Questions And Answers About Hoarding

Everything You Wanted to Know About Compulsive Hoarding (but were Afraid to Ask) by Cristina M. Sorrentino, PhD, MSW

What is compulsive hoarding?

Compulsive hoarding has been defined as the acquisition of and failure to discard items that appear to be useless or of little value. It is manifested in excessive possessions in the home interfering with the normal use of living space and furniture, and is accompanied by significant interference or distress.

Compulsive hoarding is commonly considered to be a type of obsessive-compulsive disorder. Some estimate that 19 to 25% of people with OCD also have compulsive hoarding. Recent research by Drs. Gail Steketee and Randy Frost suggests that 17% of people with compulsive hoarding have OCD separate from hoarding. Compulsive hoarding is also considered a feature of obsessive-compulsive personality disorder and may develop along with other mental illnesses, such as dementia and schizophrenia.

What kinds of things do people hoard?

Most often, people with compulsive hoarding hoard common possessions, such as paper (e.g., mail, newspapers), books, clothing, and containers (e.g., boxes, paper and plastic bags). Some individuals hoard garbage or rotten food. More rarely, people hoard animals, such as cats, and human waste.

How is compulsive hoarding different from being a “pack rat”?

In large part, the difference is one of degree. In general, people with compulsive hoarding have more clutter, acquire more items than they need, can use, or can afford, have more difficulty organizing their possessions and discarding items, and experience considerably more interference and distress from the state of their homes.

Typically, individuals with compulsive hoarding avoid inviting friends and family members to the home due to shame or embarrassment about their clutter. Oftentimes, they lose important things, such as money and bills, among unimportant things, such as old newspapers and empty containers. When these individuals attempt to discard items of little value or use, they often experience strong feelings of anxiety, guilt, or anger. Individuals with compulsive hoarding may describe their possessions as having ‘taken over.’ Family members and friends may be very concerned about the state of the home and about such behaviors as excessive acquiring of purchased and free items (e.g., possessions that others have discarded).

This said, “pack rat” is sometimes simply another way of describing someone who has a lot of things and who might be considered to have compulsive hoarding.

Why do people develop compulsive hoarding?

There are many contributors to compulsive hoarding and different individuals with this problem may develop it for different reasons. There is some evidence that compulsive hoarding has a genetic cause. For example it often runs in families, although this may also mean that hoarding behaviors and beliefs are learned.
People with compulsive hoarding often have very high standards, so high that it is impossible or impractical to meet them. These high standards and fear of making a mistake interfere with making decisions about objects. For example, it can be so difficult to organize the perfect filing system or make the perfect decision about whether or not to keep an object, that many people with compulsive hoarding simply give up and avoid putting themselves in the situation of having to decide. Holding onto things means not having to miss out on an opportunity or guarantees that an item will be in the home should a need for it arise. This is at the cost of noticing that the many possessions have a cost in themselves (e.g., they take up space, may present a fire hazard, etc.) Many people with compulsive hoarding have difficulty with attention, which interferes with sustained effort to sort their possessions. The sheer accumulation of possessions themselves is also distracting, worsening this difficulty. People with compulsive hoarding often have difficulty tolerating emotions such as anxiety, grief, and anger. Since these emotions are often triggered by the thought of having to discard a possession, these individuals are motivated to avoid discarding. Acquiring is often associated with positive emotions, such as pleasure and excitement, motivating individuals who experience these emotions while acquiring to keep acquiring, despite negative consequences (e.g., credit card debt, loss of space in the home due to the accumulation of possessions).

Is compulsive hoarding caused by some sort of deprivation?

Although this makes intuitive sense as an explanation for why a person would be very attached to items that appear to be of little use or value, research to date has not supported this idea. For example, in a study of elders, as many people who did, and did not, hoard reported a history of deprivation. More research is under way to examine the role of deprivation in compulsive hoarding.

Can compulsive hoarding be treated?

Yes, compulsive hoarding can be treated. It does not, however, respond well to traditional treatments for obsessive-compulsive disorder.

Over the last 10 years, Drs. Randy Frost and Gail Steketee and colleagues have developed a cognitive-behavioral treatment specifically for hoarding. The individual treatment program has included 26 sessions with every 4th visit taking place in the home to practice skills learned in treatment. In addition, group treatments are also helpful. In treatment, the therapist and client develop an understanding of the factors that contribute to the client’s hoarding. Examples of these factors include family history of saving, difficulty focusing attention on tasks like sorting and organizing possessions, and excessive acquiring. During treatment, clients learn skills to make decisions about their possessions, create a system for organizing paper, and to discard items. Clients also learn to identify and re-evaluate beliefs about possessions, such as the belief that they are responsible for an item, even if it has little use or value or the belief that they must safeguard items because they may be useful some day. They also learn to tolerate negative emotions associated with discarding and also to resist urges associated with acquiring more items. Throughout treatment, the therapist and client work on the client’s motivation to change; a high level of motivation for overcoming compulsive hoarding is difficult to maintain. Towards the end of the treatment program, clients learn about maintaining their gains and coping with lapses.
A recent evaluation of this treatment program showed that about 50% of clients experience moderate to substantial reduction in their symptoms of compulsive hoarding by the end of treatment. Another 25% experience some improvement. This treatment program is described in the therapist guide and accompanying workbook, Compulsive Hoarding and Acquiring (Steketee & Frost, 2007, Oxford University Press). Dr. David Tolin and Drs. Frost and Steketee have also written a self-help book, Buried in Treasures (Tolin, Frost, & Steketee, 2007, Oxford University Press) [more], that outlines some of the principles in the treatment program.

Are there medications that can help reduce hoarding?

Medication alone does not appear to help reduce the symptoms of compulsive hoarding although medication can be used to alleviate symptoms of conditions that may exacerbate hoarding, such as depression. One study by Dr. Sanjay Saxena suggests that paroxetine is equally effective for OCD and hoarding, but the benefits found in this study were modest.

Can’t compulsive hoarding be solved by simply cleaning out the home?

While this may seem appealing as a means of creating safe, useable living space and disposing of excessive possessions, attempts to “clean out” the homes of individuals with compulsive hoarding without treating the underlying problem usually fail.

Families and agencies, such as local departments of public health, may spend many hours and thousands of dollars clearing the homes of family or community members with compulsive hoarding only to find that the problem recurs, often within just a few months. Individuals with compulsive hoarding whose homes are cleaned without their consent often experience extreme distress and may become even more attached to their possessions and reluctant to let others help them overcome this problem.

In treatment, clients make all decisions regarding saving or discarding their possessions and therapists never touch clients’ possessions without the client’s explicit permission. When clients decide that they would like to discard a large number of possessions with the help of others, such as family members and friends, they take charge of the clean out session, establishing rules for what can and cannot be discarded and arranging for disposal of unwanted items.

So there is a lot of stuff. Why is that a problem?

The accumulation of a large number of things in the home over time can lead to a number of very serious problems. Because many people with compulsive hoarding have difficulty organizing their possessions, as the number of possessions grows, they must be piled on one another to make space for using furniture and moving through the home. These piles — of books, papers, clothing, and containers— are usually unstable and can topple on their own or when someone brushes against them.

This presents a danger of falling. Where the items are heavy, like boxes of books or overfilled shelves, possessions can fall on household members. This is particularly dangerous for children, elders, and pets. When there is a lot of clutter in the home, infestation by insects and rodents becomes a problem. It is both easier for these pests to make a home among the clutter relative to an uncluttered home and more difficult to treat the problem once the pests take up residence. In addition, possessions accumulate dust and mold and over time, this presents a health hazard for members of the household. Since symptoms may develop slowly, this problem can be difficult to diagnose. Clutter, particularly in the form of paper, can be a fire hazard.

Oftentimes, paper may be directly on the stove, whether due to being placed there directly or due to having encroached on the stove because adjacent areas are cluttered. Individuals with hoarding may have a heating system in disrepair due to the difficulty of accessing the heating system or shame about the condition of the home preventing the person from allowing a repair person into the home. They may use space heaters to provide heat, overloading power outlets or running power cords over flammable objects. If there is a fire or a medical emergency, the clutter in the home can prevent fire fighters or emergency personnel from entering the home or from accessing the person in need. This has resulted in death of the individual with compulsive hoarding or other family members on many occasions.

It is not unusual for compulsive hoarding to result in legal problems. Concerned neighbors or family members may seek help from the department of public health or the fire department. Because of federal and state law outlining conditions that constitute a fire, personal, or public health hazard, an individual with compulsive hoarding may be evicted or may have his or her home condemned. Where children, elders, disabled people, or pets are in the home, protective services may need to step in to remove humans and animals endangered by the problem.

What can I do if my family member or friend seems to have compulsive hoarding?

Individuals who hoard often do not recognize that their behavior is problematic or do not view it as problematic as others do. Change cannot be imposed and raising a person’s awareness of the problem often requires time and patience on the part of others.

While the use of logic and persuasion makes intuitive sense, it is usually not effective for motivating a person to recognize that he or she has compulsive hoarding and to work on the problem. This is because individuals with compulsive hoarding often have mixed feelings about the problem. For example, they may both feel safe and comfortable with their possessions while also feeling shame and embarrassment about their number or their inability to invite others into the home. Attempting to persuade the individual that he or she has too many things and that this is leading to any number of problems (e.g., social isolation, inability to find things, safety and health problems, etc.), usually leads him or her to argue for the opposite position, namely that there is no problem and that he or she is quite comfortable and safe in the home. Instead, raising a person’s awareness and motivating him or her to work on the problem requires an approach in which the concerned family member or friend expresses empathy, elicits the perspective of the person with the problem, and helps him or her to articulate his or her values and goals. Buried in Treasures provides some guidelines for motivating change and Motivational Interviewing, Second Edition: Preparing People for Change, by William Miller and Stephen Rollnick describes in detail this approach to motivating change.

Where there is imminent danger to the person with hoarding or to others in the household and the person with compulsive hoarding is not willing or able to acknowledge this difficulty, it may be necessary for concerned family members and friends to seek outside help. Because compulsive hoarding often touches on many issues, such as mental health, personal safety, and protective issues, it is ideally handled by a coordinated effort among multiple agencies. Concerned family members or friends can find out if their area has a compulsive hoarding task force made up of multiple agencies. For areas without a compulsive hoarding task force, particular agencies can be contacted directly. If at-risk individuals are involved (i.e., children, elders, disabled people, and pets), the appropriate protective service can be contacted; where no at-risk individuals are involved, the local department of public health or the fire department can be contacted.

For individuals with compulsive hoarding who are ready to work in the home and wish the help of family members or friends, the following can be helpful:

  • Decide together on the goal of the assistance, e.g., clearing an area of the home or accompanying the person on trips to places where he or she usually acquires to help him or her to resist the urge to acquire.
  • Help the person remain focused on the task in front of him or her. 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. Family members or friends can be helpful by simply reminding the person what he or she is supposed to be doing at the moment.
  • Provide emotional support. Overcoming compulsive hoarding is hard work and many people with this problem feel misunderstood. Family members and friends can express empathy, 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.” Family members and friends can also be cheerleaders, for example, by praising the effort the individual is making to overcome this problem and expressing their belief in the person’s ability to make progress.
  • Help the person make decisions but do not make decisions for him or her. It is helpful to develop rules for discarding. Good questions to ask are: “Is it useful?” “Do you need it?” “Can you do without it?” “In the long run, are you better off keeping it or letting it go?”
  • Help the person with hauling. Many people with compulsive hoarding have accumulated so many things that they can become overwhelmed by the enormity of removing such a large number of items.
  • Accompany the person on non-acquisition trips. One way to overcome the urge to acquire is to encounter situations where the urge is invoked and not give in to the urge. This allows the person to experience what happens to the urge when no acquisition takes place. Usually, the urge drops off over time. A family member or friend can support the individual to not give in to the urge in the moment.

In addition to the above recommendations, the following “don’ts” are suggested:

  • Don’t touch anything in the person’s home without his or her specific permission. Individuals with compulsive hoarding have many thoughts and feelings about their possessions and often feel uncomfortable when another person — even a family member or friend — touches their things. Ignoring the person’s wishes and handling their things without their permission breaks trust and can damage the relationship with them. It can take considerable time before an individual with this problem will allow another person to handle their things.
  • Don’t argue with the person who has the hoarding problem as this produces negative feelings and slows progress. When conflict arises, take a break. Similarly, don’t work beyond your tolerance level. Overcoming compulsive hoarding is hard work for everyone involved.
  • Don’t tell the person with the hoarding problem how he or she should feel. While it can be hard to understand why the person is keeping particular things, that seem to be useless, the thoughts and feelings about these things developed for a reason. Respecting that items that appear useless in fact have great value to the person is instrumental in helping the individual to overcome this problem.

Other individuals can also be of assistance in overcoming compulsive hoarding. Cognitive behavioral therapy tailored to this problem is effective. Therapists who are not familiar with this treatment can refer to Compulsive Hoarding and Acquiring. The Obsessive Compulsive Foundation maintains information on therapists across the country that will treat obsessive compulsive disorder. To find therapists in your area, visit the OCF's Online Information Desk.

Professional organizers, home health aides, and visiting nurses can also provide help with de-cluttering and organizing.

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