Maintaining Gains

Chapter 12 provides forms to assist clinicians and clients in re-evaluating the severity of hoarding and related daily activities to determine progress made during therapy. Clients review their hoarding model and their initial goals in therapy to consider how much progress they have made. A careful review of all of the treatment methods used during the therapy helps clients decide which methods worked best for them and which ones they should continue to use in the coming months following treatment. Clinicians help clients develop specific strategies for continuing to work on hoarding and whether to schedule booster sessions. They try to anticipate potential problems that might occur in the coming months and to develop ways clients can cope when setbacks and lapses occur.

Complications in the Treatment of Hoarding Disorder

Chapter 11 reviews a variety of potential complicating factors that may arise during the course of treatment of hoarding and acquiring problems. These cover the following topics: medical problems, financial needs, family responses and family members with hoarding, housing needs, safety problems, endangerment of children and elders living in or near the home, and animal care. In addition, people who hoard may suffer from comorbid mental health problems such as depression, generalized and social anxieties, OCD, attention deficits, stealing, trauma histories, and cognitive disabilities. Strategies for managing these problems are suggested.

Enhancing Motivation

Chapter 5 briefly discusses insight and motivation problems, and guides clinicians through the use of motivational enhancement methods with clients who experience and display ambivalence about working on their hoarding and acquiring problems. Clinicians begin with a detailed discussion of clients’ personal values and goals to provide a firm foundation. Following Miller and Rollnick’s work on motivational interviewing, basic assumptions of this approach are described. The chapter describes a variety of specific strategies to help clients resolve ambivalence whenever this occurs during the therapy process.

Introduction to Hoarding Disorder

Chapter 1 provides clinicians with a summary of the phenomenology and diagnostic aspects of hoarding, including comorbidity, demographic characteristics, prevalence and common accompanying features. This information provides basic background for understanding and diagnosing HD. Described in detail only two decades ago, hoarding disorder (HD) refers to excessive urges to save objects, with accompanying difficulty discarding or removing them from the home and extensive clutter that impairs functioning. Distress about the state of the home is common, and hoarding often affects those living with or near the person with HD. The condition is commonly accompanied by excessive acquiring behavior.

Making Decisions About Saving and Discarding

Chapter 9 helps facilitate clients’ discarding decisions. After reviewing the role of avoidance and habituation of discomfort, clinicians help clients engage in a thought listing exercise to clarify the thoughts that occur to them during decision-making about whether to keep or discard items. Clinicians help clients list questions to use and establish rules for keeping and discarding to facilitate decision-making. Other strategies include behavioural experiments to test beliefs, and practicing thought listing during in-home practice. Imagined discarding is part of a process of graduated saving and discarding exercises. Potential assistance in cleaning out clutter is discussed.

Evidence-Based Treatment for Hoarding Disorder

Chapter 2 includes a detailed description of a model for understanding hoarding disorder. This is followed by a brief review of recent research on specialized behavioural and cognitive strategies developed specifically to address hoarding problems derived from the model. These strategies include case formulation, treatment planning, motivational interviewing, skills training, practicing non-acquiring and discarding, and cognitive therapy interventions. This combination treatment has shown good, outcomes in studies of individual and group formats. The basic outline of the method and therapy format is noted and forms the basis for the next chapters in this therapist guide.

Cognitive Strategies

Chapter 10 provides clinicians with various cognitive therapy methods that can assist clients during the process of non-acquiring, sorting, and discarding activities. These include a review of problematic thinking styles, a list of self-generated questions about possessions, a review of advantages and disadvantages, the downward arrow method, using brief and longer versions of thought records, defining the importance and the value of objects using rating scales, and use of a perfection scale. Methods that appear to work best for clients can be selected for use during office and homework sessions.

Training Skills

Chapter 8 encourages clinicians to assist clients in learning various skills to assist them in sorting and organizing the clutter items. Several forms are used to assist in the organizing process, including a list of tasks, a plan for where to keep objects and papers, including suggestions for how long to keep certain types of important papers. Preparation for organizing includes assembling materials needed for filing and storing items. Clinicians train clients in problem-solving skills to enable them to move forward when challenges to organizing and sorting arise. Decision-making practice occurs in concert with training in how and where to keep wanted items, as well as where to put unwanted items to remove them from the home.

Planning Treatment

Chapter 6 beging treatment planning with the use of photos from the initial home visit, a review of the client’s conceptual model of hoarding, and the goals of treatment. Clinicians discuss rules by which they will proceed during the therapy so that clients make all of the decisions about their possessions. Clients learn to visualize their rooms in a cluttered and uncluttered state and develop an initial practice plan for how to work on the acquiring, organizing and difficulty discarding problems with regard to the order of the items and rooms. Clinicians may use problem-solving strategies if needed and can include the coach if appropriate in the planning sessions.

Reducing Acquiring

Chapter 7 focuses on reducing client’s acquiring behaviors, with initial reference to the conceptual model for hoarding from chapter 4. Clinicians use forms to assist clients with questions about acquiring to help them with decision-making and the development of a hierarchy for graduated non-acquiring practice. A review of problematic thinking patterns and the downward arrow method to serious fears associated with not acquiring are drawn from cognitive therapy methods. Two scales are used to help clarify the difference between the actual need versus the wish to acquire items. Clients are helped to generate acquiring questions they can use when confronting urges to accumulate items, as well as alternative pleasurable activities that can replace enjoyment from acquiring.