and store items out of sight is essential for successful resolution of hoarding. The intervention strategies in this chapter are aimed at training clients to improve their problem-solving skills and utilize step-wise organizing methods, while maintaining their focus on the goals and tasks. The methods can be applied in any order, depending on the client’s needs. Not everyone will need all skills. We recommend spending at least two sequential sessions on this skills training module to consolidate basic skills before interweaving them with other cognitive and behavioral methods. Publications by professional organizers and manuals for addressing attention deficit problems can provide additional strategies (see Readings and Resources).

Educating Clients and Developing Goals Following the work done during case formulation (Chapter 4), introduce the topic of skills training by noting which skill problems seem to

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contribute to clients’ hoarding problems. The following introduction is an example: “I think there may be some skills that might help you with this hoarding problem. A lot of people who develop problems with hoarding have trouble solving problems effectively. You and I have already talked about some of the problems that need solutions. For example, you were just wondering how to manage your time to get more done on the hoarding problem, so this time problem is something we might start on. Today, I’d like to go over some steps for problem solving that would help us with this and with other problems that may crop up as we work. “Another skills issue is that most people with hoarding problems need some help learning to sort and organize their possessions. From our earlier discussions, I think this might also be true for you. I know you like to keep things in sight so you won’t forget them, but you’ve commented that you have trouble remembering where things are. Although it’s probably not your intention, keeping a lot of things in sight might make them harder to find when you really need them. What do you think?” [waits for reply] “I’d like to propose that we look into developing some filing systems that will work for you. How does this sound to you?” At this point, work with your client to decide on your goals for this part of the work. These might include:

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Learn a systematic strategy for solving problems that arise during the hoarding work

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Define categories for items to be kept

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Decide on an overall organizing plan with locations for each category of saved items

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Develop a plan for sorting and moving items to interim and final destinations

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Decide on categories for unwanted items (e.g., give to people, give to charities, recycle, trash)

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Plan how to dispose of unwanted items

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Develop a plan to routinely put newly acquired or recently used items where they belong

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Decide how to make the organizing and decluttering process as pleasant as possible

Systematic Problem Solving Table 8.1 shows simple steps for problem solving that you and your client can apply to current problems that crop up during sorting and organizing efforts. This problem-solving approach can be used to deal with a variety of stressful life problems that come up during treatment. Below is a short list of the types of problem for which it is well suited: ■

Being unable to make myself start the work on sorting

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Can’t figure out how to move items around inside the home because there is no place to put them

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Haven’t been able to get unwanted bags and boxes out of the house

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Run out of time to get tasks done

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Not paying bills on time

Table 8.1 Problem-Solving Steps 1. Define the problem and the contributing factors. 2.

Generate as many solutions as possible (be as creative as you can before judging whether they would work).

3. Evaluate the solutions and select the one or two that seem most feasible. 4. Break the solution down into manageable steps. 5. Implement the steps. 6. Evaluate how well the solution worked. 7. If necessary, repeat the process until a good solution is found.

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Not making medical appointments when I need healthcare

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Don’t know who to call to fix my plumbing

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Don’t understand the legal notice I got in the mail so I haven’t done anything about it

Problem-Solving Example One of the most common problems clients have in working on hoarding is managing time to accomplish tasks between sessions. Sometimes this reflects a motivational problem that requires strategies from Chapter 5, but often it occurs because time management has never been the clients’ strong suit. This situation warrants problem-solving steps. Begin by helping the client label the failure to complete the homework as “a problem to be solved” to short circuit self-blame and guilt and free clients to focus on new ideas. This defines the problem and the goal—getting most homework done before the next session. Notice that the goal is not defined rigidly—getting most of the work done is good enough. Then, help clients identify the factors they think could be responsible for not getting work done between sessions. Like many clients, one woman found she could work effectively, both in the clinic and at home, when the clinician was present but not when she was alone. Difficulty finding time, feeling fatigued, and feeling lonely while working seemed to be interfering with working alone. At this point the clinician encouraged her to come up with as many potential solutions that addressed each contributing aspect and added a few silly ones to get the creative juices going. The silly ideas often help generate new thoughts the client might not otherwise generate. The clinician also added ideas the client hadn’t mentioned and listed all of them on a sheet of paper. The list of ideas eventually included both global and specific ones, as well as ridiculous and reasonable ones that addressed the sources of the problem (time, fatigue, loneliness): 1. Hire a cleaning crew to clean the place up 2. Burn the house down

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3. Schedule the homework in her calendar in bright red ink 4. Put up clever signs on the refrigerator door 5. Skip meals and do homework instead 6. Work in the early morning when she was alert 7. Work for shorter time periods 8. Work while watching TV or listening to the radio 9. Dress up in silly clothes while working to lighten her mood 10. Work with music on 11. Sing while she worked 12. Invite her sister-in-law over to sit with her and do other things while she worked 13. Pay someone to talk to her while she worked 14. Call the clinician before she started and after she finished homework As should be the case for most problem-solving training, this process provoked some laughter and proved to be fun for the client, so moving on to selecting the top choices was not difficult. The clinician initiated a discussion of the advantages and disadvantages of these ideas. After rejecting the options of burning the house down and skipping meals, she came up with a plan that included scheduling homework into her calendar in the morning for 30 minutes while watching a talk show program she liked but felt would not distract her. She got up earlier than usual to do this but didn’t mind because she liked the show and compensated by going to bed a little earlier at night. She also decided to invite her sister-in-law who lived nearby and knew about her hoarding problem to come for coffee on weekend mornings while she sorted. After the first week, her new plan increased her homework time to about an hour a day, enough to see progress that motivated her to keep up the new schedule. Had the plan not worked, the clinician would need to help consider the other ideas and new ones that might better solve the problem.

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Managing Attention and Distraction For a comprehensive overview of how to treat ADHD, see Mastering Your Adult ADHD by Safren, Perlman, Sprich, and Otto (2005). A variety of strategies are useful for managing attention focus during organizing and problem solving. A first step is to measure clients’ attention span. Ask clients to time how long they can sort their possessions at home until they become distracted or confused, or you can do this in the office. Time the sorting of different kinds of items, as clients are often more distractible when the task is difficult. After determining the usual attention span (which may be only a few minutes), set a timer for this time period and ask them to practice (sorting or organizing) until the timer goes off. When they can do this successfully several times in a row, increase the time by a few minutes—perhaps 3 to 5 minutes. Continue in this vein until they can work without distraction for a reasonable length of time (e.g., 30 minutes if the original time to distraction was 10 minutes) that enables them to feel some accomplishment. Remember that this procedure also exposes clients to the discomfort of making hard decisions about saving, discarding, and organizing. Longer practice will help habituate this discomfort. Assign homework to facilitate generalization of longer attention spans to their home setting when they are working alone or with a coach if they have one. Creating structure in clients’ lives will also help reduce attention problems. For example, use a calendar (electronic or written per the client’s preference) to establish a routine that improves their functioning and helps them feel more in control of their lives. The calendar should list all planned activities, including homework. Ask your client to update it frequently (several times a day if needed) as new time commitments arise. Help clients schedule appointments for organizing and sorting sessions to fit times—e.g., mornings or afternoons—that work best for them. Setting priorities and keeping track of them in the Workbook are keys to managing distractibility for hoarding clients whose priorities often shift depending on their mood and other life events. Encourage clients to use the Workbook Task List (page 157 of Workbook) with columns for task description, priority ranking, the date it was put on the list, and when

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it was completed. Safren et al. (2005) recommend three priority rankings: Priority “A” for tasks to be done within a day or two; “B” for tasks that can take longer; and “C” for lower importance tasks that might be attractive and fun, but less important than “A” and “B” tasks. Ask clients to follow a consistent routine during scheduled work times (several times a week or daily if time permits), reducing distractions by turning off the TV, radio, telephone, computer, and so forth. However, some clients find background music helpful in calming an anxious mood or lifting a depressed one. Next ask clients to review their priority list and select an appropriate goal for the session. Help them break down the project into small and manageable steps that are clearly defined and easily implemented. They might need to self-monitor what distracts them to improve their attentional focus. Common distractions are telling stories about possessions or having to find something else before deciding about the possession at hand. Setting up categories and locations for possessions, as described later in this chapter, may speed the process along. You will need to help clients establish these routines and check on their usefulness on a regular basis until clients use them automatically. Use problem-solving strategies described above to deal with difficulties that arise. For example, clients who find their eyes wandering to other items in the room might generate ideas for how to limit this distraction—for example, by using sheets or towels to cover areas next to the section they are working on. Clients who find that their thinking jumps forward in time to upcoming tasks might solve this problem by breaking the current task into brief segments they can execute quickly so they have the feeling of moving forward in their work. They might also write down distracting thoughts for later review to stay on task. In addition, practice exercises (Chapter 9) and cognitive strategies (Chapter 10) will help clients develop more adaptive ways of approaching tasks and, in turn, will help minimize distractions caused by negative emotions.

Organizing Skills for Objects The first step in sorting items is to learn to categorize and organize them. To train these skills, we recommend working first on objects and later on

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paper items, which require more complex thinking. Begin by defining categories for items to be removed from the home and then work on categorizing items that will be saved. This sequence helps clients feel more comfortable that their strong wish to avoid waste by recycling objects or giving them to a worthy cause will be respected. During the actual sorting itself, use strategies from the next two chapters to help reduce unreasonable urges to keep, give away, or try to sell worn out or useless objects that few others would want and are better put in the trash.

Categorize Unwanted Items The following categories are useful for disposing of items clients want to remove from their homes: ■

Trash

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Recycle

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Donate (e.g., charities, library, friends, family)

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Sell (e.g., yard sale, bookstore, consignment shop, Internet sales)

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Undecided

Discuss these categories and develop a short list of ways to donate or sell things that are relatively easy to execute and cover the types of items likely to fit this category (e.g., books, clothing, toys, small appliances, kitchen items). This helps plant the idea that many items will be removed but may be usefully recycled, sold, or given away. For those especially concerned about being wasteful, this discussion may increase clients’ willingness to remove items. There is no need to suggest what proportion of possessions should be placed in these categories, but the process of determining them helps clients think differently. Develop an action plan for how and when to remove items in each of these categories. This is essential, as many clients set items aside for removal but have difficulty actually getting them out of the home. Determine when items can be put out for trash pick-up or recycling or other methods of removal. Ask clients to identify local charities that could benefit from their unwanted items (e.g., donated books) and

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find out how to give these away. Local charities that come to pick up unwanted items are especially helpful. We strongly recommend that clients (who can afford it) give away items rather than selling them, as the latter requires considerably more time and effort that can derail the sorting and decluttering process. However, when items are valuable and their sale helps generate needed income, problem-solve ways to sell the items (e.g., local consignments stores, online methods). Make sure these plans are feasible. Homework assignments can include calling charities and sales outlets and scheduling removal of the unwanted items.

Select Categories for Saved Objects The plan for organizing paper items requires a finer grained approach that is described shortly. For non-paper items to be saved, help clients define a limited number of categories for each type of possession to decide where the item goes. This can be accomplished by creating an organizing plan. Table 8.2 contains an example of a completed Personal Organizing Plan including categories of saved items (e.g., mail, photos, clothing, newspapers, office supplies) and typical locations where people might keep them. A similar example is given in the Workbook (page 66). Review these examples with clients, noting that each household may have different types of items and may choose different locations for keeping them. Convey the need to keep similar items together in one main place to find them easily. Next, introduce the blank Personal Organizing Plan from the Workbook (page 68). Help clients determine what kinds of items clutter their homes and need to be categorized and organized. Reviewing the photos taken during the initial assessment may be helpful for this purpose, as well as using a random mix of items brought from home. Ask clients to list each category in the left-hand column and write down the final location (room, piece of furniture, etc.) where these items belong. Some clients have difficulty naming the categories for possessions but are more effective at deciding where they go. In this case begin by asking about rooms (e.g., living room, dining room, bedroom, basement, etc.) and storage locations within these rooms (e.g., desk drawers, closet shelves, bookcase, etc.) to find out what items belong where. Try to keep the task manageable

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Table 8.2 Example of Completed Personal Organizing Plan Target Area: Kitchen Item category

Final location

1. Dishes

cupboards above kitchen counter

2. Pots and pans

cupboard underneath stove top

3. Spices

small cupboard above counter

4. Food—boxes, cans, etc.

pantry closet

5. Tea, coffee, and cups

middle cupboard above coffee pot

6. Dish towels, aprons

drawer

7. Bowls and baking pans

corner Lazy Susan

8. Silverware

large top drawer—get dividers

9. Cooking utensils

2 drawers—large and small

10. Household cleaning products

cupboard under sink

11. Paper supplies

desk drawers

12. Odds and ends, hardware

bottom drawer in kitchen

13. Glasses, stemware

cupboard above counter

14. Trash and recycle bins

pantry floor

15. Recent magazines

shelf near table, move to recycle after 6 mos.

16. Newspapers

recycle bin when 2 days old

17. Current financial papers & bills

upright file on top of small desk

18. Older financial papers, tax papers

small file cabinet

19. New mail, advertisements

desktop “to do” pile or recycle bin for junk mail

20. Dog food

pantry bin

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(non-frustrating) by finding a method that works best for your client. Assign the form as homework if the client is comfortable using it.

Pick Locations for Categorized Items Clients must eventually have an appropriate storage/filing location for all of their things. Filing cabinets, bookshelves, and other storage furnishings will be needed, and some clients may decide to make structural changes to the home (e.g., built-in bookcase, closet) to help them get organized. During home sessions, ask clients to select a pile of disorganized possessions and talk aloud to decide the category and location for each until they can do this independently. During office visits use the same procedure for a box or bag of items brought from home. Use the Personal Organizing Plan to record these details. To help clients make organizing decisions, use a questioning style (e.g., “What category does this belong to? Where should that go?”) and comment positively whenever their ideas seem reasonable. If some ideas seem unfeasible, then prompt gently (“Interesting, how did you decide it belongs there?” “Can you think of any alternatives?”). Offer suggestions if asked, but encourage clients to develop and try out their own ideas. Sometimes information may be helpful. When one of our clients seemed not to understand the category of office supplies, her clinician used the website of a large office supply company to see the categories this company used for organizing their supplies. The client used this information to develop her own plan. Sorting and Moving Saved Items Use the Preparing for Organizing Form from the Workbook to help clients determine what preparations are needed before undertaking major sorting tasks. These are likely to include choosing and obtaining: ■

Storage furniture—filing cabinet, bookcase, desk

■

Containers—clear plastic bins, cartons, large and small boxes, kitchen containers

■

Supplies—colored labels, markers, tape

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If necessary, help clients problem solve where to find these things, how to transport them home, and other practical concerns. Clients who agonize over purchasing decisions may require help to address fears about making the wrong choices (see Cognitive Strategies in Chapter 10). Because many final destinations are already full of clutter when treatment starts, you’ll need to establish interim locations or “way stations” to store things until the final location is available. This process usually requires (1)  clearing space that serves as a staging area for sorting, (2)  clearing temporary storage areas (e.g., porch, spare room), and (3)  several large boxes labeled with the appropriate destination and contents. You might want to warn clients and family members that some sections of their home will look worse temporarily while they sort.

Implementing the Personal Organizing Plan Once the personal organizing plan, equipment, and storage locations are in place, help clients begin sorting their things using the decision tree in Figure 8.1.

Decide whether to keep or remove item

Not wanted: Determine category: Trash, recycle, donate, sell

Move to final location: Trash container Recycle bin Box for charity Box for family/friends Box for sales items Figure 8.1

Decision tree for sorting

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Wanted: Determine category Sort into nearby box

Move categorized items to interim location

Move to final location

The process of deciding whether to keep or remove items will be challenging as clients struggle with strongly held beliefs and strong emotions. Cognitive and behavioral strategies for working on these are given in Chapters 9 and 10. For now our focus is on helping clients select useful categories, plan the organizing process at home, and practice sorting into categories in the office using items brought from home.

Skills for Organizing Paper Filing System for Documents People who hoard often mix important and unimportant things, such as checks and bills intermingled with grocery store flyers and newspapers, most likely because everything seems important and therefore is put in the same pile. Help clients establish a filing system for bills and other important documents (insurance papers, tax papers, personal medical matters), as well as places to store informational materials, upcoming events of interest, pictures, etc. Establishing a filing system at the outset enables clients to sort items throughout the home. A common sense approach to creating this system is best, and clients can be encouraged to consult with friends or family members if they feel stuck deciding how and where to file papers. Many decisions are straightforward, but some difficult ones require extra thought. Examples include what to do with old bills and how long to keep financial and tax documents. We provide some suggestions in Table 8.3. If clients balk at developing a filing system and putting papers out of sight, remind them of their goals to create usable living space and to be able to find things easily. To accomplish this goal, they will need to create and use a paper filing system. You can expect that fearful beliefs (e.g., putting items out of sight means losing them) and emotional attachments will intrude as you develop the filing system with clients. Consider a behavioral experiment (e.g., filing items and seeing whether clients remember where to look when the item is needed) to examine clients’ fears regarding a filing system. Chapter 10 contains other cognitive strategies that may be useful.

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Table 8.3 How Long to Save Paper Keep for 1 Month ■

Credit card receipts

■

Sales receipts for minor purchases

■

Withdrawal and deposit slips (discard after verifying them against monthly bank statement)

Keep for 1 Year ■

Paycheck stubs/deposit receipts

■

Monthly bank, credit card, brokerage, mutual fund, and retirement-account statements

Keep for 6 Years ■

W-2’s, 1099s, and tax return information

■

Year-end credit card statements, brokerage and mutual fund summaries

Keep Indefinitely ■

Tax returns

■

Receipts for major purchases (furniture, art, etc.)

■

Real estate and residence records

■

Wills and trusts

Keep in a Safe-deposit Box ■

Birth and death certificates

■

Marriage license

■

Insurance policies

Planning the Filing Process After agreeing on the need for a filing system, the following questions are useful in the planning process: ■

“When is the best time to work on filing?” ■

■

“Where will you start?” ■

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Usually a time when clients are alert and less likely to be distracted.

Typically the area that makes the most difference to clients.

■

“How frequently should you file and for how long?” ■ ■

■

“Where will files be stored? Do you have enough storage space?” ■

■

New mail should be sorted daily. Organizing other items several times a week helps clients become comfortable with their new filing system.

If storage space is not readily available yet, then consider storing files temporarily in cardboard or plastic file boxes that can be stacked in an interim location and moved later to the appropriate place.

“What materials do you need to file effectively now and in future?” ■

■ ■

Possibilities include file cabinets, file folders, labels (especially color coded ones), pens, Rolodex, or equivalent for address/ phone information, boxes for temporary sorting. Consider adding shelves or bookcases. For categories with many items, consider large file folders or clear plastic storage bins available cheaply at discount stores.

File Categories Ask clients to review the Filing Paper Form in the Workbook (page 72) to determine which of the categories listed there are relevant for their own filing systems. Each category will need its own file folder and some categories may need to be subdivided. A list of several common categories can be found in Table 8.4.

Common Items for Filing Set aside time to discuss strategies for sorting and filing paper items, especially daily mail. Ask how clients currently handle mail, and if they avoid it, ask them to bring in several days’ worth of mail for sorting practice in the office. As usual, clients first decide which items to keep and which ones to recycle. Help clients talk aloud about thoughts and feelings regarding mail about which they are uncertain. At this stage do not point out faulty

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Table 8.4 Common Filing Categories for Paper Addresses and phone numbers Archives: Wills, insurance policies, other important papers Articles (e.g., garden, cooking, etc.) Automobile Catalogs Checking account(s) Computer Correspondence Coupons Diskettes Entertainment Financial Credit cards Bank statements Retirement Savings account(s) Stocks

Humor People: One file for each household member Instruction manuals/warranties Medical Personal/Sentimental Photographs Product information Restaurants Savings account(s) School papers Services Stamps Stationary Taxes Things to do—lists Things to file (Things that have to be reviewed) Calendar items (reminders for that specific month) Trips/Vacation information

logic or correct cognitive errors; simply ask for a decision. The Questions about Possessions from Chapter 7 may be helpful. For unwanted mail, ask whether it should go into the trash, recycle bin, or an “out” box to be delivered elsewhere. If clients want to save an item, then ask to what category it belongs and help them decide where to put it. Most people have a box or small pile of items that are of current interest (e.g., upcoming events to attend, travel plans for the near future, current sales flyers). Even these should be sorted into type, but they can be kept in view rather than filed because of their short-term nature. This group of papers should be examined weekly or monthly and out-of-date ones discarded. Another common problem concerns the accumulation of magazines and newspapers. A similar decision process can be used here with the newspapers or magazines from the past couple of weeks. Ask clients which to keep or remove from the house. If kept, does the client want the whole thing or just a part (e.g., an article)? Determine where to put each item and for how long. Help clients develop their own rules for these decisions. Typical rules are a few days for newspapers and a few months for magazines. Some magazines can be kept as resource material if clients truly use these for this purpose. Consider canceling subscriptions to magazines and newspapers that clients rarely read.

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Remember that the initial focus of these exercises is developing the organizing and filing systems without too much concern about clients’ decisions to keep too many items. You can work on these shortly (see Chapter 9). Maintaining the System The sheet in the Workbook entitled How Long to Save Papers may help address clients’ questions about this issue. As categorizing and filing progresses, help clients establish daily routines to replace old habits and prevent disorganized clutter from accumulating. The following alternative behaviors may be useful: ■

Pick a time to sort new mail and papers every day.

■

Incorporate recreational time after sorting to boost spirits and reinforce the work.

■

Empty trash twice weekly (more often if required).

■

Take trash out for pick up (or deliver to sanitation facilities) at the same time every week.

■

Do dishes daily; wake up to a clean sink and counter.

■

Do laundry every week (more often if required).

■

Establish times and a system for paying bills to meet due dates.

■

Put all new purchases away upon arrival or within the same day.

■

Put away any used items as soon as the task is done.

A few succinct general organizing rules such as the following can be posted on clients’ refrigerator doors (Anne Goodwin, personal communication): ■

If you take it out, put it back.

■

If you open it, close it.

■

If you throw it down, pick it up.

■

If you take it off, hang it up.

■

If you use it, clean it up.

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Homework The following homework examples are recommended for developing skills in problem solving and organizing:

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■

Practice the problem solving steps for a problem identified during the session.

■

Call charities and sales outlets to arrange removal of unwanted possessions.

■

Take home items sorted in the office and put them in an interim or final location where they belong.

■

Fill out the Preparing for Organizing Form and complete the selected tasks before your next session.

■

Complete the Preparing for Organizing Form and selected tasks before the next session.

■

Complete the Personal Organizing Plan for items remaining in the target work area and put the items into their intended location.

■

Complete an additional Personal Organizing Plan for paper items.

■

Identify appropriate filing space for paper and non-paper items, and assemble necessary materials

■

Generate file categories, label file folders and put papers in an interim or final location for filing.

■

Bring in a few days’ worth of mail for use in the organizing paper session.

■

Bring in items that were difficult to categorize.

■

Continue tasks begun in the office at home.

■

Develop a plan for using cleared spaces and keeping them clear of new clutter.

Chapter 9

Making Decisions About Saving and Discarding

(Corresponds to Chapter 7 of the Workbook)

Materials Needed ■

Habituation Graph

■

Questions About Possessions Form

■

Thought Listing Exercise Form

■

Behavioral Experiment Form

■

Thought Listing Exercise

■

Work with client to develop a Thought Listing Exercise hierarchy

■

Begin graduated saving/discarding exercises

Outline

This chapter and the following one will guide treatment for the discarding portion of the intervention. The exercises in this chapter are aimed at facilitating discarding decisions, whereas cognitive therapy (CT) methods described in Chapter 10 focus on helping clients evaluate problematic thoughts and beliefs about possessions that interfere with discarding. Remember to use motivational interviewing techniques from Chapter  5 when clients hit emotional roadblocks that impair their resolve. Remind clients to use their Personal Session Forms to keep track of what they learn and of their homework assignments.

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Understanding Avoidance in Hoarding Disorder Despite their intense attachment to possessions, most people with HD spend little or no time using the things they save. In fact, they spend less time with their possessions than most people. Decisions to save appear to be based on relatively brief initial interactions with possessions (acquisition, bringing them home), which then go onto a pile of disorganized objects, often remaining there for years. After that, any consideration of these possessions (i.e., decision-making activity) tends to be brief or avoided altogether, with the default being to save the item without any deliberation. This avoidance is most likely designed to escape unpleasant emotions that occur when contemplating discarding. The strategies in this chapter are designed to reduce avoidance behavior and increase the amount of time clients spend processing information and making decisions about possessions. In one of our recent studies, we asked people to spend a few minutes talking about a possession before deciding whether to keep or discard the item. Interestingly, after the exercise, HD clients discarded the possession at the same rate as those who didn’t have a hoarding problem. Further, their emotional distress from discarding decreased over the course of the 30-minute exercise. In addition, their reported emotional attachment to the object, their beliefs about its utility, and their judgments of its aesthetic value decreased during the exercise as well. This exercise worked as well as, if not better than, attempts by a therapist to restructure their thoughts about possessions. For this reason, we recommend the Thought Listing exercise detailed below as a good starting point for HD clients. It will form the basic structure of treatment for learning how to make discarding decisions. With practice, clients can increase the speed and efficiency of their decision-making about possessions. Additional exercises in this chapter, and cognitive techniques in the next, can be added as needed. To get started, review the hoarding model to remind clients what they avoid and to show how avoidance maintains their fears and their clutter. For example, keeping items in a disorganized way helps them avoid distress about making decisions that might be wrong (mistakes), worries about memory and about losing an opportunity or information, feelings of loss and vulnerability, and embarrassment about

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clutter and inviting people home. (Of course, some forms of avoidance are actually adaptive. For example, not allowing anyone into the home protects clients from ridicule, scrutiny from authorities, or eviction.) Indicate that clients’ strong negative reactions to getting rid of possessions usually trigger strong urges to avoid these feelings, fitting the pattern of most anxiety problems. Unfortunately, the more people avoid facing their fears, the more entrenched their discomfort becomes so that emotions, rather than rational thinking, soon control what they keep and discard.

Review of Habituation Exposure to avoided situations is the most effective way to overcome fear and discomfort. You can remind them of the process of “habituation,” which we encountered in working on acquiring. Describe it this way: “When we are uncomfortable in a situation in which there is no actual danger (for example, encountering a friendly dog), our discomfort declines over time as a natural process; we habituate. This is what happens to people who live near a train track or a subway line. When they first move in they hear the noise whenever it occurs, and it keeps them awake at night. But soon, they barely notice it and sleep through it easily. The same process of habituation happens when we are exposed to situations that make us anxious. Initially, we are very uncomfortable, but with time we become used to it and it no longer disturbs us. For example, children with dog phobias can overcome their fears through gradual exposure to dogs of increasing ‘scariness’ starting with puppies, then little dogs, and eventually larger dogs, and even barking dogs. Fearful children are initially uncomfortable, but this discomfort gradually decreases over time until eventually they can pet and play with the dog without discomfort. Let me illustrate what happens on a graph.” The Habituation Graph (see Fig. 9.1) illustrates the gradual drop in discomfort experienced by an HD client during the Thought Listing Exercise. You should indicate that not everyone follows exactly the same pattern. Some people habituate slowly, others quickly, and others have

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Anxiety

Discomfort during exposure

Time

Figure 9.1

Habituation Graph

up-and-down reactions that gradually reduce over time. Remind clients that discomfort is not something they can control or talk themselves out of. It is a physiological process that requires repetition to reduce discomfort. Emphasize that the experience of some discomfort is necessary for habituation to occur, and that this is part of the process of learning how to control their hoarding problem.

Thought Listing (TL) Exercise This is a very simple exercise that can have a big impact on the way HD clients make decisions about discarding. The purpose of the TL exercise is fourfold: ■

to help clarify the nature of attachments to a possession,

■

to increase the amount of time spent processing information about the value of possessions,

■

to increase exposure to discarding and reduce avoidance, and

■

to provide a mechanism for practice in sorting and organizing.

As for the categorizing and sorting practice in Chapter  8, have your client bring in boxes or bags of things, especially papers they think will be hard to make decisions about. Typical examples are stacks of papers collected from one area like the surface of a table or desk or a stack of things on the floor. Mail is often an excellent thing to bring to office

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sessions if clients have problems opening and sorting mail every day. Likewise, newspapers, magazines, or other saved paperwork that is not filed can be the focus of decisions about sorting and discarding. Be sure to have them bring in a wide range of items, including items they do not intend to discard. They may have a tendency to bring in only items that are easy for them to discard. However, the exercise will be helpful only if the items they select are challenging. Ask clients to select a possession that they believe will be moderately difficult to discard. Be sure to emphasize that they will not have to discard the item, only consider discarding it. The ultimate decision about discarding is theirs to make after the exercise is over. Below form illustrates this exercise. 1.

Begin by asking clients to indicate how much distress they anticipate experiencing if they were to actually discard the object.

2.

Then ask clients how long they think they the distress would last.

3.

Next use the following instructions: For the next 4 minutes, I would like you to speak your thoughts aloud about discarding this item. Please don’t filter any of your thoughts, even if you feel embarrassed or uncomfortable. There are no right or wrong answers. The more honest and open you are about your thoughts and feelings, the more we can learn about this process. Are you ready? Go.

4. Make note of the kinds of attachments reflected in the clients’ thoughts (e.g., “pretty,” “useful,” “need to remember,” etc.). 5.

At the end of the 4 minutes, ask the client to make a decision about whether to save of discard the item. Do not try to influence their decision. Decisions to save are as informative and valuable as decisions to discard.

6. If the decision is to discard, remove the item from the room (ideally, directly into the trash or recycle bin). 7. Then ask the client how much distress they experience about their decision. 8.

Ask the client for a new rating of distress every 5 or 10 minutes for the next 30 minutes to track their habituation.

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Example of Thought Listing Exercise Form Initials MS

Date 12/05/06

Selected Item: music box Anticipated Distress (from 0=none to 100=maximum): 70 Predicted Duration of Distress: Weeks Thoughts about Discarding: Can’t get rid of it; Too expensive looking; Gift from sister; Sister will be mad; Planned to have it in guest room, but guest room full; Bought at flea market for good price; Don’t really like it that much Discarding Decision: Discard Distress after Decision: 80 Distress after 5 minutes: 60 Distress after 10 minutes: 60 Distress after 15 minutes: 40 Distress after 20 minutes: 50 Distress after 25 minutes: 40 Distress after 30 minutes: 20 Notes from Discussion: Initial beliefs that discarding was impossible; On reflection, decided she really didn’t like it; Exercise easier than thought; Did not feel pressure like normally do when people try to help. Surprise that the distress actually went down.

9. Between these ratings, use motivational interviewing strategies to help explore their ambivalence about discarding the possession. Be careful not to advocate for discarding, because you want the client to explore reasons for saving, as well as reasons for discarding. If the decision is to save the object, then ask the client where to put this object (see organizing Chapter 8). Then pick another and repeat the process until at least one item has been discarded. At the end of the 30 minutes, ask the client what they learned by the exercise (i.e., Was it easier than they thought? Harder? Why?). 10. Be sure to note when habituation has occurred, and if it has not, why that might be the case.

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Keep in mind that one of the goals of the exercise is to learn about attachments to possessions, so even if habituation did not occur, the exercise will have taught them something about their attachment to this object. Also, the exercise will have taught them how to go about making decisions about possessions.

Developing a Thought Listing Exercise Hierarchy Exposures using the Thought Listing Exercise are easiest to accomplish by helping clients develop a hierarchy of possessions that are increasingly difficult to discard. For example, papers with unidentified phone numbers may be easier to discard, whereas getting rid of newspapers is harder. Help clients create their own list of types of items and locations in the home, ranked from easy to hard. This need not be a formal list, but serves as a general plan for sorting, moving, and removing clutter. Remind clients that they will undoubtedly experience some discomfort, and the intent is to increase their tolerance gradually for making decisions and getting rid of items. To make progress on the clutter, clients must learn to tolerate some discomfort, because removing things that cause no discomfort will not help them reduce anxiety and learn new skills to prevent future hoarding. In addition, you will introduce various cognitive therapy techniques to help them deal with beliefs that have been reinforcing hoarding problems.

Generating Questions to Facilitate Discarding After doing the TL exercise with several items, ask your client to generate a list of questions they feel might help them speed up the process of making decisions about saving or discarding. Have them write the questions down on the Questions About Possessions form from the Workbook. Be careful not to direct them too much in coming up with this list.

Establishing Rules Making decisions about saving and discarding can be facilitated by creating a set of general rules that remove the necessity of deliberating over

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each separate object. Based on their experience with the Thought Listing Exercise, ask clients to generate rules they believe will be useful in determining when to save and when to discard and record these on the Rules Form in the Workbook. For example, items not used in the past year and those with more than one copy could be discarded. Another example is to get rid of all items of clothing and jewelry that are not flattering. Because recycling, selling, and giving away items is easier for many clients than discarding, it is wise to have rules for these categories as well, especially when clients overestimate what can be sold or recycled. Clinicians can help clients obtain their community’s recycling specifications and review these to encourage compliance. Some clients want to sell or give away items that are not acceptable for this purpose or would require tremendous time and effort to clean or repair. General definitions or rules will be helpful in such cases. Cognitive therapy methods from Chapter 10 such as Socratic questioning and taking another perspective may help clients recognize what items would or would not qualify.

Combining Thought Listing and Sorting at Home Discarding exercises in the home should mimic the work done at the office. Clients will need some assistance in planning and doing Thought Listing at home, particularly in deciding where to start. Help clients develop a hierarchy of increasingly difficult discarding situations at home. For example, discarding papers with unidentified phone numbers may be easier for a client, whereas getting rid of newspapers is harder. Help clients create their own list of types of items and locations in the home, ordered from easier to harder ones. This need not be a formal list but serves as a general plan for structuring Thought Listing Exercises at home. Remind clients that they will undoubtedly experience some discomfort while they make these decisions, and the intent is to gradually increase their tolerance for making decisions and getting rid of items. To make progress, clients must learn to tolerate some discomfort, because discarding things that cause little or no discomfort will not help them reduce anxiety and learn new skills to prevent future hoarding. Discarding exercises at home should be combined with organizing skills learned in Chapter 8. Begin in areas and with objects that are relatively

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low on the discomfort hierarchy. Proceed with the following general steps to integrate organizing with decisions about discarding. ■

Select the target area.

■

Determine the types of possessions in the target area and eventual storage locations for items that will be saved.

■

Assemble the necessary organizing materials to facilitate moving the items.

■

Determine which items will be easiest and which ones will be hardest.

■

Select a type of possession to begin with (e.g., clothing, newspapers).

■

Do the Thought Listing Exercise with the first possession.

■

Speed up the Thought Listing Exercise by omitting habituation ratings for subsequent possessions.

■

Use categories and filing systems created earlier to select interim and final locations for saved items.

■

Allow a temporary “undecided” category when clients are unable to decide and place those items in a designated location for later decision making.

■

Continue until the target area is clear.

■

Plan the appropriate use of cleared target area immediately.

■

Plan how to prevent new clutter to this area.

As skill in decision-making improves, discomfort gradually habituates and progress increases. But progress is rarely entirely smooth, and many clients, especially those with traumatic histories connected to their hoarding, move forward in fits and starts. Be patient and look for incremental progress you can highlight when clients become discouraged by the slow pace. Emphasize the goals of making decisions, organizing possessions, creating living space, and the necessity for experiencing some discomfort to make progress. The exercises outlined below can help to speed up the process.

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Behavioral Experiments Behavioral experiments provide a more targeted version of the Thought Listing exercise with the added feature of testing a hypothesis or belief. As noted earlier, the testing of beliefs is often about the severity of client’s discomfort while trying to get rid of or not acquire an item. Here we use experiments to test various beliefs that support clients’ hoarding. We suggest using the Behavioral Experiment Form from the Workbook for each experiment. An example is given below. Clients first state the context and record in writing their hypothesis about what will happen and then rate the strength of belief and initial discomfort. After the experiment, clients record what actually happened and their actual discomfort. Then, they state whether their prediction came true, how they explain what happened, and their conclusion about whether their

Example of Completed Behavioral Experiment Form Initials MS

Date 12/05/13

1. Behavioral experiment to be completed: Getting rid of piles of clutter around my bed 2. What do you predict (are afraid) will happen? I will feel more unsafe and vulnerable and I won’t be able to tolerate it. I might be more likely to have a break in or assault. 3. How strongly do you believe this will happen (0-100%) 70% feeling more vulnerable; 35% more likely to have break in/assault. 4. Initial discomfort (0–100) 60% 5. What actually happened? No one broke in and I wasn’t hurt. I did feel more vulnerable but that only lasted 2 nights after I got rid of the piles around my bed. It was also easier to move around my bedroom so it took less time to get ready in the morning . 6. Final discomfort (0–100) 20% 7. Did your predictions come true? No, they didn’t and I felt better than I expected 8. What conclusions do you draw from this experiment? That some of my fears aren’t really valid. I was just too afraid to try it out. I’m safer than I think in this apartment.

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original belief was correct. Obviously, this experiment is intended for situations in which you believe there is a high likelihood that clients will learn that dire predictions do not come to pass and that their beliefs are mistaken. Behavioral experiments can be used throughout the therapy to test and modify clients’ thinking. A video located at www.ocfoundation.org/hoarding/videos.aspx provides an example of the use of the downward arrow during a behavioral experiment by Dr. Frost with a client who is working on discarding.

Complications With Behavioral Experiments Beliefs and behavior patterns in hoarding are notoriously rigid and resistant to change. Behavioral experiments allow clients to “try on” new behaviors or beliefs without having to give up their old ones. Because these patterns are so persistent, clients sometimes alter behavioral experiments to avoid discomfort. For example, a client may go shopping just before a non-shopping exposure is planned. One of our clients arranged for a friend to rescue an object she was supposed to discard as part of an experiment to test her beliefs about waste. Thus, as much as possible, clinicians should anticipate these complications and plan accordingly. When such events happen, they can be used as valuable learning experiences—for example, by examining how much the fear of wasting something has control over the client’s mood and behavior.

Imagined Discarding We have previously described visualization techniques that are useful in planning treatment (see Chapter  6). Some additional imagery exercises can be effective when clients are too fearful to begin decision making and discarding and especially when they have fears of catastrophic outcomes (e.g., house destroyed) or believe in unrealistic possibilities. The methods given below require that your client be able to form clear images and to feel the emotions associated with the images. Imagined exposures should be followed with actual exposures as soon as feasible.

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Using Imagery Before Actual Discarding As for other anxiety disorders, prolonged imagined exposures can help hoarding clients prepare for direct exposures they fear and avoid. Use this strategy when clients are reluctant to engage in discarding tasks or have been unable to complete homework, usually because they fear some catastrophic outcome from sorting and discarding. Begin by asking clients to close their eyes and imagine the feared situation. Ask them to describe the situation using the first person (e.g., “I am sitting in my living room in front of a pile of newspapers. . .”). Ask them to provide sensory and especially visual details to help make the image as clear as possible. Inquire about the client’s thoughts and emotions in reaction to the context and then gradually move the action forward so the client imagines the most unpleasant aspects of the scenario and dwells on these. Guide the imagery, asking clients to describe the details and report regularly on their thoughts, feelings, and actions. Include feared outcomes such as finding that a discarded item is desperately needed. Ask clients to rate their discomfort every 5 to 10 minutes and continue the scene until discomfort has declined noticeably, preferably by half of its peak amount. This may take up to 45 minutes or more for the initial scene.

Imagined Loss of Possessions Imagery exposures may be useful when clients have strong fears of losing their things through a catastrophe (to fire, flood, etc.). They also help clients decide the relative value of objects they own. Ask clients to imagine that their home will be destroyed soon by a forest fire, an earthquake or a flood and that they have a short window of time in which emergency personnel will allow them to remove a few personal belongings before they leave. Keep the time period long enough to allow them access to several important items but short enough that they cannot save unimportant things. What would they save if only 1minute were left and what else would they save if they had 5 minutes? What about 15 minutes? Paint this picture with sensory details, thoughts, emotions, and actions. Clients can do this exercise in the office or as a homework assignment. Ask them how they would cope if they actually lost everything they

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owned (an analogy to a recent disaster in the news may be useful, so clients imagine themselves in the place of people who have lost their homes to fire, tornado, or other cause of complete destruction). What would they mourn most? What would be okay to lose? Ask what is lost and also what they still retain without the objects (e.g., memories, capacities, family, and friends). Use the exercise to help clients establish priorities regarding the value and importance of items. This imagined exercise can be used in conjunction with the Defining Importance and Value cognitive strategy described in Chapter 7 on acquiring and also in the next chapter.

Imagined Exposure to Lost Information A consistent theme in trying to remove newspapers and magazines is the belief that they contain interesting or useful information that should not be discarded. In this case, ask clients to imagine all the newspapers and magazines in the world and all the information and potential opportunities they contain. Have them try to picture all of the newspapers in the United States they have not yet read. Of course, even for a single day, this would mean many thousands of newspapers produced in cities and towns across the United States that would fill a very large space. Related imagined exposure can focus on the number of lectures they have missed or other informational venues they have not accessed (e.g., internet information) if these are pertinent to their saving efforts. After discomfort habituates to the relevant scene, plan actual visits to newsstands or magazine shops as homework.

Needing Objects in Sight When the sight of a possession evokes strong emotions and memories that increase its perceived value, ask clients to distance themselves physically and temporally from the item and then get rid of it. Suggest that clients give the item to a friend or to you to hold for 1 week or more if needed. At the end of the time period, clients decide whether to keep or dispose of the item without seeing it again. The initial hypothesis is that the client will be unable to part with the object without careful

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scrutiny, and the final conclusion is hopefully that they find it easier to get rid of things that are not in sight, suggesting that they attach importance to objects they see that is disproportionate to its actual value. It is important subsequently to shape client’s behavior so they can eventually discard objects that are in sight.

Influence on Your Life Experiment Many hoarding clients express the belief that they could not live without some of the things they have collected. Suggest an experiment to test whether not having a newspaper truly influences their life. Help the client select a paper he or she believes to be important and give it to you for the duration of the experiment. Have the client then keep track of how not having the paper affects his life during the coming week—for example, the ability to eat, sleep, work, exercise, even to get the news from other sources. Also have him/her note whether any situation arises in which the paper was needed and whether he/she was able to cope with this. Feelings that occur without the paper (fearful, vulnerable, depressed, etc.) are also recorded. The client’s stated hypothesis will likely prove untrue as he/she forgets about the paper within a day, ends up not needing it during the week, and feels less interested in it at the next session.

Extensive Cleanouts We do not usually recommend cleanouts in hoarding cases (except in very rare cases where this is established to be essential for health and safety reasons). Forced cleanouts temporarily change the living situation but not the problem behavior. Cooperation and motivation for seeking help will be seriously impaired after forced cleanouts that are invariably traumatic. However, within the context of therapy, cleanouts can be effective if they are timed and structured properly with the client’s full cooperation. In our experience cleanouts work best when the volume of clutter is simply too large for clients to manage easily and a substantial portion of

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the material is destined for the trash or recycle rather than for donation or sale. A well-timed and planned cleanout can result in rapid improvement that is followed by renewed effort and sustained reduction in clutter. Clients must first have practiced discarding extensively so they can make decisions quickly and with limited discomfort and have established written rules for what to keep and what to remove. The timing and planning of cleanouts are crucial, as holding a cleanout before the client is ready can create frustration for everyone and set back the course of treatment. Typically, cleanouts are daylong affairs in which carefully chosen helpers (e.g., family, friends, clinic staff, neighbors, student workers) are enlisted to help sort and remove clutter. These extended sessions expose clients to a variety of situations they typically avoid, such as allowing others into the home, letting others touch and even make decisions about items (following basic rules established by the client), making decisions quickly, and, of course, discarding. Cleanout sessions require advance planning to determine who will participate, establish the rules for discarding and keeping items, set ground rules for how volunteers will remove objects from the house, and determine the method of getting rid of unwanted items. Arrangements must be made to coordinate dumpster delivery and pick-up or other trash-hauling plans to ensure that discarded items are removed from the property on the same day to prevent clients from retrieving or searching through items again. In general, volunteers follow the client’s rules unless they encounter an item for which the decision is unclear. In that case, items are brought to the client who works directly with the clinician to make rapid decisions about those objects. As this process can be very challenging for clients, do not schedule it until the client feels ready and you or a trusted assistant are able to work closely with them during the process.

Homework The following homework assignments are suggestions, but clinicians can devise any strategy that fits well with what happened in the session.

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Generally it is a good idea to assign homework that is similar to what was done during the session to reinforce new knowledge and practice. In deciding on times and schedules, give careful thought to how long clients can work alone. Try to construct assignments so they generate useful information for the client regardless of the outcome. When clients fail to do the home assignment, do it improperly, or unforeseen events occur, be prepared to use the information provided by these problems as opportunities to learn more and to refine the practice assignments. Of course, successful homework outcomes (discomfort decreased, decisionmaking became easier) will increase clients’ willingness to continue in this vein. Make sure clients write down the assignment on their Personal Session Form so there is no confusion about the task. Here are some homework suggestions for clients:

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Repeat the Thought Listing Exercise with three items at home.

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Imagine getting rid of items before actually discarding/recycling them.

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List the items to be saved if the home would be demolished by a disaster soon.

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Conduct a planned Behavioral Experiment to test a specific hypothesis, especially about discomfort and consequences of letting go of possessions. Take home items to be saved from the Thought Listing Exercise and store them where they belong.

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Bring in additional items (e.g., photos, mail, items from a particular area) to office appointments for sorting and decision-making exposures.

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Make arrangements for trash removal and, in the case of a major cleanout, for dumpster delivery and removal.

Chapter 10 Cognitive Strategies

(Corresponds to Chapter 8 of the Workbook)

Materials Needed ■

Problematic Thinking Styles list

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Questions about Possessions

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Advantages-Disadvantages Worksheet

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Downward Arrow Form

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Thought Record Form

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Defining Importance and Value Scales

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Perfection Scale

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Help client identify errors in thinking

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Work with client to apply cognitive therapy techniques while practicing sorting and discarding

Outline

If you are not already familiar with the general application of cognitive therapy (CT), we recommend reading Cognitive therapy, 2nd Edition: Basics and beyond by Judith S. Beck and Aaron T. Beck (2011) and/or Adrian Wells’ (2011) Meta-cognitive therapy for anxiety and depression. The CT techniques included here are designed to help clients step back and take a different perspective on their hoarding

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problems during the process of sorting in the office or at home and making decisions about keeping or removing possessions. Chapter 7 described some cognitive strategies to address excessive acquiring in which curbing impulsive behavior is key. Included there were techniques such as evaluating advantages and disadvantages, changing problematic thinking styles, downward arrow, Socratic questioning, estimating probability and calculating outcomes, defining need versus want, and reviewing a list of questions about acquiring. Several of these cognitive therapy methods apply equally well to work on discarding and are described below, along with additional strategies to identify and modify core beliefs. Remember as you work through this chapter that cognitive strategies take time and cannot be rushed, as clients can only change their thinking at their own pace. Gradually, as they get the hang of using these methods, they will pick up speed, but the going will be slow and can seem painstaking during the initial phases of treatment. If clients do not seem to be gaining skill in decision making about discarding by using these methods, consider whether ambivalence is still a central problem and requires motivational interviewing.

Faulty Thinking Styles or Cognitive Errors As for acquiring, hoarding clients engage in problematic thinking styles in relation to decision making about discarding possessions. Identifying these patterns helps clients learn to avoid habitual mental traps. The Problematic Thinking Styles1 list in the Workbook will help clients notice these thinking errors when they occur during office and home sessions. Determining the particular category of thinking is less important than helping clients notice illogical patterns. ■

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All-or-nothing thinking: Black-and-white thinking exemplified by extreme words like “most,” “everything,” and “nothing,” often accompanying perfectionistic standards. Examples are “It seems like everything in this box is just so important.”

List is adapted from Burns, D. (1989) Feeling Good Handbook (New York: Morrow).

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Overgeneralization: Generalization from a single event to all situations, using words like “always” or “never.” Examples are “I will never find this if I move it” and “If I don’t keep this, I’ll always regret it.”

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Jumping to conclusions: Predicting negative outcomes without supporting facts, akin to catastrophizing (see below). An example is “You know I’ll need this just as soon as I decide to get rid of it.”

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Catastrophizing: Exaggerating the severity of possible outcomes— for example, “If I throw it away, I’ll go crazy thinking about it.”

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Discounting the positive: Positive experiences are not counted, as in the statement: “Creating a filing system isn’t really progress because there is so much more to do.”

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Emotional reasoning: Emotions are used rather than logic so feelings substitute for facts. For example, “If I feel uncomfortable about throwing this away, it means I should keep it.”

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Moral reasoning: “Should” statements (including “must, ought, have to”) accompanied by guilt and frustration and often driven by perfectionistic standards: “I have to keep this health information in case something happens to John.”

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Labeling: Attaching a negative label to oneself or others, such as “I can’t find my electric bill. I’m such an idiot” and “She’s just greedy and wants all my stuff.”

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Under- and overestimating: Underestimating the time to accomplish a task or one’s ability to cope or, conversely, overestimating one’s ability to complete a task or the emotional costs of doing so. For example, “I’ll be able to read those newspapers eventually.”

We recommend asking clients to review the list of thinking styles for homework and identify a few during the week for discussion in the next session. During sorting tasks comment on thinking errors you notice by asking clients which one it might be and referring to the list. Identify potential alternative thoughts by asking, “What’s another way of thinking about this?” If clients have trouble coming up with a replacement,

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then suggest one (e.g., “Even if I feel uncomfortable about getting rid of this, I might get used to it” when clients catastrophize about their likely reaction) and discuss. Replacement thoughts should be flexible ones that promote tolerance of some uncertainty.

Automatic Thoughts, Interpretations, Beliefs, and Core Beliefs Recall that during the assessment and in building the client’s hoarding model, you and your client identified relevant thoughts about the meaning of possessions from the Saving Cognitions Inventory, the List of Reasons for Saving, the Downward Arrow method, and/or by completing Thought Records during visualizing or while trying to discard. These cognitive elements included automatic thoughts (e.g., “Oh no, I need that!”) and interpretations or beliefs that justify hoarding behavior (such as, “I might never be able to find this again” or “It’d be wasteful to get rid of this”). These interpretations often contain cognitive errors as discussed above and beliefs typically concern one or more of the topics in Table 10.1. Core beliefs are more fundamental to the person’s self; they have a global, overgeneralized, and absolute quality and can usually be very simply stated. Often they are just negative labels the client applies to themselves. When activated, core beliefs drive clients’ interpretations of events and elicit powerful negative emotions. In some cases, core beliefs may also refer to other people. Not surprisingly, these beliefs derive from important early experiences in the person’s life. Examples are “I’m bad,” “I’m a failure,” “I’m inadequate,” “I’m unlovable,” “I’m unworthy,”

Table 10.1 Hoarding Beliefs Value of objects

Responsibility for objects

Objects representing personal identity

Responsibility to people

Objects representing safety

Usefulness, avoid waste

Need for objects

Confidence in memory

Ability to tolerate discomfort

Need for control over objects

Perfectionism

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“People can’t be trusted,” and “People are mean.” In addition to these negative core beliefs, many clients also have positive ones like “I’m capable,” “I’m a good person,” and “Other people mean well.” Your aim in using the cognitive strategies described here is to help clients strengthen core positive beliefs about themselves while examining and disputing the negatives ones. Of course, CT must always be based on the evidence from past experience and current understanding.

Cognitive Strategies The CT methods for hoarding described here are best used while clients are actively sorting, organizing, and getting rid of clutter. That is, interweave cognitive methods as they fit the context of skills training and behavioral practice. An important goal is to help clients to learn how to observe their own reactions and become aware of their thinking in hoarding contexts as a first step toward changing those reactions. Once you identify the important beliefs that maintain hoarding, you’ll want to help clients to evaluate their accuracy using the strategies described below. These methods are intended to promote rational alternative viewpoints that fit the facts and are more plausible to clients than the original interpretation. Keep in mind the alternative belief for which you are aiming, such as “I’ll be able to find the information if I need it” or “These are just things; they don’t represent me as a person” or “Putting things away where they belong means I can find them when I want to.” Below are a variety of strategies; select the ones that seem to best fit the context.

Questions About Possessions When hoarding clients consider a possession, they think mostly about the qualities that led them to save it but pay little or no attention to the consequences of that decision. The Questions for Acquiring in Chapter 7 and Questions about Possessions in Chapter 9 are good ways of helping clients consider reasons for not keeping an item. Make sure clients have completed these forms and have them handy for use.

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Advantages and Disadvantages People who hoard also tend to focus on the immediate costs associated with discarding something, while ignoring the costs of saving all these possessions and the benefits of getting rid of them. Examining the advantages and disadvantages of reducing clutter has been described in Chapter 5 on motivational interviewing; here it is applied to decisions about keeping or getting rid of possessions while clients are sorting (see Table  10.2). Help clients state the personal advantages of keeping an item, followed by the disadvantages. Use the Advantages-Disadvantages Worksheet from the Workbook (page 90). Table 10.2 Example of Completed Advantages-Disadvantages Worksheet Specify the item(s) under consideration: Newspapers Advantages (Benefits)

Disadvantages (Costs)

Of keeping/acquiring:

Of keeping/acquiring:

I’ll be well informed if I read them because they might contain important information

They take up a lot of space

I always have things to read

I feel inadequate because I haven’t read them They are a burden I always have to face

I can use them as packing material once I read them

It’s hard to clean the house around these piles and some floors are damaged I can’t find things I know are in the piles

Of getting rid of item:

Of getting rid of item:

I’ll have more space

I might miss important information if I get rid of them

I’ll have more freedom and won’t feel so obligated to them

I’ll feel guilty if I don’t read them all

I’ll have more time to read books or do other things The house will be cleaner and in better condition

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If clients overlook obvious advantages or disadvantages, then suggest some possibilities, but be careful not to overdo it to avoid triggering a defensive reaction. Notice that the disadvantages of keeping items are very similar to the advantages of getting rid of them and vice versa. After listing all the ideas, summarize the costs and benefits using an alternating approach. For example, “On the one hand, you like having all this information around you. It helps you feel well informed. But on the other hand, you also find that having so many newspapers is a burden and you feel guilty, you can’t find information you want and the house is dirtier and has less space for other things.” Avoid overemphasizing costs and just state the findings. Then, ask clients what conclusions they draw from this exercise. Reinforce conclusions in favor of change with mild agreement (“That makes sense to me too” or “I tend to agree with you”). Again, don’t overdo this as tentative clients may retreat and focus on the advantages of their current behavior and the disadvantages of change. When clients agree on the need to change (e.g., remove clutter), discuss explicit methods for doing so to cement plans for discarding. You can also remind clients of costs and benefits when they become fearful and ambivalent about getting rid of things. This will help them keep the entire picture and their goals in mind when the going gets rough. The advantages-disadvantages technique can be used for individual items (like a receipt) and for classes of items (all receipts in a particular envelope or past a certain date). Obviously, using the method for groups of similar items is most efficient but some clients may require work on several individual items before they can group them together to make a global decision. This technique also works well for fears about putting things out of sight while organizing and for adhering to perfectionistic standards. Keep in mind that asking about the costs of hoarding also elicits negative emotions and even depressive feelings that require sensitivity to avoid associating negative feelings with the therapy itself.

Downward Arrow The downward arrow method helps identify catastrophic fears, as well as strong or core beliefs and is often useful during visualization or exposure tasks. Label and describe this task as a cognitive technique that helps clarify thoughts and beliefs. For example, ask clients to select an

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item that would provoke moderate discomfort when they think about discarding it and list this on the Downward Arrow form. Ask how distressed (0–100) they feel about throwing this item away and continue with a series of repetitive questions after each response: ■

“What would that mean?”

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“If that happened, what would that mean?”

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“What would be the worst part about that?”

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“Would anything else happen?”

If clients give unrelated thoughts ask, “Do you have any other concerns about this?” Avoid pressure if clients don’t identify any deeper meanings—they may not be there and/or clients may not feel prepared to address them. After reaching the client’s bottom line (no further thoughts occur), connect the final belief or catastrophic fear to the original premise to help them understand their own assumptions. These steps are illustrated below for fears of putting items out of sight.

Case Vignette

Clinician: I’d like to use what we call a Downward Arrow method to understand your thoughts about moving this out of the living room. It helps us figure out your beliefs that get in the way of organizing things by putting them away. Let me start by asking what you think would happen if we move these papers into files in your file cabinet? Client: I might never find it again. Clinician: Okay, if you didn’t find it again, what would happen then? Client: I might lose important information I would never have again. Clinician: Why would this bother you? Client: I’m not sure, maybe I wouldn’t know something I needed to know, you know, about my health or something. Clinician: Uh-huh, if you did have a health problem and couldn’t find information about it here in your home, what would that mean? Client: I’d be unprepared for it.

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Clinician: What’s the worst part about that? Client: I could get really sick or die because I didn’t know what to do. Clinician: You’d get really sick and you might die. What would be the worst part of that? Client: Just that I’d be unprepared and sick. I can’t think of anything else. Clinician: Okay. I think what you are saying is that moving these papers out of your living room means you’d be unprepared and you’d get sick and die? Is that how you see it? Client: Well, that sounds a bit extreme. Clinician: Extreme? How so? [Letting the client make logical connections to solidify learning.] Client: You know, moving the papers won’t really make me sick or even unprepared because I’d have them, just not in here. And anyway, these papers might not help with whatever sickness I get. I suppose it doesn’t make a lot of sense to keep them here. Clinician: Okay. Are you sure? Client: Yeah, I’m sure. Clinician: Shall we move them? [Reinforcing small changes in thinking by encouraging corresponding behavior change as soon as possible.] Client: Yeah, I guess so. It’s still hard, though. Clinician: Yes, I’m sure it is. [Waiting to be sure client feels ready.] As you said, your behavior of keeping them here doesn’t make much logical sense. Shall we try moving them and see if you get used to it? Client: Okay. Because many clients are unaware of the presence of beliefs that drive their hoarding, clearly stating them makes them more accessible and easier to evaluate. The downward arrow procedure can be repeated several times until the beliefs become clear (e.g., “I’ll be stupid for not buying this”; “As soon as I get rid of it, something terrible will happen and I’ll need it”). Clinicians can then help clients examine the evidence for such beliefs using other cognitive strategies suggested below, such as

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determining where the idea might have originated (e.g., parental views, personal trauma), using Socratic questioning to evaluate the logic, and designing behavioral experiments.

Socratic Questioning to Examine the Evidence The Socratic questioning method involves asking clients a series of questions about their beliefs to clarify the logic they are using. The clinician’s main aim is to point out the obvious holes in clients’ reasoning by asking questions that highlight discrepancies in their assumptions. This method relies on open-ended but directive questions. The style of Socratic questioning is not forceful or argumentative and avoids phrases like “Yes, but. . .” and “. . ., right?” as these reflect efforts to convince clients rather than ask for clarification within their own belief system and potential alternative ways of appraising situations. Thus, like motivational interviewing, the questions are exploratory to help clients review the evidence they are using to draw their conclusions. Encourage clients to think of themselves as scientists or detectives and to state their beliefs in the form of hypotheses. For example: “You have been trying to keep everything in sight on the assumption that this helps you know where things are. Let’s call this a hypothesis, that ‘Keeping things in sight helps you remember them.’ Would you be willing to examine the truth of this hypothesis and see if there are any alternative viewpoints? For example, an alternative might be, ‘Keeping everything in sight makes it hard to find things.’ Then we can determine whether there is evidence to support either hypothesis.” Ask curiosity questions to elucidate ideas and rephrase clients’ statements in slightly different words to verify that they understand correctly. These questions are generally focused on the following:

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What evidence supports your hypothesis? Is there any evidence that doesn’t?

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Is there another way of looking at that?

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What is the most likely outcome?

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Are you using any thinking errors?

Here are some Socratic questions that might be useful for a client with fears about putting things out of sight.

Case Vignette

Client: I like to keep things where I can see them. That way, I don’t forget things that are important. Clinician: Okay, your idea is that if you have things in piles you can see in front of you, you won’t forget them and you can find them. [Client nods.] How long do important things actually stay in sight before being covered? Let’s take this paper here, it looks like a receipt. Is it important? Client: Yeah, I might need to return the item. Maybe it stays there a few days or a week. I do set things on top, I know. Clinician: So it’s visible for a few days but not much more. If you wanted to return it about 3 weeks from now, then do you think you would find it easily? Client: I’m not sure. I might. Clinician: [Rather than dispute the client’s statement, the clinician moves on.] This pile here seems to have a mixture of things. Are you able to remember everything in this pile? I think that was your goal, to put it in sight and remember it, yes? Client: Yeah, I do know some of what is in the pile, but maybe not everything. Clinician: So, if you wanted to be sure to find something, like the phone bills you were looking for the other day, is it best to put them in this pile when they come? Or is there a better place to put it? Client: I should keep them all together, probably on the desk. It’s a hassle though, you know. Clinician: Um, I think you are saying that putting the bill on the pile isn’t really the best way to remember that you have it or where you put it. Is that right? Client: Yeah, not really.

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Clinician: You also mentioned that you put things on the pile so you didn’t forget about them and I’m wondering what you think is the best way not to forget things. Maybe we could use an example like a bill you have to pay or an event you want to go to. What’s the best way to remember? Client: Oh, I put those on the fridge door, you know, then I see it. Clinician: So the pile isn’t the best place for things you really want to remember. What about a clipping you want to show me? Suppose you put this clipping on that pile and I come to your home 6 months from now and you want to show it to me. Client: Oh, it’d be buried by then. Clinician: Would you remember you had it or where it was? Client: I’d know I had it, but I might not be able to find it. Clinician: So you would remember it without actually seeing it. Maybe you don’t really need to see everything to remember it? Client: Yeah, probably true. Clinician: But remembering it doesn’t always help you find it after it goes on the pile. Let me ask another thing. Are you sometimes surprised to find things in the pile that you had forgotten about? Client: Oh yeah, just the other day . . . Clinician: So putting things on top of a pile so you can see it doesn’t always help you remember you have it later on? Client: I guess that’s true. Clinician: I think you are telling me that your original idea that putting things on the piles so you can see them doesn’t necessarily help you remember them or find them after some time has passed. You like to keep them in sight, and that makes you feel better but it doesn’t always help you find or remember them better. What do you think? Notice that the clinician restates the original hypothesis and conclusion but does not press the point too strongly to avoid triggering defensive reactions that entrench these beliefs. From here, the clinician can proceed to helping the client think about other ways to remember and

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find things, perhaps considering what other people she knows do. These methods require more time and effort, so that must also be explored, perhaps using the advantages and disadvantages method. Saving old newspapers is a very common hoarding trait. For this, the following Socratic questions and calculations of cost may be helpful: ■

“How long would it take you to read one newspaper like this one?”

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“How much time do you spend reading newspapers these days?”

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“I bet you and I could probably figure out how many papers you have now if we estimate from this pile here and multiply. [Showing the calculations] Looks like you’ve got about 1,200 papers. Let’s see, each paper takes you about 30 minutes to read and you read for about 2 hours a week. At that rate you can finish 4 papers a week, so divide 1200 by 4—it would take 300 weeks, about 6 years to catch up. But you are also getting new papers, 7 more every week. So reading 4 papers a week, you’d always be behind and the newspaper piles will just get bigger.”

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“If you doubled your reading time to 4 hours each week, then it would take only 3 years to read everything here, but you’d still have all the new papers. Let’s see now, if you read for 4 hours plus the additional 3.5 hours every week for new papers, that’s  7.5 hours per week to completely catch up in 3 years’ time. To catch up in 1 year, it’d take you 22 to 23 hours of reading every week, sort of like a half-time job. Is that how you want to spend your time?”

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“Do you like having piles of unread newspapers around you?” [Remember, this may actually be comforting to some people.]

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“I’m wondering what your day-to-day life would be like if you never read one of these older newspapers. Suppose you died some years from now and never read one? How much would it matter in your life?”

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“How does keeping these newspapers to read help you with the goals you had at the beginning of treatment?”

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If, in response to some of these questions, clients indicate clearly that they want to change the saving and reading of newspapers, then you could ask:  “What do you think you’d have to do to change this?” At this point, problem solving will be useful. If the problem is defined as having too many newspapers to read, then options might include stopping current newspapers and reducing time spent reading old ones. It can also be helpful to provide some personal feedback during Socratic questioning. For example: ■

“I actually don’t read my newspaper every day because sometimes, like you, I just don’t have time. Some days I only scan the headlines and some days I read just 2 or 3 stories, sometimes only parts of the stories. I only remember a little of what I’ve read, sometimes nothing at all after a few days have passed. Some days I don’t read it at all and just put it in the recycle bin. It seems wasteful, but my time is actually more important to me than the newspaper. How does this compare with your experience?”

Look for clients’ unrealistic and perhaps perfectionistic expectations that they are inadequate if they don’t read everything and remember it. These attitudes can be challenged with some of the strategies below.

Taking Another Perspective Most cognitive strategies are designed to help clients step back from the immediate situation and examine it from a different angle. Taking another perspective and taking the opposite position can help them develop alternative views. Using a model of a same sex friend, family member, or child can make the analogy more relevant. The following questions may be useful:

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Would this also be true for one of your friends?

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Do you think your sister [brother] would agree with you?

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Is this something you would want to teach your daughter [son]?

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Would you recommend to me that I do (think) that? Why? Why not?

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What would you say to a friend or loved one who told you this?

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If you were being very kind to yourself, what would you tell yourself?

Another method is for the clinician to take the opposite perspective, trying to convince the client to keep an item while the client practices arguing against keeping it. Use this strategy to help clients who are making progress getting rid of things but need to strengthen their resolve. Ask clients to select one or two items they are considering discarding. Then give arguments for keeping the item using reasons for saving the client has expressed before. Here’s an example with a stuffed animal.

Case Vignette

Clinician: Let’s try out a strategy where I try to talk you into keeping something while you convince me you should get rid of it. This will help you take a different perspective and I think it will help you become more confident of your decisions. Shall we try this? Client: Okay, I’m willing to try. Clinician: Great. So remember—I try to talk you into keeping it and you tell me why not. How about we use this stuffed bunny you brought? Client: That’s fine. Clinician: Here we go. [Pause] But this is so pretty and you like furry things! Client: Yes, I do but I already have as many as I want. Besides, this one isn’t as nice as the ones I already have. Clinician: Well, you could keep this so the neighborhood kids would have something to play with at your house. Client: I could, but they already have lots of toys. Clinician: You could save this for one of your grandchildren when you have them. Client: Uh oh, I can’t think of why I wouldn’t want to do that. Clinician: Well, let’s look at some of the questions on your list to see if these help you make an argument that convinces you. Client: Okay. . .Here’s one. It will waste my time and take up space I want for other things. It’ll be in my way and just be one more thing to deal with. Besides, it really isn’t that nice a toy anymore—it’s sort of ugly.

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Clinician: But wouldn’t you be hurting its feelings? Client: . . .You almost got me there. . .No, this is just a pile of stuffed fake fur that’s not even pretty. It doesn’t have feelings. I’m getting rid of it now. Clinician: You did a great job on these with very little help. Is there anything I left out that would have swayed you?

Thought Records In Chapter  4 we suggested using the Brief Thought Record form to help your clients understand the connection between triggering events, thoughts, emotions, and behaviors. During sorting and discarding practice, help clients gradually change their thinking by adding two more steps to the Thought Record in which they (1) identify alternative thoughts or interpretations that make more sense to them and (2) record the outcome after doing this. An example is provided in Below form based on the Brief Thought Record example from Chapter 4. Ask your client to record their saving-related thoughts and emotions, as well as rational alternatives and outcomes using the expanded Thought Record forms in the Workbook. Clients can come up with alternative beliefs by using any of the CT methods suggested here (questions about possessions, advantages/disadvantages, downward arrow, examining the evidence, taking another perspective). We suggest assigning Thought Records at home when clients become stuck on a particular item that provokes strong feelings. Recording the item, their thoughts, emotions, alternative beliefs, and outcome helps clients concretize the process of deliberately generating alternative ideas to counter usual thought patterns while sorting. We recommend assigning only one or two Thought Records per sorting session for cases of difficult decisions.

Defining Importance: Need Versus Want Thinking styles of magnifying, overgeneralizing, and emotional reasoning lead clients to magnify the importance of possessions to such a point that it seems crucial to save them. To help clarify the true value of a possession based on personal goals and rational thinking requires clients

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Example of Completed Thought Record Initials: PK Trigger situation

Date: 11/30/13 Thoughts about Meaning of Possessions

Emotions

Rational Alternative

Outcome

Sorting stuff on kitchen table, found some old financial forms

I might need these for taxes or something else. I’m afraid to throw them out.

Anxious

These papers are just old utility receipts from more than 7 years ago. I don’t need them for taxes, and even if I did, I could get the information from the utility provider.

Put them in the recycle bin

Found some old magazines

I should read these. There might be something important in them.

Anxious

These are 7 years old and really out of date. Anything important can be found online.

Put pile into the recycle bin.

Somebody could use them. I could give them to my neighbor, she likes this kind of magazine.

Guilty that I haven’t read them.

My neighbor doesn’t want or need old magazines just because I feel guilty. Enough!

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to distinguish what they truly need from what they merely want. The Defining Importance and Value Scales form from the Workbook serves this purpose. Ask clients to select a current possession that would be moderately difficult but appropriate to discard. If clients select items that the clinician believes are reasonable to keep, then ask them to choose another that most people would probably discard. Ask clients for an initial rating of need and want using the scales from 0 to 10 below. Then, review the questions on the worksheet and given below to see whether clients alter their ratings after thinking through the true value of possessions in relation to their other important goals in life. Ask clients to reflect on what they have learned from this exercise and to make a decision about keeping or getting rid of the item. Need Scale 0 ------- 1 ------- 2 ------- 3 ------- 4 ------- 5 ------- 6 ------- 7 ------- 8 ------- 9 -------10 No need

Required to survive Want Scale

0------- 1 ------- 2 ------- 3 ------- 4 ------- 5 ------- 6 ------- 7 -------8 -------9 ------- 10 Don’t want

Desperate for

Questions to evaluate importance and value of objects ■

Would you die without it?

■

Would your safety be impaired without it?

■

Would your health be jeopardized without it?

■

Must you have this for your work?

■

Do you need it for financial purposes? (e.g., tax or insurance records)

■

Is there some other reason why you need the item?

■

To what extent do you want the item more than you actually need it?

Perfectionism Continuum Especially useful for patients with dichotomous and perfectionistic thinking is a discussion of the continuum of perfection. Ask clients

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to indicate how perfect a decision or action needs to be using the scale below. Perfection Scale 0 ------- 1 ------- 2 ------- 3 ------- 4 ------- 5 ------- 6 ------- 7 ------- 8 ------- 9 ------- 10 Defective Wrong

Average Okay

Perfect Exactly Right

Review the consequences for clients of trying to do something perfectly, using various activities, including some they must do perfectly (give object to the right person, set up a file system) and some that don’t involve perfectionism (watching the sunset, listening to music, eating breakfast). Ask clients to report how much enjoyment they experience (or would experience) from each. Once clients understand the potential advantages of being less perfectionistic, devise a homework experiment to test the hypothesis that they will enjoy something and/or accomplish more if they make only a good effort rather than a perfect effort.

Metaphors and Stories Clinicians may also find that metaphors and stories convey helpful information that is easily understood. As with other cognitive strategies, the aim is to permit clients to step outside themselves and examine their situation from another perspective. Metaphors or stories can be simple or elaborate. Here are a few examples: “A man who was very concerned about mistakes found that as time went by, he could no longer tolerate ordinary mistakes at work, so he was forced to quit working. Before long he could not tolerate what he believed to be mistakes in his driving, even though he had never had an accident or even come close. He quit driving. Soon he became worried about the mistakes he made when trying to cook in his kitchen. He quit going into his kitchen. Then he couldn’t tolerate the mistakes he made in walking down the stairs. He stayed upstairs. Finally, every action seemed fraught with potential mistakes. He quit moving. He died a perfect man who never made mistakes.”

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Ask clients to consider the effects of working for a coach or a boss who has very rigid standards compared to one with a more forgiving and informative style who explains what was wrong and asks for improved behavior. This is especially effective when the coach is a powerful adult and the player is a child because clients can easily see that children respond best to suggestions and corrections given in a supportive and encouraging style, rather than rigid rules delivered with harsh criticism and negative labeling (“How can you be so stupid?”). Most clients can easily apply this metaphor to the effects of their own strict rules and self-statements on their emotions, thinking, and behaviors. When clients’ perfectionism centers on memory or knowing information, consider comparing people who want to know or keep everything perfectly to librarians or museum curators. Explore the consequences of having to store all kinds of details in their head or keep everything just so. Compare this to just knowing where to look up information to find what is needed. Consider using this next story to generate a discussion of the necessity of giving up opportunities. One woman felt compelled to take advantage of every opportunity to learn. Whenever she saw a magazine or newspaper that looked interesting, she just had to get it. If a lecture was announced, she had to attend, lest she would miss new information. This compulsion got so bad that one day she was found standing in front of a newsstand unable to move. All she could think about was all the newspapers and magazines in front of her that were too numerous to buy and too full of information to read everything. She couldn’t decide which ones to buy and which ones to “lose.” When progress in treatment seems slow, especially if family members are pressing for more rapid change, a metaphor that may be helpful is to suggest that change in very cluttered homes is like losing weight on a sensible diet. The change is not immediately evident but the person feels better and has more energy, although the change in body weight is hard to notice for those who see the person every day. Someone who has not visited for a few months will see the weight reduction immediately.

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Valuing Time This exercise asks clients to evaluate how they use time rather than just focusing on possessions. Many hoarding clients have elaborate plans for what they are going to do with their things “when I can find the time.” But they never seem to find enough time. In most cases, clients seriously underestimate the time required to deal with possessions and overestimate their capability. We have mentioned this problem earlier in calculating how long it would take clients to read all of their collected newspapers. This calculation can begin a discussion about how they WANT to spend their time: ■

“Do you want to spend that much time every day reading old newspapers?”

■

“What other parts of your life will you miss by doing so?”

■

“How does this fit with your values and goals? Let’s look back at those now.”

Assigning a “time value” to possessions might offer a new way of thinking about them. For example, a piece of junk mail might be given a value of 3 minutes if that is how long it takes the client to read and discard it. The time value would go higher if it is saved for further consideration at a later time.

Uncovering Core Beliefs and Finding Alternatives Downward arrow and Socratic questioning can also be used to uncover the core beliefs and link them to the faulty thinking that results in collecting and saving. Socratic questions that help clients review the evidence for core beliefs, take another perspective, and evaluate the labels they have given themselves (e.g., inadequate, stupid) can be used to guide clients toward alternative non-rigid views of themselves. For a detailed review of these strategies, see Wilhelm and Steketee (2006) Chapter 13.

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Homework The following cognitive methods can be assigned as homework:

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■

Review the List of Thinking Styles to identify some that occur during the intervening week. Identify alternative thinking that avoids the error.

■

Apply the Questions about Possessions while sorting.

■

Complete Thought Records and/or a Downward Arrow form to identify beliefs associated with letting go of possessions.

■

Use Thought Records to evaluate the accuracy of current reasons for saving and consider alternative ones.

■

Practice the specific cognitive strategies that seemed to work best (e.g., questions about possessions, advantages/disadvantages, downward arrow, examining the evidence, taking another perspective).

■

Use the Importance (Need vs. Want) and Perfectionism Scales during sorting at home when decision making seems difficult.

■

Write down the metaphors or stories that seemed most helpful and post these in home locations where the reminder will be helpful.

■

Calculate the time cost associated with keeping objects.

Chapter 11 Complications in the Treatment of Hoarding Disorder

Hoarding often involves a host of other problems that can complicate treatment. It is important to anticipate the range of such difficulties that your client will be facing. This chapter reviews the most frequent kinds of complicating factors in hoarding disorder. Other resources that may be helpful in addressing these problems include Bratiotis, Schmalisch, and Steketee’s (2011) The Hoarding Handbook: A Guide for Human Service Professionals. Designed for a variety of health and mental health professionals, this book provides an in-depth review of many of the issues noted in this chapter.

Health and Medical Concerns People with HD are often overweight and in relatively poor physical health, including a broad range of chronic and severe medical conditions (Tolin et al., 2008a). Among the most common are arthritis and joint problems, high blood pressure, asthma, diabetes, and autoimmune disorders. These problems may create difficulties in accomplishing treatment activities and require special assistance. Clients may be unable to lift and move heavy objects. Medical conditions may also result in hazardous material in the home. For example, one of our clients required home dialysis and had kept hundreds of used dialysis bags that were never returned to the medical clinic. Saving of such hazardous waste products may require special intervention. In addition, a variety of problems with the physical environment in the home may impact health and need immediate attention. These include mold, insect infestation, spoiled food, and pathogens from lack of sanitation. Because of fears of allowing others into the home, people

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with HD sometimes live without electricity, heat, and plumbing, with accompanying contributions to unhealthy and/or unsanitary conditions in the home. Because people with hoarding may be somewhat isolated, you may be the only person to know about these conditions. A thorough assessment of health complications and level of sanitation in the home is important. Keep in mind that serious health and sanitation problems may trigger inspection by the local health department and potential citations for code violations. Typically, health departments give people a specified amount of time to correct code violations, but they usually offer little in the way of advice or resources unless they are part of a hoarding task force within the community that is able to marshal resources to assist people with hoarding problems. When health departments are involved, it is advisable to be in direct communication with the health officer to help the client correct the problem. This will require the client’s written consent to communicate with other authorities. In discussing this, be sure to find out what information your client feels comfortable allowing you to share and what should remain confidential within your clinician–client relationship. This issue of consent and confidentiality will apply to other service providers discussed below.

Financial Needs Financial strains are inevitable in most hoarding cases. Some research suggests that people with HD have lower incomes, but findings are not consistent (Steketee & Frost, 2013). Regardless of income, certain aspects of hoarding create problems in managing finances and may need attention from a therapist. Paying bills on time can be difficult because bills become lost in the piles and scattered throughout the house. Even when money is not a problem, there may be angry creditors who have not been paid. Storing and managing paperwork for things like taxes, insurance, credit cards, and assets (e.g., house, auto, investments) can be a significant challenge. When this material is not readily accessible, it can lead to emergencies that interrupt treatment and cause further financial problems (late or unpaid taxes and bills with expensive penalties and even legal consequences). If these are issues for your client, then be sure that the organizing systems developed during treatment will enable them to solve some of these problems as quickly as possible.

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In addition, you may need to identify special resources to assist clients with financial management related to their hoarding. If there is a local hoarding task force in your area, then this group may be able to recommend financial resources for clients.

Family Behaviors Family members of people with HD may suffer considerable burden. If they lived with a hoarding parent while growing up, then they report elevated distress in childhood, including less happiness, difficulty making friends, fewer social contacts in the home, embarrassment about living conditions, and increased family strain. Even if they didn’t grow up in a hoarded home, they experience considerable frustration in attempts to get aging parents to declutter. In general, family members of people with HD express high levels of hostility toward and rejection of their hoarding family member (Tolin et al., 2008b). These attitudes are understandable in the context of often decades of conflict over the hoarding behavior. Because of this intense and long-standing conflict, it is difficult for family members to interact with their hoarding loved one about the hoarding. When considering including family members as helpers, it is important to explore these issues ahead of time and to determine whether they will be able to contribute in a manner that is consistent with a therapeutic approach. A second issue is whether other family members suffer from hoarding disorder as well. As noted in Chapter 1, hoarding seems to run in families, and growing evidence supports a genetic connection. This means that having someone else in the family who engages in (and likely condones) hoarding behavior is not uncommon. When this situation arises, more care and planning are needed for treatment because your client’s decisions to discard things might trigger concern by other family members. Whether the concern is about family burden or familial patterns of hoarding, the Family Response to Hoarding Scale (FRHS; Steketee, Ayers, Umbach, Tolin, & Frost, under review) may be a useful way to measure the extent of relationship disruption and facilitation of hoarding behaviors. Tested in an Internet study of more than 400 family participants,

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this 16-item scale (see Appendix) produced two subscales:  Behavior Changes (e.g., making decisions, keeping things, surreptitious discarding, helping acquire, taking over responsibilities) and adverse Personal Consequences with regard to threats to health, hygiene, distress, and family relationships. Scores on the total scale and for the two subscales are given in the table below: Family Response to Hoarding Scale (FRHS) for 400 family members

Meanscore

Standard deviation

Range

15.0

10.4

0–53

Behavior Change

6.0

5.9

0–27

Consequences

6.9

4.2

0–20

Total score

Not surprisingly, more severe hoarding and clutter was associated with worse personal consequences for family members. In addition, family members who reported having hoarding symptoms themselves were more tolerant and more facilitating of their relative’s hoarding behaviors, suggesting that special efforts to reduce family facilitating behaviors are likely to be needed when family members share similar tendencies. Whether family members are affected by hoarding or participate in this behavior, presuming your client agrees, plan a family meeting to engage those living in the household or in frequent contact with their relative in a discussion of hoarding treatment planning. Discussion treatment expectations and the need for your client to learn to make independent decisions will help set the stage for greater family support for (and possibly helpful participation in) the process.

Housing Concerns People with HD often find themselves in conflict with landlords over the condition of their home. Here the severity of hoarding and potential consequences must be weighed against individual privacy rights. Landlords have a right to inspect and a responsibility to ensure that living conditions meet codes and standards set by the community. This can create an adversarial relationship between landlords and hoarding clients and increase the likelihood of eviction. In fact, a recent study indicated that nearly one quarter of clients at an eviction intervention service in

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New York City had HD (Rodriguez et al., 2012). Eviction proceedings sometimes bring clients into treatment, whether voluntarily or mandated by the court, and this situation is likely to increase in frequency with recognition of hoarding as a mental disorder. Pressure from landlords may provide additional motivation to work at therapy, or it may create stress that interferes with clients’ ability to work on their hoarding. In either case, your role as therapist may necessitate communication with a landlord to forestall eviction while therapy progresses or to smooth the process of finding alternative housing. Again, these circumstances raise issues related to confidentiality and must be handled carefully.

Safety Issues The news media often report stories of people with HD who have suffered serious injury or even death resulting from clutter. We recommend using the Safety Questions in Chapter 3 to quickly assess the level of concern early in the treatment process. In some cases, clients have fallen or been buried under an avalanche of piled clutter. As falling is much more dangerous for elderly hoarding clients, if your client is older or suffers mobility problems, then be especially alert to this risk in planning the work on clutter. Perhaps the most dangerous threat posed by hoarding is the increased risk of fire. In a review of 10 years’ worth of residential house fires in the state of Victoria in Australia, less than one-fourth of 1% of fires involved hoarding, but hoarding fires accounted for 24% of fire-related deaths. The conditions to look for in hoarding cases are flammable materials (e.g., papers, clothing, etc.) near sources of heat (e.g., furnace, radiator, stove, overloaded outlets). In addition, blocked exits and rooms that can’t be traversed quickly add to the danger. Sometimes these safety concerns necessitate moving possessions away from heat sources, windows, and doors before starting on attempts to clear clutter.

Endangerment of Children and Elders Most states mandate that mental health clinicians must report conditions in the home that might threaten the health or safety of children or elders. Reviewing your state’s laws regarding mandated reporting is a

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necessity to ensure compliance with these laws and your ability to provide your client with effective treatment. The decision regarding what constitutes a serious threat can be difficult. The assessment methods described in Chapter  3 will be helpful in making that determination. For clients who have had children or elders removed from the home, close consultation with the authorities may be needed to secure return of the loved ones when it is safe to do so. Again, the presence of such authorities in an HD case can facilitate motivation for change or create undue stress that interferes with treatment. Working closely with the case manager or social worker in the oversight agency (e.g., child protective services) will increase the chances of a positive outcome.

Problems With Animal Care Although we have noted that this therapist guide is designed to treat people who hoard objects and not animals, the presence of even one animal in a hoarded home can sometimes cause major difficulties. If your client has any pets, then determine how well they are able to care for them. Are they able to walk them or let them out regularly? Do the pets urinate or defecate inside the home? If needed, work with your client to devise a plan for how to best care for pets during the course of therapy while the home is still cluttered. Temporary placement outside the home might make sense in some situations.

Comorbidity Depression As we have noted, up to half of people with serious hoarding problems also experience major depression. Sometimes depression can be quite severe, involving poor appetite, sleeping problems, and low motivation to do almost anything. This is especially likely for someone who has suffered recent losses (e.g., family death or departure, loss of a job, health-related disability). If clients exhibit depression (e.g., poor appetite, sleeping problems, low energy), and especially if they report significant suicidal ideation (fortunately, this is rare in our clinical experience

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so far), then clinicians may wish to request an additional psychiatric evaluation. In most cases, moderate depression will resolve as the clutter and hoarding behaviors improve. Clients may also benefit from antidepressant medications or from cognitive behavioral therapy for depression. You can advise clients that one way of coping with depression is to increase activity such as exercise and social activities. Getting started with this is difficult but is often very effective in improving mood, though this may take some time. Note that the activities required during this treatment program may also have a beneficial effect on mood, but initially clients may need to force themselves to do things until their mood improves as they make progress. You may need to soft-pedal praise for tasks accomplished early in treatment, as depression may interfere with clients’ ability to accept overly positive comments. When this is not a problem, strong encouragement for activity scheduling may helpful.

Anxiety and Worry As noted in Chapter  1, about one-fourth to one-third of people with HD also exhibit symptoms of generalized anxiety disorder (GAD). This is most likely to be manifest in worrying about many life concerns, and also in worrying about bad consequences happening if desired items are not acquired or discarded. It is not clear that the presence of GAD needs to alter your treatment for hoarding as outlined in this manual, as we did not find that GAD symptoms had an influence on immediate or longer term therapy outcomes (Muroff et al., under review). We recommend continuing with standard methods outlined here as these behavioral and cognitive strategies will also be relevant to anxiety and worry symptoms.

Social Anxiety and Autism Spectrum Disorders Problems with social relationships are not uncommon among people with hoarding disorder and may account for what appears to be a lower marriage rate and social support network for this group of people. Social

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phobia is found among about 25% of people with HD. Hoarding is also found among people diagnosed with autism spectrum disorder (ASD), but it is not yet clear how often hoarding behavior is simply a manifestation of a narrowed focus of attention and interests often seen in ASD or whether it is a separate mental health condition or perhaps related to other problems such as OCD or ADHD (see Pertusa et al., 2012). Regardless of the possible connection to hoarding, it is likely that individuals with either social phobia or ASD will have a difficult time allowing other people into their homes. This may make it more difficult to plan to use others (including coaches, other human service professionals, family members, etc.) to accompany clients on non-shopping trips or to assist them within the home in sorting and discarding efforts. If these conditions are evident, then take care to ensure that your client agrees with bringing others into the home, and choose these assistants carefully, providing training as needed to maximize the likelihood that these interventions will be helpful.

Obsessive Compulsive Disorder Symptoms A number of clients with hoarding disorder also have OCD symptoms, including contamination fears and washing or cleaning rituals, fears of making mistakes, and concomitant checking and reassurance rituals. In the case of contamination fears, decide whether additional work on this problem is needed before, during, or following work on hoarding. Contamination fears that interfere with progress on hoarding symptoms will require attention at the outset of therapy. Several manuals (see Readings and Resources) are available to help clinicians work on this problem. When OCD rituals are mild enough to address during hoarding treatment, clinicians can ask clients to minimize and eventually eliminate them. For example, one client agreed to reduce her excessive washing of items for her cupboards so she simply wiped them briefly and put them away. She agreed that after her sorting was completed, she would decide how much general cleaning was needed in her kitchen and that this would be much easier when all items were put away. Checking rituals are often inherently tied to hoarding fears as clients check papers, envelopes and other things to make sure they have not

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missed something. After discussing the problem and determining what “normal checking” would look like among friends or relatives, encourage clients to gradually reduce the time they take for this. Several sessions of sorting will probably be needed to practice minimizing checking and increase efficiency and speed. The Questions about Possessions, various cognitive strategies, and behavioral experiments to see if refraining from checking is tolerable can be useful here. Eventually, clients should establish formal rules to limit their checking behavior. Many clients avoid decision-making and assuage their fears of making mistakes by seeking reassurance from the clinician, family members, friends, coworkers, and others. It may be difficult to distinguish clients’ requests to clarify a treatment assignment or to decide about discarding an item from repetitive reassurance seeking that reduces discomfort. Problematic requests can usually be identified by their persistence. Clients repeat their question, often in several different forms, seeking to allay their anxiety rather than obtain new information. If in doubt, ask clients directly whether they already know the answer but felt anxious and obliged to verify by asking again. Inquire about their thoughts just before they asked to determine automatic thoughts and interpretations. Other cognitive strategies described in Chapter 10 may prove useful here, or simply arrive at an agreement about minimizing or eliminating requests for reassurance. Be sure to ask family and friends to follow the same rule. If clients do exhibit significant OCD symptoms, then plan to add specific interventions focused on exposure to feared situations or items, as well as blocking of cleaning, checking and ordering/arranging rituals, and altering beliefs about the rationale for these fears. These methods can be employed before hoarding treatment for those with severe OCD symptoms or during hoarding treatment for those with less interfering symptoms. For details regarding how to implement CBT for OCD symptoms, see Abramowitz’ (2006) guide entitled Obsessive Compulsive Disorder.

Attention Deficits Another problem associated with hoarding is distractibility or difficulty staying focused on any task, not just hoarding, and managing their time. Some clients recognize this in themselves, and may have received

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a diagnosis of attention deficit disorder with or without hyperactivity. Such problems with attention might be partly responsible for their hoarding problem. Review information collected during the assessment and refer to strategies suggested in Chapter 6 to work on this during treatment. The therapist guide Mastering your Adult ADHD (Safren et al., 2005) provides detailed interventions for ADHD problems.

Stealing Although rare, stealing does occur in approximately 10% of HD cases (Frost et al., 2011). For example, one of our clients felt slighted when store clerks did not engage with her socially, as they were her only source of social contact on most days. Her resulting anger led her to steal small items from the store. Recognizing the cause of her stealing helped her re-evaluate her interpretation of the clerk’s behavior and relieve her need to steal. Another client who was trying to curtail her excessive shopping stole following the thought that she could still acquire things and not worry about spending money. Of course, stealing is dangerous behavior, but criticizing clients who know this behavior is illegal and urging them to stop is unlikely to resolve the problem and may ruin your relationship with them. Rather, help clients analyze the sequence of events that lead to this behavior to develop a strategy for eliminating it. For those whose stealing is impulsive, it is sometimes effective to have them engage in a detailed visualization (much like those described in Chapter 6) of the consequences of their actions. For example, imagining having the police arrive, putting on the handcuffs, taking them to jail, calling their relatives, and so forth. In one such case, the image of having the grandchildren come to the police station to bail out the client was effective in eliminating a persistent stealing problem (Frost & Steketee, 2010).

Post-Traumatic Stress Disorder and Trauma History A number of studies have found greater trauma histories in people with HD (Frost et  al., 2011). Interestingly, however, the frequency of

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post-traumatic stress disorder (PTSD) is no higher in HD than in other mental health problems (e.g., OCD; Frost et  al., 2011). However, the existence and nature of trauma history can play a role in the course of treatment. For example, one of our hoarding clients made great progress on her hoarding until the focus of attention turned to the most cluttered room in which she was raped some years earlier. All progress on hoarding stopped, and symptoms of PTSD appeared. We turned our attention to treating her PTSD before returning to hoarding. Obtaining a trauma history is an important part of the assessment process prior to beginning therapy.

Cognitive Disabilities Hoarding also occurs among people with developmental disabilities who may show very similar symptoms to those described here. Training in basic skills for problem solving, organizing, and decision making, plus the addition of immediate reinforcement for non-hoarding behavior, are appropriate intervention strategies for this group. Similarly, behavioral methods in developing rules for acquiring and practicing non-shopping trips will be helpful, as will repeated practice sorting, organizing, and making decisions to discard within the home. However, cognitive therapy methods are unlikely to be helpful for those with limited cognitive ability. For more information about treating hoarding in developmental disabilities, see Berry and Schell (2006). Similar basic behavioral strategies are also likely to be useful with older clients whose cognitive capacity may be more limited than their younger counterparts, and cognitive therapy may not be as useful for older adults. Please note that clients with dementia are unlikely to respond to strategies in this book and will most likely need to live in supported housing settings where decisions about acquiring and keeping items are deliberately limited by other people.

Summary and Comment The mental and physical health problems and the family and safety concerns described in this chapter are only some of the potential concurrent

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challenges that can be present for people with hoarding. In general, when hoarding is severe and other comorbidities are present, we encourage you to identify and engage appropriate other human service professionals in your client’s treatment. When hoarding task forces exist in your client’s community, the professionals involved are often very knowledgeable about hoarding, as well as community resources that can be especially helpful. You may need advice or assistance from public health officers, fire and safety officers, housing inspectors, or other professionals who understand the relevant codes. A variety of social service professionals can also be helpful with regard to housing and other services, including social workers and case managers working with the department on aging, disabilities, protective services, or other special needs areas. When mental health comorbidity is significant and threatens to derail the focus on hoarding, consider helping your client engage another therapist who can address the non-hoarding diagnoses and related functioning problems. This will free you to focus mainly on hoarding which is often the problem of greatest immediate concern because of its social, economic, employment, and functional costs.

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Chapter 12 Maintaining Gains

(Corresponds to Chapter 9 of the Workbook)

Materials Needed ■

Hoarding Rating Scale (HRS)

■

Saving Inventory–Revised (SI-R)

■

Clutter Image Rating (CIR)

■

Saving Cognitions Inventory (SCI)

■

Activities of Daily Living for Hoarding (ADL-H)

■

Client’s Compulsive Hoarding Model (from Chapter 4)

■

Client’s Personal Goals Form (from Chapter 6)

■

List of Treatment Techniques

■

Review client’s progress up to this point

■

Help client develop strategies for continuing work and booster sessions

■

Identify the treatment methods that worked best

■

Anticipate and develop ways to cope when setbacks and lapses occur

Outline

This module presumes that clients have made progress toward meeting their goals, but that more work will be needed to complete the process and to maintain their gains in the future, especially when life stressors

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may lead to the recurrence of old hoarding habits. Plan the activities in this chapter for the final two therapy sessions, spaced about 2 weeks apart. Later booster sessions can be added as needed.

Reviewing Progress In these final sessions, emphasize what clients have accomplished to foster confidence in maintaining and improving gains. This must be an honest appraisal that also considers clients’ weaknesses and how to overcome them. Compliment clients on their progress so far and their use of particular tools from the therapy. Review progress in therapy and ask clients what they think their future course is likely to be with regard to hoarding symptoms. Most will have made very good progress but will not be completely free from hoarding problems yet. They will need to work on remaining clutter and periodic strong urges to acquire for months to come. We suggest reviewing the original photos of the home and comparing those to new photos of the home as it looks currently. Ask clients to match the new pictures as closely as possible to the original angle and size. If you are able, travel to the home to view all the rooms and compare those to the original photos. In any case, a photo record of progress is important for future reference as well. We also strongly recommend readministering the assessment forms given at the outset (e.g., Saving Inventory-Revised, Clutter Image Rating, Saving Cognitions Inventory, Activities of Daily Living), as well as asking the questions about safety and structural problems to determine how much change has occurred. The scores from the standard forms provide a basis for discussion about how much progress clients have made in acquiring, organizing, and sorting/discarding clutter. The first edition of this treatment manual was used in a waitlistcontrolled study in which we randomly assigned clients with primary hoarding problems of at least moderate severity to either treatment or a 12-week waitlist followed by treatment (Steketee et  al., 2010). Participants were excluded if they showed significant cognitive impairment that would interfere with learning, were not stable on psychotropic

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medication, or were unable to participate consistently in this relatively lengthy intervention. Doctoral students in psychology and social work, trained and supervised closely by the authors, provided 26 sessions that followed the format described in this manual. Treatment duration ranged from 9 to 12 months. In contrast to our pilot study where 4 of 14 patients (29%) discontinued treatment prematurely, in this study, the dropout rate was only 10%. The average age of clients was 54 years. Treated clients showed significant reductions in hoarding symptoms (15%–27%) at week 12, outperforming waitlisted patients (2%–11%). After 26 sessions 37 patients had received the full treatment; they showed a 26% to 39% reduction in hoarding symptoms depending on the measures used. Seventy-one percent were rated by the therapist as “much” or “very much” improved, whereas 81% of clients rated themselves in those categories. These data indicate very positive outcomes based on the methods employed in this manual. We were able to follow 31 patients for 3 to 12 months after treatment and to study longer term maintenance as well as predictors of outcome (Muroff et al., under review). Clients with significant improvement after therapy were able to sustain those gains at the follow-up point, with clinical global improvement (CGI) ratings by clinicians and clients indicating that 62% and 79% were rated “much” or “very much” improved, respectively. More severe hoarding and worse general functioning at the outset of treatment predicted less benefit (as might be expected). Perfectionism also emerged as a significant predictor of worse outcome. More research is needed on outcomes and predictors for larger samples to direct efforts to improve treatment for hoarding. Table 12.1 illustrates average scores on the Saving Inventory-Revised for clients who completed 26 sessions of the treatment presented in the first edition of this book. A graph of the client’s scores can be used to illustrate the amount of improvement on specific measures from before to the end of treatment (see the sample graph in Fig. 12.1). Clarifying how clients accomplished their gains strengthens clients’ confidence in their ability to continue their progress. Discuss the specific actions and strategies they used (see below) that seemed to work best. If progress was uneven, you can review the ups and downs with an eye toward

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Table 12.1 Change in Hoarding Symptoms Pre-test score (n = 41)

Post-test score (n = 41) (% improvement)

12-mo Follow-up score (n = 31)* (% improvement)

Hoarding Rating Scale

28.2

17.2 (39%)

18.7 (33%)

Saving Inventory-Revised—Total score

61.7

44.8 (27%)

45.4 (30%)

SI-R clutter

26.9

19.6 (27%)

20.2 (29%)

SI-R difficulty discarding

19.8

14.4 (27%)

15.0 (28%)

SI-R acquisition

15.0

10.7 (29%)

10.1 (34%)

Clutter Image Rating

4.1

2.9 (29%)

90.0

67.3 (26%)

2.1

1.5 (29%)

Measure

Saving Cognitions Inventory Activities of Daily Living for Hoarding

* We were not able to reassess all participants from the original study.

what clients might expect in the future. What would clients predict about future progress in each of these areas? For those who tend to underestimate what they have accomplished and become discouraged, help them avoid day-to-day comparisons and look instead at the big picture. If your work with the client is time limited, then remind him or her when the final session will occur. Invite clients to voice their thoughts (and fears) three to four sessions before the end of treatment, especially if they are concerned about progress and the prospect of ending regular contact with the clinician. If these concerns seem irrational, then Socratic questioning strategies can help evaluate faulty thinking. It may 70 60 50 40

HRS

30

SI-R

20 10 0 Before

16 weeks

End of treatment

Figure 12.1

Sample graph showing clients’ improvement on specific measures.

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be helpful to ask about the advantages of ending treatment (e.g., less dependence on the clinician, a chance to practice learned skills and self-reliance, more time for other activities, less expense). Reassure clients that they are not alone in their struggle and it is common for people to need to continue their work on hoarding for some months to come. Remind clients that you will both review the strategies that seemed to work best and will develop a plan for continuing the work based on their needs. In the final session, ask clients to reflect on the entire course of the intervention to describe what they have learned about themselves and what they need to do next to address this. Comment especially on progress and clients’ hard work and knowledge and skills gained during treatment. Ask for feedback about the treatment in general. Finally, express honest feedback to the client: “It was great working with you,” “I’ll miss working with you,” I’m so glad our work together helped,” “I have a lot of confidence in you.”

Continuing the Work with Self-Sessions and Booster Sessions Help clients develop a self-therapy plan they can implement during alternate weeks when they are tapering treatment sessions. We suggest clients schedule self-sessions on the same day and time slot when meetings with the clinician usually occurred—that is, if the session was usually scheduled for Mondays at 4 p.m., then they can use this same time for their own sessions. Encourage clients to schedule self-sessions at least a month in advance on their calendar. At the end of treatment, they can start with weekly sessions, taper these gradually as fits their progress to twice a month, once a month, and so on. Review the advantages and disadvantages and/or fears about self-sessions. For example, advantages might be to make it easier for clients to remember to use techniques when they need them; disadvantages might be that sessions seem to take too much time or aren’t needed. Clients can evaluate the pros and cons of these viewpoints. Work out a schedule for resolving clients’ remaining symptoms of organizing, acquiring, and letting go of possessions and plan how to accomplish this using self-session time. This may require a formal plan

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to engage in selected activities (e.g., filing). In addition, develop a specific plan for preventing the re-accumulation of clutter. First, identify how this could happen (e.g., too tired to put away purchased items, too rushed to open mail that day, saw a sale and stocked up on needed items). Then decide what the next step should be, how to implement it, and how to reinforce it. Determine who might assist clients in solving these problems when they arise. We recommend planning two to three booster sessions that can be scheduled at any time during the year after regular sessions end. We suggest planning the first one for 1 to 2  months hence and others as needed at the next appointment. Booster sessions are intended to help clients feel connected and motivated to continue their work. Sessions can focus on any aspects of hoarding that remain problematic or on other concerns (comorbid problems, problem solving regarding old debts, etc.) that arise once hoarding is under control. Some clients may benefit from monthly check-ins by phone or electronically if this helps maintain motivation to work on the problem. Arrange for follow-up assessments as appropriate to the clinic setting. Consider suggesting to clients that they join or organize a Buried In Treasures (BIT) workshop. The BIT workshops are peer-led groups of six to nine people who meet for 15 sessions over 20 weeks. The meetings are highly structured and action-oriented support groups for dealing with hoarding. Evidence from several studies has indicated that they are effective in reducing hoarding symptoms and keeping people active in battling clutter. Such groups can provide a great way for clients to continue making progress on conquering their hoarding disorder. Detailed instructions for setting up and running a BIT workshop can be found on the International Obsessive Compulsive Disorder Foundation website at www.ocfoundation.org/hoarding. You can also provide clients with written information about other local support groups or online support groups if available. Other ways to find support to continue work on hoarding include joining organizations such as the International Obsessive Compulsive Disorder Foundation (www.ocfoundation.org/hoarding) and reading self-help books (see Tolin, Steketee, & Frost [2013], Buried in Treasures). The resources section at end of this book provides additional reading and resources on hoarding.

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Review Treatment Techniques Reviewing the therapy process enables clients to recall what they did and what worked particularly well and helps guide post-treatment efforts to continue improvement and prevent relapse. Begin by reviewing the hoarding and acquiring models developed early in treatment (see Chapter  4). Ask clients whether they would make any further modifications to the models, and if so, revise them and provide clients with copies for reference. Ask what the models imply about what they need to do after treatment ends. Help them recall the general principles on which they have been working during treatment and formulate these in a way that emphasizes their own skills and personal goals. Examples are: 1.

Begin with easier items and work toward harder ones.

2.

Be patient; change takes time.

3.

Notice small gains.

4. Ask for help when you aren’t strong enough to do it alone. 5.

Be firm with yourself, but not perfectionistic.

Next, remind clients of their original treatment goals by examining the Treatment Goals Form they completed early in treatment. Review what clients have actually accomplished regarding the goals, and take special note of symptom improvement in reduced acquiring, less clutter, and ability to get rid of things, as well as skills of problem solving, managing attention, organizing, and decision making. Then, review the techniques learned during therapy by going over the clients’ Personal Session Forms and material in their Workbook. Instruct clients to review the List of Treatment Techniques in the Workbook to pick out strategies for use in the future (see Table 12.2). Use the metaphor of a toolbox, describing each technique as a tool. Help clients identify the methods that worked best for them and in which contexts (acquiring, sorting and organizing, discarding). Some of this review can be assigned as homework between sessions.

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Table 12.2 List of Treatment Techniques Identify the methods below that worked best for you. Many of these apply not only to letting go of possessions but also to resisting acquiring and to organizing. ■

Review the client’s Hoarding Model and consider the current state of affairs with regard to: ■

Personal and family vulnerabilities

■

Information processing problems

■

Thoughts and reasons for saving

■

Positive and negative emotions

■

Acquiring, saving, and avoidance behaviors

■

Review the functional analysis of acquiring episodes

■

Repeat the clutter, unclutter, and ideal home visualizations to determine client reactions

■

Review personal goals

■

If initial barriers to working on hoarding were identified, then review progress on these

■

Acquiring—examine and review the following: ■

Acquiring Form to see progress and determine whether unwanted items continue to come into the home

■

Questions for acquiring

■

Client’s rules for acquiring

■

Hierarchy of acquiring situation to determine additional work needed

■

Progress on alternative sources of enjoyment

■

Faulty thinking about acquiring

■

Cognitive strategies—downward arrow, estimating probability, need versus want

■

Review problem-solving steps

■

Review strategies for managing attention

■

Review Personal Organizing Plan and Filing Paper Form: ■

Keep discarding decisions simple: Trash, recycle, sell, donate

■

Keep supplies on hand for organizing

■

Review progress on OHIO rule

■

Implement decisions as soon as possible

■

Review rules for how long to save paper

■

Schedule times to organize and file

■

Keep surfaces clear to prevent recluttering

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Table 12.2 List of Treatment Techniques continued ■

Consider the presence of any problematic avoidance behaviors related to acquiring, sorting, and discarding

■

Review Questions About Possessions and/or rules for saving that facilitate decision making

■

Review Thought-Listing Exercise

■

Review Behavioral Experiment Form

■

Review imagined exposures to discarding and loss of possessions and information

■

Review the following cognitive strategies for parting with possessions: ■

Thinking Styles list

■

Questions about possessions

■

Advantages–Disadvantages

■

Downward arrow

■

Examine the evidence for keeping or discarding items

■

Take another perspective—review questions

■

Thought Record Form

■

Need versus want

■

Perfection Continuum Scale

■

Metaphors and stories

■

Valuing Time

■

Finding alternatives to problematic core beliefs

■

Plan social activities outside your home

■

Invite others to visit you at home

■

Schedule self-treatment sessions

Remind clients that when they experience some discomfort when practicing nonacquiring and sorting, it is usually a sign they have used the method correctly. It is often easier to change behaviors first and then observe whether attitudes and emotions follow. Remind clients that when formal treatment ends, many people experience an increase in general discomfort but that long-term gains require perseverance and commitment to continuing work. If some beliefs and behaviors have not changed as much as desired, a reassessment of the worst fears via the downward arrow may be useful.

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Sometimes the worst fears are missed because they are buried beneath more obvious fears and only emerge when these are resolved. Also, some clients may benefit from using problem solving to gain control over other problem areas. Remind clients of the steps in the problem solving process and determine when they could be useful after therapy ends. Examples might be when certain expected stressors occur (e.g., someone offers to give them items they do not want to keep, a plan goes awry and they are disappointed).

Dealing with Setbacks Address any unrealistic expectations clients might have so they are prepared for ups and downs and have a plan for what to do if they hit a low point in their progress. In addition, discuss the difference between a lapse and a relapse: “A lapse is a temporary period during which some of the behaviors return. A lapse does not necessarily indicate a relapse. Just because some clutter accumulates or you overbuy does not mean you will return to where you were before treatment, but it is a warning sign. A temporary return of symptoms is usually a sign that something stressful is going on in your life. If you encounter problems you need to discuss, or if you have questions, what would you do?” Discuss various strategies for managing setbacks (e.g., call the clinician, seek help from a friend, review treatment notes), and stress that it is normal to have low points and that these usually get shorter and less severe as time passes. Especially if the client tends to have dependent traits, take care not to imply that the client must depend on the clinician’s help. Encourage clients to identify potentially stressful situations that might exacerbate residual hoarding symptoms. Ask clients to think of stressors they expect over the coming year. How would they handle them? Examples might be stressful interpersonal situations or expectations, extra responsibilities, media information that is disturbing,

202

or a serious loss. Consider posing an unexpected stressor, such as the following: ■

Suppose your mother died unexpectedly and left you her things. What would you do?

■

Suppose you have a major expense you hadn’t planned on?

Ask clients to describe what they anticipate their initial reactions might be to such circumstances. Identify possible thinking styles or mistaken interpretations and inquire about alternative ways of thinking about the situation. Identify bad habit patterns that might return and discuss how alternative methods they have learned might apply. Encourage them to use effective coping strategies from the list to deal with setbacks. For example, they might conduct experiments to test predictions (e.g., about needing information) in response to these stressors. For clients whose time has been consumed with hoarding symptoms, plan what they can do with the extra time available. To identify potential problems, you can ask: ■

How is your life different now from how it used to be?

■

How are you spending most of your time?

If it is evident that they have not found healthy behaviors to replace time spent acquiring, then prompt clients to consider restarting former fun activities or to begin new ones like joining a gym, volunteer work, or taking a class.

Homework Before the final treatment session, ask clients to: ■

Review Workbook and make a list of all methods learned.

■

Highlight the methods that were most helpful.

■

List anticipated stressors and potential coping strategies.

■

List and locate potential resources needed for the future.

■

Locate sources of support for continuing nonacquiring and clutter removal efforts.

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Appendices

1. Clinician Session Form 2. Hoarding Interview 3. Hoarding Rating Scale 4. Saving Inventory–Revised (SI–R) 5. Clutter Image Rating (CIR) 6. Saving Cognitions Inventory (SCI) 7. Activities of Daily Living for Hoarding (ADL-H) 8. Safety Questions 9. Home Environment Inventory (HEI) 10. Scoring keys for assessment instruments 11. General Conceptual Model of Hoarding 12. Brief Thought Record 13. Acquiring Form 14. Clutter Visualization Form 15. Unclutter Visualization Form 16. Acquiring Visualization Form 17. Practice Form 18. Thought Record 19. Instructions for Coaches 20. Family Response to Hoarding Scale (FRHS)

All forms and worksheets in the Appendices are available for download and printing at www.oup.com/us/ttw

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Clinician Session Form Client: _______________

Session #: _______________

Date: _______________

Basic Session Content:

Agenda:

Homework report:

Degree of homework compliance (1 to 6): _________________

(1 = did not attempt; 2 = attempted but did not complete; 3 = did about 25%; 4 = did about 50%; 5 = did about 75%; 6 = did all homework) Symptoms and topics discussed during session:

Intervention strategies used or reviewed:

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Clinician Session Form continued Homework assigned:

Comments on client’s summary and feedback:

Goals for next or future sessions:

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Hoarding Interview Client initials: _______________

Date: _______________

1) What kind of home do you live in? Who else lives there with you?

2) Let’s talk about the rooms in your home. [Use the Clutter Image Rating pictures to determine the extent of clutter in each room and also in other living spaces like the attic, basement, garage, car, etc.] How much does the clutter interfere with how you’d like to use each room and which rooms bother you most? Living room: Dining room: Kitchen: Bedrooms: Bathrooms: Hallways: Basement: Attic: Porch: Garage: Yard: Car: Work or office space: Other: 3) Do you keep any items in other places outside your home like a storage space, another person’s home, and so forth? How much stuff is there and what kinds of items?

208

4) What kinds of things to you save? For example, what would I mainly see in these rooms?

5) Tell me how you feel—your emotions—when you look at or think about the clutter? (e.g., anxiety, guilt, sadness, pleasure, etc.)

6) How much discomfort would you feel if you had to get rid of some of your _____? (Ask about each major category of items identified earlier, such as books, junk mail, kitchen trash, bottle caps.)

7) Which rooms would you like to work on first? Why? Which one will be easiest and which one most difficult? Why? (Discuss where the pros and cons with regard to the usefulness of space if clutter is cleared, the quickest visual improvement in the space, the most pressing need to locate important items, the most reduction of distress, and so forth.)

8) Are your possessions organized in some way? How do you decide what goes where? How well does this plan work for you?

9) How do you acquire new things? Tell me about the most recent things you got—how did you get them (e.g., shopping, store sales, yard/tag sales, trash picking, free things)?

continued

209

Hoarding Interview continued 10) Let’s talk about the sequence of thoughts, emotions, and behaviors when you acquire new items. For example, the [most recent items acquired], how did you feel when you first got it and what were you thinking? What did you do with it once you got it home?

11) What happens if you try to avoid getting something?

12) Tell me about why you save these items. (If clients do not mention the reasons below, ask about each.)

a. Sentimental: Do you save things because they seem sentimental or emotionally significant to you? That is, you are so emotionally attached items that you do not want to part with them? Can you give an example?

b. Instrumental/useful: Are you afraid of losing important information you might need someday when you try to throw something out? Are you concerned about being wasteful because the object may eventually be put to good use? Can you give an example?

c. Intrinsic/beauty: Do you save things just because you like them or think they are pretty? Do you think they will be valuable someday? Can you give an example?

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13) Do your family members or friends help you get items or store them for you?

Do some people help you organize things you can’t deal with?

What about helping you get rid of things?

Does anyone get upset by your collecting and clutter or do they mostly tolerate it?

Do you prevent others from touching your things?

Are your family members/significant others supportive of treatment? If so, would any of them be interested in coming with you to a treatment session?

14) Does the clutter present a health or safety problem for you or your family? (If yes) What kinds of problems (e.g., falling, fire hazard, hygiene, medical problems, nutrition, insect)? (If no) Do other people think the clutter presents a problem for you or for your health or safety?

15) Has your buying or acquiring things caused any problems (e.g., family arguments, financial burden or debt, negative mood such as guilt, depression, anxiety)? (If yes) What kinds of problems? (If no) Do family or friends think buying or acquiring items is causing any problems?

16) Has your social life been affected by the clutter (e.g., avoids having visitors; avoids going to others home because can’t reciprocate)? Are you interested in having some people come over once the clutter is less of a problem? Who, for example?

continued

211

Hoarding Interview continued 17) Do you have any problems with washing, checking, putting things in order, repeating actions, or other mental compulsions? Do these thoughts and behaviors affect the hoarding problem (e.g., contamination fears make it difficult to put things away, checking lengthens the time it takes to put away or discard items)?

18) Do other family members have hoarding problems? Who? Tell me about the saving and clutter.

19) When you were young, did you spend a lot of time in any other household (e.g., grandparents, other family members, friends) that was cluttered?

20) Did anyone in the household you grew up in acquire things excessively? Who? What types of things?

21) When you were a child, did you experience any kind of deprivation (e.g., not enough to eat, not enough clothes, too few toys, no spending money) or serious losses (e.g., death, major move, fire)? How old were you when this occurred? Do you think it has any relationship to your hoarding problem?

212

22) When was the first time you noticed that you had trouble acquiring too many things, throwing things away, or had a lot of clutter in your home? How old were you? Was anything special going on in your life at that time (e.g., traumatic experience, moving, loss of a family member, etc.)?

23) Have you had any previous therapy (medication, behavior therapy, psychotherapy, family efforts to help) for hoarding problems? What about for other types of problems? How long did the treatment last? Did it help? Why or why not? (Later you will need to give a rationale for the hoarding treatment that addresses concerns the client may have because of previous treatment experiences.)

24) Have other people tried to intervene in the hoarding problem? Have you ever been contacted by landlords, health department officials, or other officials about problems related to their hoarding. What happened? What was your reaction?

25) Are there other aspects of hoarding you haven’t mentioned like legal or financial problems, problems with collecting animals, special embarrassments?

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Hoarding Rating Scale (HRS) [This measure can be given as an interview or as a self-report form.] 1.

Because of the clutter or number of possessions, how difficult is it for you to use the rooms in your home?

0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 ---------- 8 Not at all Mild Moderate Severe Extremely difficult difficult 2. To what extent do you have difficulty discarding (or recycling, selling, giving away) ordinary things that other people would get rid of? 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 ---------- 8 No Mild Moderate Severe Extreme difficulty difficulty 3. To what extent do you currently have a problem with collecting free things or buying more things than you need or can use or can afford? 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 ---------- 8 No Mild, Moderate, Severe, Extreme, very problem occasionally (less regularly (once frequently often (daily) than weekly) or twice weekly) (several times per acquires items acquires items not acquires items week) acquires not needed, or needed, or acquires not needed, or items not needed, acquires large a few unneeded acquires some or acquires many numbers of items unneeded items unneeded items unneeded items 4. To what extent do you experience emotional distress because of clutter, difficulty discarding or problems with buying or acquiring things? 0 ----------- 1 ----------- 2 ----------- 3 ----------- 4 ----------- 5 ----------- 6 ------------ 7 ----------- 8 None/not at all

Mild

Moderate

Severe

Extreme

5. To what extent do you experience impairment in your life (daily routine, job/school, social activities, family activities, financial difficulties) because of clutter, difficulty discarding, or problems with buying or acquiring things? 0 ----------- 1 ----------- 2 ----------- 3 ----------- 4 ----------- 5 ----------- 6 ----------- 7 ------------- 8 None/not Mild Moderate Severe Extreme at all

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Saving Inventory—Revised (SI-R) For each question below, circle the number that corresponds most closely to your experience DURING THE PAST WEEK. 0 -------------------- 1 -------------------- 2 --------------------- 3 -------------------- 4 None A little A moderate Most/Much Almost All/ amount Complete

1. How much of the living area in your home is cluttered with 0 possessions? (Consider the amount of clutter in your kitchen, living room, dining room, hallways, bedrooms, bathrooms, or other rooms).

1

2

3

4

2. How much control do you have over your urges to acquire possessions?

0

1

2

3

4

3. How much of your home does clutter prevent you from using?

0

1

2

3

4

4. How much control do you have over your urges to save possessions?

0

1

2

3

4

5. How much of your home is difficult to walk through because of clutter?

0

1

2

3

4

For each question below, circle the number that corresponds most closely to your experience DURING THE PAST WEEK. 0 ---------------------- 1 --------------------- 2 --------------------- 3 ---------------------4 Not at all Mild Moderate Considerable/ Extreme Severe

6. To what extent do you have difficulty throwing things away?

0

1

2

3

4

7. How distressing do you find the task of throwing things away?

0

1

2

3

4

8. To what extent do you have so many things that your room(s) are cluttered?

0

1

2

3

4

9. How distressed or uncomfortable would you feel if you could not acquire something you wanted?

0

1

2

3

4

10. How much does clutter in your home interfere with your social, work or everyday functioning? Think about things that you don’t do because of clutter.

0

1

2

3

4

11. How strong is your urge to buy or acquire free things for which you have no immediate use?

0

1

2

3

4

continued

215

Saving Inventory—Revised continued 12. To what extent does clutter in your home cause you distress?

0

1

2

3

4

13. How strong is your urge to save something you know you may never use?

0

1

2

3

4

14. How upset or distressed do you feel about your acquiring habits?

0

1

2

3

4

15. To what extent do you feel unable to control the clutter in your home?

0

1

2

3

4

16. To what extent has your saving or compulsive buying resulted in financial difficulties for you?

0

1

2

3

4

For each question below, circle the number that corresponds most closely to your experience DURING THE PAST WEEK. 0 ---------------------- 1 -------------------- 2 --------------------- 3 ------------------------4 Never Rarely Sometimes/ Frequently/Often Very Often Occasionally 17. How often do you avoid trying to discard possessions because it is too stressful or time consuming?

0

1

2

3

4

18. How often do you feel compelled to acquire something you see? e.g., 0 when shopping or offered free things?

1

2

3

4

19. How often do you decide to keep things you do not need and have little space for?

0

1

2

3

4

20. How frequently does clutter in your home prevent you from inviting people to visit?

0

1

2

3

4

21. How often do you actually buy (or acquire for free) things for which 0 you have no immediate use or need?

1

2

3

4

22. To what extent does the clutter in your home prevent you from using parts of your home for their intended purpose? For example, cooking, using furniture, washing dishes, cleaning, etc.

0

1

2

3

4

23. How often are you unable to discard a possession you would like to get rid of?

0

1

2

3

4

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Clutter Image Rating (CIR) Client: _______________

Date _______________

Using the 3 series of pictures (CIR:  Living Room, CIR:  Kitchen, and CIR:  Bedroom), please select the picture that best represents the amount of clutter for each of the rooms of your home. Put the number on the line below. Please pick the picture that is closest to being accurate, even if it is not exactly right. If your home does not have one of the rooms listed, just put NA for “not applicable” on that line.

Room

Number of closest corresponding picture (1-9)

Living Room Kitchen Bedroom #1 Bedroom #2 Also, please rate other rooms in your house that are affected by clutter on the lines below. Use the CIR: Living Room pictures to make these ratings. Dining room Hallway Garage Basement Attic Car Other

Please specify: 

217

Saving Cognitions Inventory (SCI) Use the following scale to indicate the extent to which you had each thought when you were deciding whether to throw something away DURING THE PAST WEEK. (If you did not try to discard anything in the past week, indicate how you would have felt if you had tried to discard.) 1----------------2----------------3----------------4----------------5----------------6----------------7 Not at all 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18 19. 20. 21. 22. 23. 24.

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Sometimes

I could not tolerate it if I were to get rid of this. Throwing this away means wasting a valuable opportunity. Throwing away this possession is like throwing away a part of me. Saving this means I don’t have to rely on my memory. It upsets me when someone throws something of mine away without my permission. Losing this possession is like losing a friend. If someone touches or uses this, I will lose it or lose track of it. Throwing some things away would feel like abandoning a loved one. Throwing this away means losing a part of my life. I see my belongings as extensions of myself; they are part of who I am. I am responsible for the well-being of this possession. If this possession may be of use to someone else, I am responsible for saving it for them. This possession is equivalent to the feelings I associate with it. My memory is so bad I must leave this in sight or I’ll forget about it. I am responsible for finding a use for this possession. Throwing some things away would feel like part of me is dying. If I put this into a filing system, I’ll forget about it completely. I like to maintain sole control over my things. I’m ashamed when I don’t have something like this when I need it. I must remember something about this, and I can’t if I throw this away. If I discard this without extracting all the important information from it, I will lose something. This possession provides me with emotional comfort. I love some of my belongings the way I love some people. No one has the right to touch my possessions.

Very much 1 1 1 1

2 2 2 2

3 3 3 3

4 4 4 4

5 5 5 5

6 6 6 6

7 7 7 7

1

2

3

4

5

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7

1 2 3 4 5 6 7 1 2 3 4 5 6 7 1

2

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1 2 3 4 5 6 7 1

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1 2 3 4 5 6 7 1

2

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7

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4

5 5 5 5 5

6 6 6 6 6

7 7 7 7 7

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2

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1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7

Activities of Daily Living in Hoarding (ADL-H) Instructions: For each of the following activities, please circle the number that best represents the degree of difficulty you experience in doing this activity because of the clutter or hoarding problem. If you have difficulty with the activity for other reasons (e.g., unable to bend or move quickly because of physical problems), then do not include this in your rating. Rather, rate only how much difficulty you would have because of hoarding. If the activity is not relevant to your situation (e.g., you don’t have laundry facilities or animals), then check the Not Applicable (N/A)’box. Activities affected by clutter or hoarding problem

Can do it Can do it with Can do it with great Can do it with a little moderate difficulty difficulty difficulty easily

Unable Not to do Applicable

1. Prepare food

1

2

3

4

5

NA

2. Use refrigerator

1

2

3

4

5

NA

3. Use stove

1

2

3

4

5

NA

4. Use kitchen sink

1

2

3

4

5

NA

5. Eat at table

1

2

3

4

5

NA

6. Move around inside the house

1

2

3

4

5

NA

7. Exit home quickly

1

2

3

4

5

NA

8. Use toilet

1

2

3

4

5

NA

9. Use bath/shower

1

2

3

4

5

NA

10. Use bathroom sink

1

2

3

4

5

NA

11. Answer door quickly

1

2

3

4

5

NA

12. Sit in sofa/chair

1

2

3

4

5

NA

13. Sleep in bed

1

2

3

4

5

NA

14. Do laundry

1

2

3

4

5

NA

15. Find important things (such as bills, tax forms, etc.)

1

2

3

4

5

NA

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Safety Questions Please circle the number below that best indicates how much of a problem you have with the following conditions in your home:

Safety problems in the home

A Somewhat/ None little moderate Substantial Severe

1. Structural damage to the floors, walls, roof, or other parts of the home

1

2

3

4

5

2. Water not working

1

2

3

4

5

3. Heat not working

1

2

3

4

5

4. Does any part of your house pose a fire hazard? (stove covered with paper, flammable objects near the furnace, etc.)

1

2

3

4

5

5. Would medical emergency personnel have difficulty moving equipment through your home?

1

2

3

4

5

6. Are exits from your home blocked?

1

2

3

4

5

7. Is it unsafe to move up or down the stairs or along other walkways?

1

2

3

4

5

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Home Environment Index (HEI) Please circle the answer that best fits the current situation in the home. To what extent are the following situations present in the home? 1.

Fire hazard 0 = No fire hazard 1 = Some risk of fire (e.g., lots of flammable material) 2 = Moderate risk of fire (e.g., flammable materials near heat source) 3 = High of fire (e.g., flammable materials near heat source; electrical hazards, etc.)

2. Moldy or rotten food 0 = None 1 = A few pieces of moldy or rotten food in kitchen 2 = Some moldy or rotten food throughout kitchen 3 = Large quantity of moldy or rotten food in kitchen and elsewhere 3. Dirty or clogged sink 0 = Sink empty and clean 1 = A few dirty dishes with water in sink 2 = Sink full of water, possibly clogged 3 = Sink clogged; evidence that it has overflowed onto counters, and so forth. 4. Standing water (in sink, tub, other container, basement, etc.) 0 = No standing water 1 = Some water in sink/tub 2 = Water in several places, especially if dirty 3 = Water in numerous places, especially if dirty 5. Human/animal waste/vomit 0 = No human waste, animal waste, or vomit visible 1 = Small amount of human or animal waste (e.g., unflushed toilet, on bathroom or other floor) 2 = Moderate animal or human waste or vomit visible in more than one room 3 = Substantial animal or human waste or vomit on floors or other surfaces 6. Mildew or mold 0 = No mildew or mold detectable 1 = Small amount of mildew or mold in limited amounts and expected places (e.g., on edge of shower curtain or refrigerator seal) 2 = Considerable, noticeable mildew or mold 3 = Widespread mildew or mold on most surfaces 7. Dirty food containers 0 = All dishes washed and put away 1 = A few unwashed dishes 2 = Many unwashed dishes 3 = Almost all dishes are unwashed

221

8. Dirty surfaces (floors, walls, furniture, etc.) 0 = Surfaces completely clean 1 = A few spills, some dirt or grime 2 = More than a few spills, may be a thin covering of dirt or grime in living areas 3 = No surface is clean; dirt or grime covers everything 9. Piles of dirty or contaminated objects (bathroom tissue, hair, toilet paper, sanitary products, etc.) 0 = No dirty or contaminated objects on floors, surfaces, and so forth. 1 = Some dirty or contaminated objects present around trash cans or toilets 2 = Many dirty or contaminated objects fill bathroom or area around trash cans 3 = Dirty or contaminated objects cover the floors and surfaces in most rooms 10. Insects 0 = No insects are visible 1 = A few insects visible; cobwebs and/or insect droppings present 2 = Many insects and droppings are visible; cobwebs in corners 3 = Swarms of insects; high volume of droppings; many cobwebs on household items 11. Dirty clothes 0 = Dirty clothes placed in hamper; none are lying around 1 = Hamper is full; a few dirty clothes lying around 2 = Hamper is overflowing; many dirty clothes lying around 3 = Clothes cover the floor and many other surfaces (bed, chairs, etc.) 12. Dirty bed sheets/linens 0 = Bed coverings very clean 1 = Bed coverings relatively clean 2 = Bed coverings dirty and in need of washing 3 = Bed coverings very dirty and soiled 13. Odor of house 0 = No odor 1 = Slight odor 2 = Moderate odor; may be strong in some parts of house 3 = Strong odor throughout house During the last month, how often did you (or someone in your home) do each of the following activities? 14. Do the dishes 0 = Daily or every 2 days; 15 to 30 times per month 1 = 1–2 times a week; 4 to 10 times per month 3 = Every other week; 2 to 3 times per month 3 = Rarely; 0 times per month 15. Clean the bathroom 0 = Daily or every 2 days; more than 10 times per month 1 = 1–2 times a week; 4 to 10 times per month 2 = Every other week; 2 to 3 times per month 3 = Never; 0 times per month

222

Scoring Keys Hoarding Rating Scale (HRS) Total score = sum of all 5 items; Range = 0–40

Saving Inventory–Revised (SI-R) Clutter Subscale (Nine Items) Sum items: 1, 3, 5, 8, 10, 12, 15, 20, 22 Difficulty Discarding/Saving Subscale (Seven Items) Sum items: 4 (reverse score), 6, 7, 13, 17, 19, 23 Acquisition Subscale (Seven Items) Sum items: 2 (reverse score), 9, 11, 14, 16, 18, 21 Total score = sum of all items Range = 0–92

Saving Cognitions Inventory (SCI) Emotional Attachment (10 items) Sum items: 1, 3, 6, 8, 9, 10, 13, 16, 22, 23 Control (three items) Sum items: 5, 18, 24 Responsibility (six items) Sum items: 2, 7, 11, 12, 15, 19 Memory (five items) Sum items: 4, 14, 17, 20, 21 Total score = sum of all items Range = 0–168

Activities of Daily Living–Hoarding (ADL-H) Total score = sum all 15 items after excluding those rated “Not Applicable”; divide the summed score by the number of items given a numerical rating. This will yield an average of all applicable items. Range = 1–5

223

Safety Questions Examine individual items rated 2 and above to identify problematic areas requiring immediate attention.

Home Environment Inventory (HEI) Total score = sum all items Range = 0–45 Items rated 2 or above may indicate serious problems.

224

General Conceptual Model of Hoarding General Conceptual Model of Hoarding Personal & Family Vulnerability Factors:

Information Processing Problems:

Meaning of Possessions:

Emotional Reactions: Positive Negative

Negative Reinforcement: Escape and/or Avoidance

Positive Reinforcement: Pleasure in Acquiring/Saving

Excessive Acquiring, Difficulty Discarding, Clutter

225

226

Brief Thought Record Initials:

Date: Trigger Situation

Thought or Belief

Emotions

Actions/Behaviors

Acquiring Form List the types of items you typically bring home and how you acquire them. Include items you acquired last week and those you acquire during the coming week. Do not include groceries or other perishable goods. Rate how uncomfortable you would feel if you had not acquired this item when you saw it.

Item and location where you found it:

Discomfort if not acquired (0–100)

227

Clutter Visualization Form Room: A. Visualize this room with all of its present clutter. Imagine standing in the middle of the room slowly turning to see all of the clutter. B. How uncomfortable did you feel while imagining this room with all the clutter? Use a scale from 0 to 100, where 0 = no discomfort and 100 = the most discomfort you have ever felt. Initial Discomfort Rating: C. What feelings were you having while visualizing this room? 1. 2. 3. D. What thoughts (beliefs, attitudes) were you having while visualizing this room? 1. 2. 3.

228

Unclutter Visualization Form Room: A. Visualize this room with the clutter gone. Imagine that all the items are in a place where you can find them, and picture cleared surfaces and floors, tabletops without piles, and uncluttered floors with only rugs and furniture. B. How uncomfortable did you feel while imagining this room without all the clutter? Use a scale from 0 to 100, where 0 = no discomfort and 100 = the most discomfort you have ever felt. Initial Discomfort Rating: C. What thoughts and feelings you were having while visualizing this room? 1. 2. 3. D. Imagine what you can do in this room now that it is not cluttered. Describe your thoughts and feelings. 1. 2. 3. E. How uncomfortable did you feel while imagining the room this way? (0 = no discomfort and 100 = the most discomfort you have ever felt) Final Discomfort Rating: 

229

Acquiring Visualization Form Visualize a typical situation in which you have a strong urge to acquire something. In your image, don’t actually pick up the item, just look at it. Please describe the location and item you imagined.

Rate how strong was your urge to acquire the item (0 = no urge to acquire, 100 = irresistible urge). Acquiring Urge What thoughts did you have while you imagined this scene? 1. 2. 3. Visualize this scene again, but this time, imagine leaving without the item. How much discomfort did you experience while imagining (0–100). Discomfort Rating Please list any thoughts you think would help you to not acquire an object. 1. 2. 3. Now rate how uncomfortable you feel about leaving without the item(s) from 0 to 100. Discomfort Rating

230

Practice Form What was the item (to remove or not acquire)? Initial discomfort (0 = none to 100 = max) What did you do (not acquire, trash, recycle, give away, other

Discomfort rating (0 to 100)

)?

after 10 mins _________________ after 20 mins _________________ after 30 mins _________________ after 40 mins _________________ after 50 mins _________________ after 1 hour

_________________

after next day _________________ Conclusion regarding experiment: 

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232

Thought Record Initials:  Trigger situation

Date:  Thoughts

Emotions

Rational alternative

Outcome

Instructions for Coaches Overcoming compulsive hoarding is often very difficult. Many people find it extremely helpful to have a support person or “coach” who can assist them with the process. As a coach, you will work together as a team with the clinician and the person with the hoarding problem. This guide outlines some ways to make your involvement most helpful. Compulsive hoarding is not a single, simple problem but consists of several interconnected problems. These usually include: ■

Excessive clutter: This is the most easily recognized symptom of hoarding. Often, the clutter becomes so overwhelming that the person has a hard time knowing where to start.

■

Problems organizing and making decisions: A person with a hoarding problem may have difficulty thinking clearly about their clutter or what to do about it. They may have a hard time recognizing the difference between items that are useful vs. nonuseful, valuable vs. nonvaluable, or sentimental vs. nonsentimental. Therefore, to be on the safe side, they may treat all items as if they are useful, valuable, or sentimental. This leads to difficulty deciding when it is time to throw something out.

■

Difficulty letting go of possessions: One of the most striking problems is difficulty letting go of and removing things—discarding, recycling, selling, and giving away items. This occurs even with items that seem to have little or no value. The amount of distress associated with removing clutter is often enormous.

■

A tendency to avoid or procrastinate: People with hoarding problems often feel very overwhelmed by the sheer volume of clutter and the difficult task of decision-making. They may also feel depressed or nervous, which can add to a sense of fatigue and a tendency to avoid taking action. As a result, the person with hoarding is often tempted to decide, “This is too big to tackle today. I’ll do it tomorrow.”

■

Difficulty resisting urges to acquire objects: For many people with hoarding problems, the urge to acquire things can be very strong, almost irresistible. Some people may feel a need to buy things; others may feel a need to pick up free things.

Not everyone who hoards has all of these problems. Every person and every hoarding problem are a little bit different, but all involve strong emotional reactions to possessions, thoughts, and beliefs about saving things that may not always seem rational to you, and behaviors that enable the problem to persist. As part of the treatment program, the clinician will carefully review these aspects of hoarding with the person you are assisting and determine which problems are particularly troublesome. This is important, because the particular kinds of problems the person is facing guide what interventions to use. We recommend coaches do the following: ■

Meet as a team with the clinician and the person with the hoarding problem. Three people working together is a recipe for success, whereas three people working in different directions is unlikely to work.

233

■

Help the person remain focused on the task in front of them. People with hoarding problems often find themselves easily distracted, especially when they are trying to reduce clutter, make decisions about possessions, or resist the urge to acquire things. Often, the coach can be very helpful by politely reminding the person what they are supposed to be doing right now.

■

Provide emotional support. Because people who hoard have often been criticized by others, it is very important not to act like a taskmaster, as this just makes people feel nervous or angry and interferes with their ability to learn new approaches. Use a gentle touch and when it feels right to you, express sympathy with statements such as, “I can see how hard this is for you,” or “I understand that you have mixed feelings about whether to tackle this clutter.” The person with the hoarding problem is going through some major stress, and often needs a sympathetic ear or even a shoulder to cry on.

■

Help the person make decisions but DO NOT make decisions for them. During treatment, the person with the hoarding problem is learning to develop new rules for deciding what to keep and what to remove. The coach can remind the person of these rules by asking questions, but not by telling them what to do. Ask them to simply talk out loud about their decision-making process for saving and discarding an item. Your task is not to convince them to get rid of things, but just to support them while they work through the process of making a decision. It may seem tedious, but often your mere presence will speed them along.

■

Be a cheerleader. Sometimes, we all need an extra boost when things get difficult. Calling the person to remind them of their homework assignment, telling them you believe they can do it, and noticing when they are doing a good job are all good cheerleading strategies. But at the same time, don’t do too much of this or the encouragement will seem burdensome and the praise hollow.

■

Help with hauling. Many people who hoard have accumulated so much clutter that it would take them a year or more to discard it all by themselves. This makes it easy to get discouraged because progress is slow. Coaches are very helpful when they roll up their sleeves and help remove items from the home, so long as the person with hoarding makes all the decisions and remains fully in charge of the process.

■

Accompany the person on non-acquiring trips. For people who acquire too many things, treatment often requires going to tempting stores or yard sales and not buying anything. It can be extremely helpful to have someone go with them to help resist temptation and make the trip a success.

We have also found that even the most well-meaning coaches can make themselves less helpful by using the wrong strategies. Here are some DON’Ts: ■

234

Don’t argue with the person about what to get rid of and what to acquire. Long debates about the usefulness of an item or the need to get rid of it will only produce negative emotional reactions that don’t facilitate progress. Rather, whenever you feel in conflict, take a break, relax a bit, and remind yourself how difficult this is for the person.

■

Don’t take over decisions. It would certainly be easier and quicker if coaches simply took charge, decided what should stay and what should go, and hauled the clutter out themselves. But this method doesn’t teach people how to manage their problem. The clutter will just build up again. Rather, be sure the person with hoarding is in charge at all times and makes all decisions, with the coach’s support and guidance.

■

Don’t touch or move anything without permission. Imagine how you would feel if a well-meaning person came into your home and handled your things without permission. Doing this can damage the trust between you and make it impossible for the person to proceed.

■

Don’t tell the person how they should feel. It can be very hard to understand why someone feels so sentimental about keeping what looks like trash to you or fearful about getting rid of something that is clearly useless. But these feelings developed for reasons even the client may not yet understand. Be as patient as you can. We know that coaching can be frustrating.

■

Don’t work beyond your own tolerance level. To be a good coach, you have to take care of yourself first and then help your friend or family member. So feel free to set limits on how long and how much work you can do on any given occasion. Pat yourself on the back for your own efforts; helping someone who hoards is very hard work.

We hope these guidelines are helpful in working with someone who has a hoarding problem.

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Family Response to Hoarding Scale (FRHS) INSTRUCTIONS: The purpose of these questions is to learn about the ways in which you may be modifying your behavior or routines because of a loved one (e.g., family member, friend, significant other) with hoarding problems. Please note that hoarding is defined by: ■

Persistent difficulty discarding or parting with possessions, regardless of their actual value.

■

Strong urges to save items and/or distress associated with discarding.

■

Clutter in the living areas of the home so these spaces cannot be used as intended.

■

Significant distress or impairment in social, occupational, or other important areas of functioning.

For each question below, in part “a.” please indicate whether the behavior occurred during the past month. If you answer YES to part “a.”, then please indicate in part “b.” how often that behavior occurred. If you answer NO to part “a.”, then please leave part “b.” blank.

During the past month, did you: 1

1. a. Help your family member decide whether to acquire, save, or discard items because he/she was having difficulty making a decision? b. [if yes] How often did you help him/her decide on discarding or saving?

2

3

Yes

No

1–2 times

3–4 times

5–9 times

4

10 or more times

2. a. Wait for your family member because of hoarding-related behaviors, interfering with plans you had made? (For example, prolong the time you would normally spend shopping in a store, or take longer to leave the house because of difficulty finding items?) b. [if yes] How often, during the past month, did you wait for your family member because of his/her hoarding?

Yes

No

1–2 times

3–4 times

3. a. Keep items longer than you normally would because of your family member’s hoarding? (For example, did you keep old newspapers or trash because he/she had not reviewed them?) b. [if yes] How often, during the past month, did you not discard items you normally would throw out?

Yes

No

1–2 times

3–4 times

4. a. Discard, recycle, or remove items without telling your family member? b. [if yes] How often, during the past month, did you discard items secretly without telling your family member?

Yes

No

1–2 times

3–4 times

5. a. Help your family member acquire items that may have contributed to hoarding? (For example, providing money to buy items, telling about a sale, buying something likely to be hoarded, bringing home extra copies, providing storage space.) b. [if yes] How often, during the past month, did you help your family member undertake or complete compulsive acquiring behaviors?

Yes

No

1–2 times

3–4 times

5–9 times

10 or more times

5–9 times

10 or more times

5–9 times

10 or more times

5–9 times

10 or more times

237

(continued)

238

1

2

3

5–9 times

10 or more times

I have assumed my family member’s responsibilities in more than one area of life.

I have assumed most or all of my family member’s responsibilities.

I have definitely modified my activities in more than one area of life.

I am unable to attend to leisure, work or family responsibilities.

6. a. Engage in odd or senseless behaviors at your family member’s request, or because you thought he/she would want you to do these things? (For example, checking items to make sure he/she didn’t lose or miss something important.) b. [if yes] How often, during the past month, did you engage in these behaviors?

Yes

No

1–2 times

3–4 times

7. a. Take over duties that would be your family member’s responsibility if s/he did not have a hoarding problem? (For example, paying bills, doing taxes, taking out trash.) b. [if yes] How much do you do these things?

Yes

No

I occasionally handle one of my family member’s responsibilities, but there has been no substantial change in my role.

I have assumed my family member’s responsibilities in one area of life.

8. a. Modify your personal, leisure, or family activities because of your family member’s hoarding? (For example, unable to watch TV, engage in hobbies, or cook because of hoarding?) b. [if yes] How much are you modifying these activities?

Yes

No

I have modified these activities slightly but my overall functioning has not been affected.

I have definitely modified my activities in one area of life.

4

9. a. Modify your social activities because of your family member’s hoarding? (For example, not inviting friends or relatives to the home.) b. [if yes] How much are you modifying these activities?

Yes

No

I have modified these activities slightly but my overall functioning has not been affected.

I have definitely modified my activities in one area of life.

10. a. Modify your work activities because of your family member’s hoarding problems? (For example, changing work schedule to attend to clutter; unable to work at home because of clutter.)

Yes

No

I have modified my work slightly but my overall functioning has not been affected.

I have definitely modified some aspect of my work.

b. [if yes] How much are you modifying these activities?

I have definitely modified my activities in more than one area of life.

I am unable to engage in social activities.

I have definitely modified my work routine in more than one area of work.

My work is extremely disrupted.

(continued)

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240 1

2

11. a. Spend money you would not normally spend because of your family member’s hoarding? (For example, storage expenses, purchasing extra items, rebuying items lost in clutter, billing or tax penalties, or compulsive buying uses funds intended for other things.) b. [if yes] How much are you spending?

Yes

No

I have slight extra expenses but there is no overall effect on my budget.

I have definite extra expenses, but there is only a minor effect on my budget.

12. a. Experience health problems because of your family member’s hoarding? (For example, asthma exacerbated by dirty home, dermatitis caused by bathing difficulties, home infested with insects or rodents caused by hoarding, injury from fall due to hoarding.)

Yes

No

I have slight health problems caused by hoarding.

I have moderate health problems caused by hoarding.

b. [if yes] How bad are your health problems caused by hoarding?

3

4

I have many extra expenses, and this prevents me from buying things I need.

I have so many extra expenses that I am unable to afford basic household items.

I have serious health problems caused by hoarding.

I have extreme health problems caused by hoarding.

13. a. Experience problems with hygiene or cleanliness because of your family member’s hoarding? (For example, unable to use the bath or shower, unable to clean the home, or other unsanitary conditions because of hoarding.) b. [if yes] How severe are the hygiene or cleanliness problems?

Yes

No

I/we have slight hygiene or cleanliness problems caused by hoarding.

I/we have moderate hygiene or cleanliness problems caused by hoarding.

14. a. Experience emotional distress because of your family member’s hoarding? (For example, anxiety, guilt, frustration, embarrassment, depression, sleeplessness caused by hoarding.) b. [if yes] How severe is the emotional distress?

Yes

No

I/we have mild emotional distress caused by hoarding.

I/we have moderate emotional distress caused by hoarding.

I/we have serious hygiene or cleanliness problems caused by hoarding.

I/we have extreme hygiene or cleanliness problems caused by hoarding.

I/we have serious emotional distress caused by hoarding.

I/we have extreme emotional distress caused byhoarding.

(continued)

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242 1

2

15. a. Experience difficulty in your relationships because of your family member’s hoarding? (For example, disagreements or arguing about hoarding.) b. [if yes] How severe are the relationship problems?

Yes

No

We have mild relationship problems or minor arguments caused by hoarding.

We have moderate relationship problems or occasional disagreements caused by hoarding.

16. a. Experience difficulty planning for the future because of your family member’s hoarding? (For example, unable to sell home, unable to move to desired dwelling, unable to complete plans for event or goal.) b. [if yes] How severe is the difficulty in planning for the future?

Yes

No

I have mild problems planning for the future caused by hoarding, but it is minimally disruptive.

I have moderate problems planning for the future in 1 or 2 areas of life resulting from hoarding.

3

4

We have serious relationship problems or frequent disagreements caused by hoarding.

We have extreme relationship problems, open hostility, or refuse communicate caused by hoarding.

I have serious problems planning for the future in several areas of life resulting from hoarding.

I have extreme problems planning for the future caused by hoarding and am unable to plan or make important changes.

References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, D.C.: Author. Abramowitz, J.S. (2006). Obsessive Compulsive Disorder. Boston:  Hogrefe & Huber Publishers. Abramowitz, J.S., Franklin, M.E., Schwartz, S.A., & Furr, J.M. (2003). Symptom presentation and outcome of cognitive behavior therapy for obsessive compulsive disorder. Journal of Consulting and Clinical Psychology, 71, 1049–1057. Ayers, C. & Patronek, G. (in press, 2013). Animal hoarding. In R.O. Frost & G. Steketee Oxford Handbook of Hoarding and Acquiring. New York: Oxford. Beck, J.S., & Beck, A.T. (2011). Cognitive therapy, Basics and beyond, 2nd Edition. New York: Guilford. Berry, C.L. & Schell, R.M. (2006). Reducing hoarding behavior with individualized reinforcement and item return. Behavioural Interventions, 21, 123–135. Black, D.W., Monahan, P., Gable, J., Blum, N., Clancy, G., & Baker, P. (1998). Hoarding and treatment response in 38 nondepressed subjects with obsessive-compulsive disorder. Journal of Clinical Psychiatry, 59, 420–425. Bratiotis, C., Schmalisch, & Steketee, G. (2011). The hoarding handbook: A guide for human service professionals, New York: Oxford. Buboltz, W.C., Thomas, A. & Donnell, A.J. (2002). Evaluating the factor structure and internal consistency reliability of the Therapeutic Reactance Scale. Journal of Counseling & Development, 80, 120–125. Bulli, F., Melli, G., Sara, M., Carraresi, C., Stopani, E., Pertusa, A., & Frost, R.O. (2013). Hoarding behaviour in an Italian non-clinical sample. Behavioural and Cognitive Psychotherapy. doi:10.1017/ S1352465812001105. Burns, D. (1989). Feeling good handbook. New York: Morrow.

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Cermele, J.A., Melendez-Pallitto, L., & Pandina, G.J. (2001). Intervention in compulsive hoarding:  A  case study. Behavior Modification, 25, 214–232. Davidow, J. & Muroff, J. (2011). Coaching and hoarding:  What’s the right approach? Poster presented at the Annual Conference of the International OCD Foundation. San Diego, CA: July 29–31, 2011. DiMauro, J., Tolin, D.F., Frost, R.O., & Steketee, G. (2013). Do people with hoarding disorder under-report their symptoms. Journal of Obsessive Compulsive and Related Disorders, 2, 130–136. Frost, R. & Gross, R. (1993). The hoarding of possessions. Behaviour Research and Therapy, 31, 367–382. Frost, R. & Hartl, T. (1996). A cognitive-behavioral model of compulsive hoarding. Behaviour Research and Therapy, 34, 341–350. Frost, R.O., Hristova, V., Steketee, G., & Tolin, D.F. (2013). Activities of daily living in hoarding disorder. Journal of Obsessive Compulsive and Related Disorders. 2, 85–90. Frost, R.O. & Mueller, A. (in press, 2013). Acquisition of possessions in hoarding disorder. In R.O. Frost & G. Steketee (Eds.), Oxford Handbook of Hoarding and Acquiring. New York: Oxford. Frost, R.O., Pekarava-Kochergina, A., & Maxner, S. (2011a). The effectiveness of a biblio-based support group for hoarding disorder. Behaviour Research and Therapy, 49, 628–634. Frost, R.O., Rosenfield, E., Steketee, G., & Tolin, D.F. (in press). An examination of excessive acquisition in hoarding disorder, Journal of Obsessive-Compulsive and Related Disorders. Frost, R.O., Ruby, D., & Shuer, L. (2012). The Buried in Treasures Workshop: Wait list control trial of facilitated self-help for hoarding disorder. Behaviour Research and Therapy, 50, 661–667. Frost, R.O., & Steketee, G. (2010). Stuff:  Compulsive hoarding and the meaning of things. New York: Houghton/Mifflin/Harcourt. Frost, R.O. & Steketee, G. (2013) (Eds.). Oxford handbook of hoarding and acquiring. New York: Oxford. Frost, R.O., Steketee, G., & Greene, K. (2003). Cognitive and behavioral treatment of compulsive hoarding. Brief Treatment and Crisis Intervention, 3, 323–337. Frost, R.O., Steketee, G., & Grisham, J. (2004). Measurement of compulsive hoarding:  Saving Inventory-Revised. Behaviour Research and Therapy, 42, 1163–1182. Frost, R.O., Steketee, G., & Tolin, D. F. (2011b). Comorbidity in hoarding disorder. Depression and Anxiety, 28, 876–884.

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Frost, R.O., Steketee, G., Tolin, D.F., & Renaud, S. (2008). Development and validation of the Clutter Image Rating. Journal of Psychopathology and Behavioral Assessment, 30, 180–192. Frost, R.O., Steketee, G., & Williams, L. (2000a). Hoarding: A community health problem. Health and Social Care in the Community, 8, 229–234. Frost, R.O., Steketee, G., Williams, L., & Warren, R. (2000b). Mood, disability, and personality disorder symptoms in hoarding, obsessive compulsive disorder, and control subjects. Behaviour Research and Therapy, 38, 1071–1082. Frost, R.O., Tolin, D.F., & Maltby, N. (2010). Insight-related challenges in the treatment of hoarding. Cognitive and Behavioral Practice, 17, 404–413. Grisham, J., Frost, R.O., & Steketee, G. Kim, H-J., & Hood, S. (2006). Age of onset of compulsive hoarding. Journal of Anxiety Disorders, 20, 675–686. Hartl, T.L., Duffany, S.R., Allen, G.J., Steketee, G., & Frost, R.O. (2005). Relationships among compulsive hoarding, trauma, and attention deficit hyperactivity disorder. Behaviour Research and Therapy, 43, 269–276. Hartl, T.L., & Frost, R.O. (1999). Cognitive-behavioral treatment of compulsive hoarding:  a multiple baseline experimental case study. Behaviour Research and Therapy, 37, 451–461. Hirschtritt, M.E. & Mathews, C.A. (in press, 2013). Genetics and family models of hoarding disorder. In R.O. Frost & G. Steketee (Eds.), Oxford Handbook of Hoarding and Acquiring. New York: Oxford. Hogstel, M.O. (1993). Understanding hoarding behavior in the elderly. American Journal of Nursing, 93, 42–45. Iervolino, A.C., Perroud, N., Fullana, M.A., et al. (2009). Prevalence and heritability of compulsive hoarding: a twin study. American Journal of Psychiatry, 166, 1156–1161. Kim, H-J., Steketee, G., & Frost, R.O. (2001). Hoarding by elderly people. Health & Social Work. 26, 176–184. Lucini, G., Monk, I., & Szlatenyi, C. (2009). An analysis of fire incidents involving hoarding households (Bachelor’s thesis). Retrieved from Worcester Polytechnic Institute website:  http://web.cs.wpi.edu/~rek/ Projects/MFB_D09.pdf. Accessed 14 June, 2013. Mataix-Cols, D., Billotti, D., de la Cruz, L. & Nordsletten, A.E. (2013). The London field trial for hoarding disorder. Psychological Medicine, 43, 837–847.

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Mataix-Cols, D., Frost, R.O., Pertusa, A., Clark, L.A., Leckman, J.E., Saxena, S., et  al. (2010). Compulsive hoarding:  A  new disorder for DSM-V? Depression and Anxiety, 27, 556–572. Mataix-Cols, D., Rauch, S.L., Manzo, P.A., Jenike, M.A., & Baer, L. (1999). Use of factor-analyzed symptom dimensions to predict outcome with serotonin reuptake inhibitors and placebo in the treatment of obsessive-compulsive disorder. American Journal of Psychiatry, 156, 1409–1416. Miller, W.R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York: Guilford. Mueller, A., Mitchell, J. E., Crosby, R. D., Glaesmer, H., & de Zwaan, M. (2009). The prevalence of compulsive hoarding and its association with compulsive buying in a German population-based sample. Behaviour Research and Therapy, 47, 705–709. Muroff, J., Steketee, G., Bratiotis, C., & Ross, A. (2012). Group cognitive and behavioral therapy and bibliotherapy for hoarding: A pilot trial. Depression and Anxiety, 29(7), 597–604. Muroff, J., Steketee, G., Frost, R.O., & Tolin, D.F. (under review). Cognitive behavior therapy for hoarding disorder: Follow-up findings and predictors of outcome. Muroff, J., Steketee, G., Rasmussen, J., Gibson, A., Bratiotis, C., & Sorrentino, C. (2009). Group cognitive and behavioral treatment for compulsive hoarding: A preliminary trial. Depression and Anxiety, 26(7), 634–640. Muroff, J., Steketee, G., & Underwood, J. (2014). Group treatment for hoarding disorder: Therapist guide. New York: Oxford. Norberg, M. & Snowdon, J. (in press, 2013). Severe domestic squalor. In R.O. Frost & G. Steketee (Eds.), Oxford Handbook of Hoarding and Acquiring. New York: Oxford. Nortsletten, A.E., & Mataix-Cols, D. (2012). Hoarding versus collecting:  Where does pathology diverge from play? Clinical Psychology Review, 32, 165–176. Pertusa, A., & Fonseca, A. (in press, 2013). Hoarding behavior in other disorders. In R.O. Frost & G. Steketee (Eds.). Oxford handbook of hoarding and acquiring. New York: Oxford. Pertusa, A., Frost, R.O., Fullana, M.A., Samuels, J., Steketee, G., Tolin, D., Saxena, S., Leckman, J.F., & Mataix-Cols, D. (2010a). Refining the boundaries of compulsive hoarding:  a review. Clinical Psychology Review, 30, 371–386.

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Pertusa, A., Frost, R.O., & Mataix-Cols, D. (2010b). When hoarding is a symptom of OCD:  A  case series and implications for DSM-V. Behaviour Research and Therapy, 48, 1012–1020. Pertusa, A., Fullana, M. A., Singh, S., Alonso, P., Menchon, J. M., & Mataix-Cols, D. (2008). Compulsive hoarding: OCD symptom, distinct clinical syndrome, or both? American Journal of Psychiatry, 165, 1289–1298. Rasmussen, J.L., Steketee, G., Frost, R.O., & Tolin, D.F. (under review). Assessing squalor in hoarding: The Home Environment Index. Rodriguez, C.I., Herman, D., Alcon, J., Chen, S., Tannen, A., Essock, S., & Simpson, H.B. (2012). Prevalence of hoarding disorder in individuals at potential risk of eviction in New York City: A pilot study. The Journal of Nervous and Mental Disease, 200, 91–94. Safren, S.A., Perlman, C.A., Sprich, S., & Otto, M.W. (2005). Mastering your adult ADHD:  A  cognitive-behavioral treatment program. New York: Oxford. Samuels, J. F., Bienvenu, O. J., Grados, M. A., Cullen, B., Riddle, M. A., Liang, K.-y., et al. (2008). Prevalence and correlates of hoarding behavior in a community-based sample. Behaviour Research and Therapy, 46, 836–844. Samuels, J., Bienvenu III, O.J., Riddle, M.A., Cullen, B.A.M., Grados, M.A., Liang, K.Y., et  al. (2002). Hoarding in obsessive compulsive disorder:  Results from a case-control study. Behaviour Research and Therapy, 40, 517–528. Saxena (2013). Pharmacotherapy for compulsive hoarding. In R.O. Frost & G. Steketee (Eds.). Oxford handbook of hoarding and acquiring. New York: Oxford. Saxena, S., Ayers, C.R., Maidment, K.M., Vapnik, T., Wetherell, J.L., & Bystritsky, A. (2011). Quality of life and functional impairment in compulsive hoarding. Journal of Psychiatric Research, 45, 475–480. Saxena, S., Brody, A.L., Maidment, K.M., & Baxter, L.R. (2007). Paroxetine treatment of compulsive hoarding. Journal of Psychiatric Research, 41(6), 481–487. Saxena, S., Maidment, K.M., Vapnik, T., Golden, G., Rishwain, T., Rosen,  R., et  al. (2002). Obsessive-compulsive hoarding:  Symptom severity and response to multimodal treatment. Journal of Clinical Psychiatry, 63, 21–027. Steketee, G., & Frost, R.O., (2007). Compulsive hoarding and acquiring: Therapist guide. New York: Oxford University Press.

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Steketee, G. & Frost, R.O. (in press, 2013). Phenomenology of hoarding. In R.O. Frost & G. Steketee (Eds.). Oxford Handbook of Hoarding and Acquiring. New York: Oxford. Steketee, G., Frost, R.O., & Kyrios, M. (2003). Beliefs about possessions among compulsive hoarders. Cognitive Therapy & Research, 27, 463–479. Steketee, G., Frost, R.O., Tolin, D.F., Rasmussen, J., & Brown, T.A. (2010). Waitlist-controlled trial of cognitive behavior therapy for hoarding disorder. Depression and Anxiety, 27, 476–484. Steketee, G., Frost, R.O., Wincze, J., Greene, K., & Douglass, H. (2000). Group and individual treatment of compulsive hoarding: A pilot study. Behavioural and Cognitive Psychotherpy, 28, 259–268. Steketee, G., Gibson, A., Frost, R.O., Alabiso, J., Arluke, A., & Patronek, G. (2011). Characteristics and antecedents of animal hoarding: A comparative interview study. Review of General Psychology, 15, 114–124. Thomas, N.D. (1997). Hoarding: Eccentricity or pathology: When to intervene? Journal of Gerontological Social Work, 29, 45–55. Timpano, K.R., Exner, C., Glaesmer, H., Rief, W., Keshaviah, A., Brahler, E., et al. (2011). The epidemiology of the proposed DSM-5 hoarding disorder:  Exploration of the acquisition specifier, associated features, and distress. Journal of Clinical Psychiatry, 72, 780–786. Tolin, D.F., Fitch, K.E, Frost, R.O., & Steketee, G. (2010a). Family informants’ perceptions of insight in compulsive hoarding. Cognitive Therapy and Research, 34, 69–81. Tolin, D.F., Frost, R.O., & Steketee, G. (2007a). An open trial of cognitive-behavioral therapy for compulsive hoarding. Behaviour Research and Therapy, 45, 1461–1470. Tolin, D. F., Frost, R., & Steketee, G. (2010b). A brief interview for assessing compulsive hoarding: The Hoarding Rating Scale-Interview. Psychiatry Research, 178, 147–152. Tolin, D.F., Frost, R.O., & Steketee, G. (2012). Working with hoarding vs. non-hoarding clients: A survey of professionals’ attitudes and experiences. Journal of Obsessive Compulsive and Related Disorders, 1, 48–53. Tolin, D.F., Frost, R.O., Steketee, G., & Fitch, K.E. (2008b). Family burden of compulsive hoarding: Results of an internet survey. Behaviour Research and Therapy, 46, 334–344. Tolin, D.F., Frost, R.O., Steketee, G., Gray, K.D., & Fitch, K.E. (2008a). The economic and social burden of compulsive hoarding. Psychiatry Research, 160, 200–221. Tolin, D.F., Meunier, S.A., Frost, R.O., & Steketee, G. (2011). Compulsive hoarding among patients seeking treatment for anxiety disorders. Journal of Anxiety Disorders, 25, 43–48.

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Tolin, D.F., Meunier, S.A., Frost, R.O., & Steketee, G. (2010c). The course of compulsive hoarding and its relationship to life events. Depression & Anxiety, 27, 829–838. Tolin, D.F. & Villavicencio, A. (2011). Inattention, but not OCD, predicts the core features of hoarding disorder. Behaviour Research and Therapy, 49, 120–125. Turner, K., Steketee, G., & Nauth, L. (2010). Treating elders with compulsive hoarding: A pilot program. Cognitive and Behavioral Practice, 17, 449–457. Wells, A. (2011). Meta-cognitive therapy for anxiety and depression. New York: Wiley. Wheaton, M. & VanMeter, A. (in press, 2013). Comorbidity in hoarding disorder. In R.O. Frost & G. Steketee (Eds.), Oxford Handbook of Hoarding and Acquiring. New York: Oxford. Wilhelm, S., & Steketee, G. (2006). Treating OCD with cognitive therapy. Oakland, CA: New Harbinger. Wincze, J.P., Steketee, G., & Frost, R.O. (2007). Categorization in compulsive hoarding. Behaviour Research and Therapy, 45, 63–72. Winsberg, M.E., Cassic, K.S., & Korran, L.M. (1999). Hoarding in obsessive-compulsive disorder: A report of 20 cases. Journal of Clinical Psychiatry, 60, 591–597.

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Readings and Resources

Books on Hoarding Bratiotis, C., Schmalisch, & Steketee, G. (2011). The hoarding handbook: A guide for human service professionals. New York: Oxford. Frost, R.O., & Steketee, G. (2010). Stuff:  Compulsive hoarding and the meaning of things. New York: Houghton/Mifflin/Harcourt. Frost, R.O. & Steketee, G. (Eds.) (2013). Oxford handbook of hoarding and acquiring. New York: Oxford. Muroff, J., Steketee, G., & Underwood, J. (2013). Group treatment for hoarding disorder: Therapist guide. New York: Oxford. Neziroglu, F., Bubrick, J., & Yaryura–Tobias, J. (2004). Overcoming compulsive hoarding. Oakland, CA: New Harbinger. Tolin, D., Frost, R.O., & Steketee, G. (2014). Buried in treasures: Help for compulsive hoarding, 2nd Ed. New York: Oxford.

Articles on Assessment of Hoarding Frost, R.O., Hristova, V., Steketee, G., & Tolin, D.F. (2013). Activities of daily living in hoarding disorder. Journal of Obsessive Compulsive and Related Disorders.2, 85–90. Frost, R.O., Steketee, G., & Grisham, J. (2004). Measurement of compulsive hoarding:  Saving Inventory-Revised. Behaviour Research and Therapy, 42, 1163–1182. Frost, R.O., Steketee, G., Tolin, D.F., & Renaud, S. (2008). Development and validation of the Clutter Image Rating. Journal of Psychopathology and Behavioral Assessment, 30, 180–192. Rasmussen, J.L., Steketee, G., Frost, R.O., & Tolin, D.F. (under review). Assessing squalor in hoarding: The Home Environment Index.

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Steketee, G., Frost, R.O., & Kyrios, M. (2003). Beliefs about possessions among compulsive hoarders. Cognitive Therapy & Research, 27, 463–479. Tolin, D. F., Frost, R., & Steketee, G. (2010). A brief interview for assessing compulsive hoarding: The Hoarding Rating Scale-Interview. Psychiatry Research, 178, 147–152.

Articles on Treatment of Hoarding Ayers, C R., Wetherell, J. L., Golshan, S., & Saxena, S. (2011). Cognitive-behavioral therapy for geriatric compulsive hoarding. Behaviour Research and Therapy, 49, 689–694. Frost, R. & Hartl, T. (1996). A cognitive-behavioral model of compulsive hoarding. Behaviour Research and Therapy, 34, 341–350. Frost, R.O., Pekorava-Kochergina, A., Maxner, S. (2011). The effectiveness of a biblio-based support group for hoarding disorder. Behaviour Research and Therapy, 49, 628–634. Frost, R.O., Ruby, D., & Shuer, L. (2012). The Buried in Treasures Workshop: Wait list control trial of facilitated self-help for hoarding disorder. Behaviour Research and Therapy, 50, 661–667. Hartl, T.L., & Frost, R.O. (1999). Cognitive-behavioral treatment of compulsive hoarding:  a multiple baseline experimental case study. Behaviour Research and Therapy, 37, 451–461. Muroff, J., Steketee, G., Rasmussen, J., Gibson, A., Bratiotis, C., & Sorrentino, C. (2009). Group cognitive and behavioral treatment for compulsive hoarding: A preliminary trial. Depression and Anxiety, 26(7), 634–640. Muroff, J., Steketee, G., Bratiotis, C., & Ross, A. (2012). Group cognitive and behavioral therapy and bibliotherapy for hoarding: A pilot trial. Depression and Anxiety, 29(7), 597–604. Saxena, S., Maidment, K.M., Vapnik, T., Golden, G., Rishwain, T., Rosen, R., et  al. (2002). Obsessive-compulsive hoarding:  Symptom severity and response to multimodal treatment. Journal of Clinical Psychiatry, 63, 21–027. Steketee, G., Frost, R.O., Tolin, D.F., Rasmussen, J., & Brown, T.A. (2010). Waitlist-controlled trial of cognitive behavior therapy for hoarding disorder. Depression and Anxiety, 27, 476–484.

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Steketee, G., Frost, R.O., Wincze, J., Greene, K., & Douglass, H. (2000). Group and individual treatment of compulsive hoarding: A pilot study. Behavioural and Cognitive Psychotherpy, 28, 259–268. 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. Turner, K., Steketee, G., & Nauth, L. (2010). Treating elders with compulsive hoarding: A pilot program. Cognitive and Behavioral Practice, 17, 449–457.

Therapist Guides for Problems Related to Hoarding Abramowitz, J.S. (2006). Obsessive Compulsive Disorder. Boston:  Hogrefe & Huber Publishers. Foa, E.B., Yadin, E. & Lichner, T.K. (2012). Exposure and Response (Ritual) Prevention for Obsessive-Compulsive Disorder (2nd ed.). New York: Oxford University Press. Miller, W.R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York: Guilford. Safren, S.A., Perlman, C.A., Sprich, S., & Otto, M.W. (2005). Mastering your adult ADHD:  A  cognitive–behavioral treatment program. New York: Oxford University Press. Wilhelm, S., & Steketee, G. (2006). Treating OCD with cognitive therapy. Oakland, CA: New Harbinger.

Self-Help Books on Organizing Hemphill, B. (1992). Taming the paper tiger: Organizing the paper in your life. Washington, DC: The Kiplinger Washington Editors. Kolberg, J., & Nadeau, K. (2002). ADD—Friendly ways to organize your life. New York: Routledge. Smallin, D. (2002) Organizing plain and simple: A ready reference guide with hundreds of solutions to your everyday clutter challenges. North Adams, MA: Storey Publishing. Waddill, K. (2001). The organizing sourcebook: Nine strategies for simplifying your life. New York: McGraw–Hill.

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Report on Animal Hoarding Patronek, G.J., Loar, L., & Nathanson, J. (Eds.) 2006. Animal hoarding:  structuring interdisciplinary responses to help people, animals and communities at risk. Hoarding of Animals Research Consortium. Available at www.tufts.edu/vet/cfa/hoarding. Accessed June 14, 2013.

Web Resources International Obsessive Compulsive Disorder Foundation: www.ocfoundation.org/hoarding. Accessed June 14, 2013. Hoarding of Animals Research Consortium:  www.tufts.edu/vet/cfa/hoarding. Accessed June 14, 2013.

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About the Authors

Gail Steketee, PhD, is Dean and Professor of the Boston University School of Social Work. She received her MSS and PhD from the Bryn Mawr Graduate School of Social Work and Social Research. Her research has focused on understanding the causes and consequences of obsessive-compulsive (OC) spectrum conditions, especially hoarding disorder, and on developing and testing evidence-based treatments for these conditions. She has received several grants from NIMH and from the International OCD Foundation to examine family factors that influence treatment outcomes for anxiety disorders and to test cognitive and behavioral treatments for OCD, hoarding disorder and body dysmorphic disorder. Her research on hoarding with collaborators Drs. Randy Frost and David Tolin has contributed significantly to the development of diagnostic criteria for hoarding disorder (HD) in the major revision of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5, 2013). Dr. Steketee has published more than 200 articles and chapters and more than a dozen books on research findings and evidence-based treatments for OCD, hoarding, and related disorders. Her research has been funded by the National Institute of Mental Health and the International OCD Foundation (IOCDF). Her best-selling book Stuff:  Compulsive Hoarding and the Meaning of Things, co-authored with Dr.  Frost, was a finalist for the Books for a Better Life Award. She is a Fellow in the American Academy of Social Work and Social Welfare and has received awards from the Association of Behavioral and Cognitive Therapies, the Society of Social Work Research, the International OCD Foundation, and the Aaron T. Beck Institute for Cognitive Studies. She serves on editorial boards and as ad hoc reviewer for multiple journals in social work, psychology, and psychiatry. She also serves on scientific advisory boards of U.S. and Canadian OCD foundations and on a Commission for the Council of Social Work Education. She has appeared in a variety of media venues regarding her work on hoarding. Dr. Randy O. Frost is currently the Harold and Elsa Siipola Israel Professor of Psychology at Smith College. He received his PhD from the University of Kansas in 1977 following a doctoral internship at the University of Washington School of Medicine. He is an internationally recognized expert on obsessive-compulsive disorder and hoarding disorder and has published more than 150 scientific articles and book chapters on these topics. Dr. Frost serves on the Scientific Advisory Board of the International OCD Foundation, and with Dr. Gail Steketee, co-edits the Hoarding Center on the IOCDF website. He has co-authored several books on hoarding including Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding (with Drs. David Tolin and Gail Steketee and published by Oxford University Press). Buried in Treasures received

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a Self-Help Book of Merit Award from the Association for Behavioral and Cognitive Therapy in 2010. His best-selling book, Stuff:  Compulsive Hoarding and the Meaning of Things (with Gail Steketee), was published by Houghton, Mifflin, Harcourt in 2010 and was a finalist for the 2010 Books for a Better Life Award. Stuff was also named a Must Read Book for 2011 by Massachusetts Book Awards. Stuff has been translated into four languages. His work has been funded by the International Obsessive Compulsive Foundation and the National Institute of Mental Health. Dr. Frost is one of the original members of the Hoarding of Animals Research Consortium and has served as consultant to numerous communities in setting up task forces to deal with the problem of hoarding. In 2012 he was awarded the Lifetime Achievement Award for excellence in innovation, treatment, and research in the field of hoarding and cluttering by the Mental Health Association of San Francisco and by the International OCD Foundation.

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Index

Page numbers followed by “t” indicate a table and “f ” indicate a figure. Acquiring form, 56, 57f, 92, 93f, 227 Acquiring behaviors, 55–56 Acquiring reduction advantages and disadvantages, 110–11, 111t, 164–65, 164t attention focus, 109–10 avoidance, 109 changing thinking, 116–22 coping skills, 109, 114, 115 downward arrow method, 117–19, 165–68, 178 drive-by non-shopping, 113 enjoyment, alternative sources, 115 faulty thinking, 116–17, 160–62, 178 habituation, 112, 112f, 145–46, 146f homework, 123 importance (need vs. want), 121–22, 174–76 model, 56, 108–9 positive reinforcement, 107–8, 115 practice hierarchy, 112–14, 112f, 113t questions for, 110 rules for, 111 Socratic questioning, 73, 90, 102, 119–20, 168–72, 178 treatment planning, 108–9 value, overestimating, 120–21 visualization, 56, 57f, 92, 93f, 227 Acquiring visualization form, 230 Activities of Daily Living in Hoarding (ADL-H), 30, 30t, 219, 223 Advantages and disadvantages strategy, 110–11, 111t, 164–65, 164t Advising clients, 76 Affirmations, 74–75 All-or-nothing thinking, 116, 160 Ambivalence, identifying, 64, 70–73, 75, 80, 160 Anger, 101–2 Animal hoarding, 11–12, 186

Anosognosia, 8, 65, 66 Anxiety, 9, 16–17, 40–42, 50, 187 Arguing, 70–71 Asking for elaboration, 76–77 Assessment family members discussion, 34–35 hoarding symptoms, 27–31, 28–30t home visit, 32–37 homework for, 36–37 in-office, 27–31, 28–30t plan, 24–27 psychiatric problems, 31–32 Attachments, 5–6, 29–30, 48, 146–149 Attention deficit, 9, 31–32, 47, 130, 189–90 Attention/distraction management, 130–31 Autism, 4, 7, 187–88 Automatic thoughts strategy, 162–63, 162t Avoidance behaviors, 9–10, 51–52, 69, 144–45 Baxter, L. R., 19 Behavioral experiments decision making, 152–53, 152f form, 152, 152f motivation enhancement, 79–80 Black, D.W., 19 Booster sessions, 197–98 Brain injury, 4, 7 Brief Thought Record, 54–55, 226 Brody, A. L., 19 Buried In Treasures (BIT) workshop, 198 Case formulation acquiring behaviors considerations, 55–56 Brief Thought Record, 54–55, 226 collaboration, 42–44, 66, 85 conceptual model building (see conceptual model building)

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Case formulation (Cont.) coping behaviors, 40–41t, 58–61 functional analysis, 39, 56–63, 62f homework, 63 triggers, 40–41t, 58–61 Catastrophizing, 116, 161 CBT (see cognitive behavioral treatment) Cerebrovascular disease, 4, 7 Cermele, J. A., 14 Change talk, 77 Checking rituals, 188–89 Child, elder endangerment, 185–86 Cleanouts, 156–57 Clinician session form, 25–26, 206–7 Clutter Image Rating, 28–29, 29t, 217 Clutter visualization form, 88, 228 Coaches CBT, 20 friends, family members as, 35–36 instructions for, 233–35 in treatment planning, 13, 20, 83, 103–4 trust, 235 Cognitive behavioral treatment (CBT) age, ethnicity effects, 16 behaviors, focus of, 5 benefits, 18 coaches, 20 development, 13–14 evidence base, 14–16 goals, 1–3 home visits, 13–14, 20 homework, 21 model, 16–17, 17f motivation (see motivation enhancement) predictors of outcome, 15–16 program outline, 19–21 risks, 17–18 session structure, 21 strategies (see cognitive strategies) Workbook usage, 22 Cognitive biases, 102 Cognitive disabilities, 191 Cognitive strategies advantages and disadvantages, 110–11, 111t, 164–65, 164t automatic thoughts, 162–63, 162t core beliefs, 162–63, 162t, 178 downward arrow method, 117–19, 165–68, 178 faulty thinking, 116–17, 160–62, 178 homework, 179 implementation, 163 importance (need vs. want), 121–22, 174–76

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metaphors and stories, 80, 177–78 need versus want, 121–122, 174–176 perfectionism (see perfectionism) questions about possessions, 163 reassurance seeking behaviors, 189 Socratic questioning, 73, 90, 102, 119–20, 168–72, 178 taking another perspective, 172–74 Thought Records, 174, 175f, 232 valuing time, 178 Collaboration, 42–44, 66, 85 Complaining, 70 Complications animal hoarding, 11–12, 186 attention deficit, 9, 31–32, 47, 130, 189–90 autism, 4, 7, 187–88 child, elder endangerment, 185–86 depression, 45–46, 69, 186–87 developmental disabilities, 191 family behaviors, 183–84 financial, 182–83 generalized anxiety disorder, 9, 187 health, medical, 181–82 housing, 184–85 OCD (see obsessive compulsive disorder) PTSD, 190–91 resources, 181 safety issues, 31, 185, 220, 224 social phobia, 9, 46, 187–88 stealing, 190 trauma, 190–91 Compulsive buying, 7–8 Conceptual model building brief thought record, 54–55, 226 decision-making problems, 40t, 46 elements of, 39–44, 40–41t, 54f emotional responses, 41t, 50–51 information processing, 40–41t, 46–47 learning processes, 41t, 51–53 meaning of possessions, 40–41t, 48–49 vulnerability factors, 40–41t, 44–46, 69 Confidence, 67, 72 Control issues, 85 Coping behaviors, 40–41t, 58–61 Coping skills, 109, 114, 115 Core beliefs strategy, 162–63, 162t, 178 Criticism, sensitivity to, 100–101 Davidow, J., 13 Deadlines, ultimatums, 105 Decision-making avoidance of, 144–45

behavioral experiments, 152–53, 152f cleanouts, 156–57 guided imagery, 154 habituation, 112, 112f, 145–46, 146f homework, 150–51, 157–58 imagined discarding, 153 imagined exposure to lost information, 155 imagined loss of possessions, 154–55 influence on your life experiment, 156 needing objects in sight, 155–56 newspapers, magazines, 140 problems with, 40t, 46 questions for, 149 rules establishment, 149–50 skills training, 144, 151 thought listing exercise, 146–49, 148f, 149 treatment planning, 85–86 Defensiveness, 66 Dementia, 191 Depression, 45–46, 69, 186–87 Developmental disabilities, 191 Diagnosis acquisition, 4, 7–8 background, 3–4 comorbidities, 9–10 congestion, clutter, 6 diagnostic criteria, 4 differential, 9–10 difficulty discarding, 4, 5 impairment, 4, 6 insight, 4–5, 8 medical, mental disorders causing, 6–7 specifiers, 4–5 Discarding, imagined, 153 Discounting the positive, 116, 161 Discouraged despite progress, 72 Discrepancy, developing, 67–68, 74 Discussion, diverting, 70 Documents, organization of, 137–41, 138t, 140t Downward arrow method, 117–19, 165–68, 178 Drive-by non-shopping, 113 Elaboration, asking for, 76–77 Elder endangerment, 185–86 Emotional reasoning, 116, 161 Emotional responses, 41t, 50–51 Empathy, understanding, 69–70 Eviction, 184–85 Evocative questions, 76 Exploring pros and cons, 76

Exposure exposure and ritual prevention (ERP), 18, 189 imagined exposure, 153–155 practice, 95–97, 145–146 Extreme contrasts, using, 77 Family members assessment discussion, 34–35 behaviors, as complication, 183–84 coaching by, 35–36 impediments, addressing, 68–69 reassurance seeking behaviors, 189 Family patterns, 10–11 Family Response to Hoarding Scale (FRHS), 183–84, 236–42 Faulty thinking, 116–17, 160–62, 178 Feeling overwhelmed, 103 Feelings, avoidance of, 104 Filing paper, 137–41, 138t, 140t Financial complications, 182–83 Forced cleanouts, 18 Forms acquiring, 56, 57f, 92, 93f, 227 acquiring visualization, 230 Activities of Daily Living in Hoarding (ADL-H), 30, 30t, 219, 223 behavioral experiments, 152, 152f brief thought record, 54–55, 226 clinician session, 25–26, 206–7 Clutter Image Rating, 28–29, 29t, 217 clutter visualization, 88, 228 Family Response to Hoarding Scale (FRHS), 183–84, 236–42 filing paper, 139 general conceptual model of hoarding, 42, 225 Hoarding Interview, 27, 208–13 Hoarding Rating Scale, 27–28, 28t, 214, 223 Home Environment Index, 31, 221–22, 224 practice, 94–95, 231 preparing for organizing, 135 safety questions, 31, 185, 220, 224 Saving Cognitions Inventory, 29–30, 30t, 218, 223 Saving Inventory-Revised, 28, 29t, 215–16, 223 scoring keys, 223–24 thought records, 174, 175f, 232 unclutter visualization, 89–90, 91f, 229 Free things acquisition, 7–8, 107–8. see also acquiring reduction Friends as coaches, 35–36

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Frost, R. O., 14 Functional analysis, 39, 56–63, 62f General conceptual model of hoarding form, 42, 225 Generalized anxiety disorder, 9, 187 Genetic patterns, 10–11 Guided imagery, 154 Habituation, 112, 112f, 145–46, 146f Hartl, T. L., 14 Health, medical complications, 181–82 Hoarding Disorder background, 1–3 complications (see complications) course, 10–11 diagnosis (see diagnosis) family patterns, 10–11 impairment, 6 medical, mental disorders causing, 6–7 prevalence, 10–11 terminology, 1–2 Hoarding interview form, 27, 208–13 Hoarding of Animals Research Consortium (HARC), 11–12 Hoarding Rating Scale, 27–28, 28t, 214, 223 Home Environmental Index, 31, 221–22, 224 Home visit assessment, 32–34 criticism, sensitivity to, 100–101 family members discussion, 34–35 friends, family members as coaches, 35–36 special issues, 36 Homework acquiring reduction, 123 case formulation, 63 cognitive strategies, 179 compliance, 80–81 connecting methods to model, 96–100, 97f decision making, 150–51, 157–58 maintenance of gains, 203 non-completion, 72 skills training, 133, 142 treatment planning, 105–6 Housing concerns, 184–85 Imagined exposure discarding, 153 lost information, 155 loss of possessions, 154–55 Impediments, addressing, 68–69 Importance (need vs. want), 121–22, 174–76 Influence on your life experiment, 156

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Information processing, 40–41t, 46–47. see also skills training Insight, 65–66 (see also diagnosis, insight) Interventions. see also treatment alternative, 18 behaviors focus of, 5 goals, 1–3 impediments, 64 Jumping to conclusions, 116, 161 Kim, H.-J., 65 Labeling, 117, 161 Landlords, 184–85 Lapses, 202–3 Learning processes, 41t, 51–53 Looking forward, back, 77 Loss of possessions, imagined, 154–55 Magazines, 140, 155, 171–72 Maidment, K. M., 19 Maintenance of gains booster sessions, 197–98 homework, 203 progress review, 194–97, 196f, 196t self-sessions, 197–98 setbacks, dealing with, 202–3 treatment techniques review, 199–202, 200–201t Major depressive disorder, 4, 7, 9, 31–32 Mandated reporting, 17, 36, 185–86 Mataix-Cols, D., 19 Meaning of possessions, 40–41t, 48–49 Medical complications, 181–82 Melendez-Pallitto, L., 14 Metaphors, 80, 177–78 Miller, W., 64, 72 Moral reasoning, 117, 161 Motivational interviewing, 64, 67, 72–74 Motivation enhancement affirmation, 74–75 ambivalence, identifying, 70–73, 75 arguing, 70–71 asking for elaboration, 76–77 assumptions underlying methods, 72–74 avoiding accepting responsibility, 75 behavioral experiments, 79–80 change talk, 77 complaining, 70 defensiveness, 66 discouraged despite progress, 72 discrepancy development, 67–68, 74

discussion, diverting, 70 empathy, understanding, 69–70 evocative questions, 76 exploring pros and cons, 76 extreme contrasts, using, 77 factors in sustaining, 67 homework, not completing, 72 homework compliance, 80–81 impediments, addressing, 68–69 informing, advising, 76 insight, 65–66 looking forward, back, 77 metaphors, 80, 177–78 methods to avoid, 78–79 open ended questions, 74 overvalued ideation (OVI), 65–66 personal choice, emphasizing, 77 persuasion vs. curiosity, 73 problem solving, 79 rating importance and confidence in change, 78 reflective listening, 75, 90 reframing statements, 77 resistance, rolling with, 74 strategies, 74–78 successful clients, speaking to, 80 summarizing, 75 taking the negative side, 76 therapeutic reactance, 66 therapy-interfering behaviors, 71–72 trust, 2, 5, 10, 13, 73, 85, 105, 235 Muroff, J., 13 Needing objects in sight, 155–56 Need vs. want (importance), 121–22, 174–76 Negative reinforcement, 51–53, 60 Neurocognitive disorders, 4, 7 Newspapers, 140, 155, 171–72 Obsessive compulsive disorder (OCD) CBT, 14 differential diagnosis, 3, 4, 7, 9 ERP, 18, 189 overvalued ideation (OVI), 65–66 symptoms, 188–89 Only handle it once (OHIO), 86 Open ended questions, 74 Organization objects, 125, 131–37, 134t paper, 137–41, 138t, 140t Overestimating, 117, 161 Overgeneralization, 116, 161 Overvalued ideation (OVI), 65–66

Pandina, G.J., 14 Paranoid personality, 9–10 Paroxetine, 19 Perfectionism advantages and disadvantages strategy, 110–11, 111t, 164–65, 164t all-or-nothing thinking, 116, 160 anger, 101–2 arguing, 70–71 in conceptual model development, 41t continuum, 176–78 core beliefs strategy, 162–63, 162t, 178 moral reasoning, 117, 161 predictive value of, 16, 195 Socratic questioning, 73, 90, 102, 119–20, 168–72, 178 as symptom, 9–10, 17f Personal choice, emphasizing, 77 Personal organizing plan, 133, 134t, 136–37, 136f Photographs, 33, 72, 90, 94 Possessions, meaning of, 40–41t, 48–49 Practice form, 94–95, 231 Prader-Willi Syndrome, 4, 7 Preparing for organizing form, 135 Problem solving decision-making problems, 40t, 46 motivation enhancement, 79 skills training, 125, 127–29, 127t Progress review, 194–97, 196f, 196t Pros and cons, exploring, 76 Psychosis, 4, 7, 65 PTSD, 190–91 Rating importance and confidence in change, 78 Reassurance seeking behaviors, 189 Reflective listening, 75, 90 Reframing statements, 77 Relapses, 202–3 Rollnick, S., 64, 74 Safety deadlines, ultimatums, 105 housing concerns, 184–85 issues, 31, 185, 220, 224 questions form, 31, 185, 220, 224 Sanitation issues, 181–82 Saving Cognitions Inventory, 29–30, 30t, 218, 223 Saving Inventory-Revised, 28, 29t, 215–16, 223 Saxena, S., 14, 19 Schizophrenia, 4, 7, 9–10, 65

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Self-sessions, 197–98 Setbacks, dealing with, 202–3 Skills training attention/distraction management, 130–31 client education, 125–27 goals development, 125–27 homework, 133, 142 organization (objects), 125, 131–37, 134t organization (paper), 137–41, 138t, 140t personal organizing plan, 133, 134t, 136–37, 136f problem solving, 125, 127–29, 127t system maintenance, 141 Social phobia, 9, 46, 187–88 Social support, 103–4 Socratic questioning, 73, 90, 102, 119–20, 168–72, 178 Sorting, 83, 86. see also organization Speaking aloud, 86 SSRI medications, 14, 19 Statements, reframing, 77 Stealing, 190 Stories strategy, 80, 177–78 Successful clients, speaking to, 80 Suicidal ideation, 186–87 Summarizing technique, 75 Taking another perspective strategy, 172–74 Taking the negative side, 76 Therapeutic reactance, 66 Therapy-interfering behaviors, 71–72 Thought listing exercise, 146–51, 148f Thought Record, 174, 175f, 232 Time, valuing strategy, 178 Tolin, D. F., 65 Training skills. see skills training Trauma, 10, 190–91 Treatment approach to, 66 CBT (see cognitive behavioral treatment) techniques review, 199–202, 200–201t Treatment planning acquiring reduction, 108–9 anger, 101–2 coaches, 83, 103–4 connecting methods to model, 96–100, 97f control issues in, 85 criticism, sensitivity to, 100–101

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deadlines, ultimatums, 105 decision making, 85–86 feeling overwhelmed, 103 feelings, avoidance of, 104 flexibility, 87 goals, 83–85 homework, 105–6 only handle it once (OHIO), 86 practice, 94–95, 231 rules, 85–87 social support, 103–4 Socratic questioning, 73, 90, 102, 119–20, 168–72, 178 sorting defined, 83 sorting plan, 86 speaking aloud, 86 systematic process in, 86 troubleshooting barriers, 100 unusual beliefs, 104–5 visualization (see visualization) Triggers avoidance, 109 case formulation, 40–41t, 58–61 Trust, 2, 5, 10, 13, 73, 85, 105, 235 Unclutter visualization form, 89–90, 91f, 229 Underestimating, 117, 161 Understanding, empathy, 69–70 Valuing time strategy, 178 Venlafaxine, 19 Visitor effect, 68 Visitors, 36 Visualization acquiring, 56, 57f, 92, 93f, 227 clutter, 87–89, 228 discrepancy development, 67–68 guided imagery, 154 ideal home, 90–92 imagined discarding, 153 imagined exposure to lost information, 155 imagined loss of possessions, 154–55 influence on your life experiment, 156 needing objects in sight, 155–56 unclutter, 89–90, 91f, 229 Vulnerability factors, 40–41t, 44–46, 69 Winsberg, M. E., 19