Hoarding disorder has no “cure” but must be managed. This articles explores screening tools, clinical assessments, and effective treatments clinicians can employ when working with this client population.
Previous articles in this series: Understanding Hoarding Disorder, Hoarding Disorder: The Items and the Impact.
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Introduction
By now you will be aware – if you have read our first two articles (part 1 and part 2) on hoarding disorder – that hoarding is a big issue, for physical and mental health, safety, and quality of life, and not just for the person hoarding. It also greatly impacts the hoarding person’s household, family members, neighbours, and the community at large.
But hoarding disorder is typically ego-syntonic: that is, those who hoard see the behaviours as part of themselves. They often do not wish to change them, nor do they see themselves as able to do so. Putting those realities together, there are many people out there who have excessive accumulations of things they can’t bear to discard. They could probably use your help to overcome the disorder, but they are unlikely to front up to your rooms without being pushed there by an external force (e.g., a frustrated family member, social services worker, or even a court mandate). Even then, they may not be inclined to disclose the full extent of the problem, as there is often much stigma and shame associated with it.
Hence, the questions arise:
- How will you find out if someone may be suffering from hoarding disorder?
- What will be your purpose in assessing any hoarding behaviours?
- How would you treat someone diagnosed with hoarding disorder?
In this final article of our hoarding disorder series, we touch on those questions.
Screening and assessment tools: Purpose-driven
You would get strong indications about the first question above if you were to come into a hoarding person’s home, but you would be unlikely to be invited. Regarding the second question, you could have all these reasons for needing to find out what is going on for the client relative to hoarding disorder:
- As part of a more comprehensive intake session to find out whether further assessment is warranted
- When there is reason to believe that the person has the disorder, and you need to conduct a clinical interview/assessment to either diagnose it, rule it out, or show that the symptoms are part of another disorder
- When the person has been diagnosed with hoarding disorder and you need to assess how severe their symptoms are or just how much clutter there is
- When you need to see how severely impaired a diagnosed individual is in terms of everyday functionality
- When you are working with someone who has hoarding disorder and you need to assess how strong any unrealistic/irrational beliefs are, and how poor or even absent their insight is
Thus, the tools and instruments identified in this article are arranged according to these five reasons to assess. Some are self-report measures; others require a clinical interview to complete. Most of them are free to use. Where possible, we have included links, current at this writing, to pdfs of the instruments. You can read a fuller discussion of all assessment tools in the upcoming Mental Health Academy course: Helping Clients with Hoarding Disorder.
Screening tools
The purpose of (brief) screening instruments is to identify potentially at-risk individuals: at a visit to a general practitioner, during an assessment for a medical/psychiatric problem, or perhaps at an event, such as a health fair. Positive screening results indicate that more assessment is warranted. Here we can name:
- The two-question screen
- Hoarding Disorder Dimensional Scale (HD-D)
- The Hoarding Rating Scale-Self Report (HRS-SR) The Hoarding and Squalor Rating Scale, put out by Catholic Healthcare, is basically a version of the HRS, and can be found here.
Clinical Interview Tools
When little time is available, brief, often self-report, screening tools are useful. However, many clients with compulsive hoarding have poor insight into their condition, so obtaining collateral information can often be helpful. A clinician-administered assessment, especially one that does not solely rely on client self-report but can incorporate other sources of information, is crucial for accurate and valid assessment of hoarding symptoms and functional impairment. Existing self-report measures also do not contain quantifiable anchor points for a client’s subjective ratings of “mild,” “moderate,” or “severe.” Further, they do not allow for secondary questions, integration of other history, or clinical judgment to obtain a more accurate rating (Saxena et al, 2015). Thus, these measures requiring clinical assessment are highly useful for ensuring accuracy of diagnosis and assessment of severity:
- The UCLA Hoarding Severity Scale (UHSS)
- The Structured Interview for Hoarding Disorder (SIHD)
- Hoarding Rating Scale Interview (HRS-I) (Tolin et al, 2010)
Symptom severity measure
Many of the screening and assessment tools can signal the degree of symptom severity, especially the HRS-SR and the UHSS, but we wish to highlight a made-to-order measure for assessing how bad the hoarding symptoms are. It is the Saving Inventory-Revised (SI-R).
Links to PDFs of the SI-R, the HRS, and the CIR (discussed below) can also be found at the International OCD Foundation (IOCDF) website.
Tool to assess clutter
The Clutter Image Rating is a tool that helps standardise definitions of clutter by showing a series of images depicting rooms in various stages of clutter. This allows the client, the clinician, or another observer non-judgmentally to select the image on the scale that best corresponds with the state of the main rooms in the home.
Functional impairment measures
The functional impairment measures look into a crucial reason for which hoarding disorder needs to be identified and treated. The excessive clutter impairs people in multiple aspects of their daily lives, generating the terrible sequelae we outlined in earlier articles, from elevated hazards for fires, falls, and pest infestations to ill health due to inability to heat food or bathe. In this category are:
- Activities of Daily Living – Hoarding (ADL-H) Scale
- Clutter Hoarding Scale (CHS)
- Home Environment Index (HEI)
- Uniform inspection checklist (UIC)
- Health obstacles, mental health, endangerment, structure and safety (HOMES)
Assessing beliefs and insight
You may work with someone who has already been diagnosed with hoarding disorder, and you need to assess how strong any unrealistic or irrational beliefs are, and how poor/absent their insight is. Here you need to illuminate which beliefs are most problematic. For this, use:
The therapies showing some promise
Overview
The harsh reality of hoarding disorder is that it’s a chronic condition, like diabetes, so treatments are about “management” rather than “cure”. Those diagnosed with hoarding disorder can moderate their symptoms over time but are likely to continue experiencing difficulties discarding items – and perhaps will continue to acquire excessively – throughout their lives. Nevertheless, much benefit can be gained from appropriate treatment, which can improve the quality of life, increasing the safety and functionality of an individual’s living space. Learning how to decrease acquisition and maintain a regime of regular discarding can greatly help to maintain gains made in treatment (Mathews, 2021).
When we say “treatment”, we are not talking about pharmacology. Improvements from pharmacological treatments have been modest (Mathews, 2021). Here we identify instead the psychotherapeutic treatments which have shown some efficacy in treating hoarding disorder. But which of these get a mention here? We exclude psychodynamic psychotherapies, which have helped myriad clients but have not demonstrated effectiveness with hoarding disorder. Rather, the most effective therapies are cognitive behavioural therapy (CBT), motivational interviewing (MI), cognitive rehabilitation and exposure/sorting therapy (CREST), compassion-focused therapy (CFT), and acceptance and commitment therapy (ACT), with emotional freedom technique (EFT) and mindfulness contributing as self-help techniques. We briefly note which types of clients can be expected to benefit from them, or alternatively, should not be treated with them.
Cognitive behavioural therapy (CBT)
Typically, a CBT program has three parts. The first is psychoeducation to help the client understand what hoarding disorder is and what they can expect from treatment. Focus is directed to increasing awareness of the client’s symptoms, fears, and triggers, and the contexts in which they manifest. The second component, cognitive restructuring, involves identifying mental distortions, erroneous thought patterns, and unrealistic beliefs: in this case related to hoarding. What, the client will be asked, is the underlying emotional attachment to particular objects, and what are the thought patterns surrounding the attachment? Given that, what goals can the client set to free themselves from limiting attachments? It’s common for it to be interspersed with the third, or behavioural component, of the CBT.
From thoughts to behavioural testing
The chief difficulty in hoarding is the worry about what will happen if the person discards the item. Thus, the therapist can initiate work on the behavioural component by asking the client to first identify those potential occurrences, helping the client to construct some “if/then” scenarios such as: “If I throw away this newspaper/pair of shoes, then I will worry that I will need it in future and not have it; I will be so anxious thinking about having gotten rid of it that I won’t be able to think of anything else.” The idea is for the client to generate some alternative consequences, such as: “If I throw away this newspaper/pair of shoes, then I will worry that I will need it in future and not have it; I may be somewhat anxious thinking about this for a day or so, but it won’t last. My attention will then turn to something else that I need to think about.” This gets tested.
The therapist asks the client to surrender the item, and the behavioural, or “testing” part begins. The item is given over to the care of the therapist. The client, meanwhile, monitors their feelings, evaluates how upset they were to have discarded the item, and notes how long they were upset for. Often, the clients finds that life carried on fairly normally without the item.
Graded exposure
After testing potential attachments through graded exposure to discarding them, the client identifies how the actual outcome differed from the feared outcome. In other words: how upset was the client really about donating those old shoes? And for how long? The protocol could involve graded steps of exposure, such as first sorting into piles of “need”, “don’t need” and “not sure”. The client could first imagine discarding items in the “don’t need pile”, then practice discarding them, say, by leaving them with the therapist for a week, and then finally doing so.
Who should not undertake CBT?
If an individual disavows any effect of hoarding on their life (i.e., “I know I’m a bit of a packrat, but I’m not hurting anyone else by collecting stuff”), they may be diagnosed with the specifier of “poor” insight. Such individuals are not good candidates for CBT treatment; they are not ready. Additionally, any clients with cognitive impairment may struggle with the cognitive restructuring aspects of CBT treatment (Mathews, 2021).
For more on CBT, refer to the Mental Health Academy course collection, CBT and Its Applications.
Motivational interviewing (MI)
MI differs from CBT in that the goal of the latter is to directly affect behavioural change through continuing practice in modifying maladaptive thoughts and behaviours. Conversely, in MI, the motivation to change is elicited by the client, not the therapist. The client, likewise, must identify and resolve their own ambivalence; the therapist does not coerce the client into changing. The therapist stands by, in an open but quiet style, facilitating the eliciting of information from the client that will help clarify and resolve the ambivalence. Motivation and readiness to change are understood to fluctuate over time and with environment rather than being an innate, unvarying trait. The relationship between client and therapist is a true partnership (Miller & Rollnick, 2002;1995).
MI, especially in combination with CBT, is a potent combination for helping clients to heighten their awareness of how hoarding is decreasing their quality of life, resolve their ambivalence about changing hoarding behaviours, and begin to implement a program for thinking, feeling, and behaving differently in regard to their possessions (Prochaska & DiClemente, 1986).
Who will not benefit from MI?
Those who are at the very first level of changing from hoarding behaviours in the Stages of Change Model (called “pre-contemplation”) used by MI therapists are not deemed to be ready to change and may not even be willing to attend counselling sessions about any change. Such individuals would be likely to get more out of any treatment if they were at least at the second level of change: that is, contemplation (Mathews, 2021).
For more on MI, refer to the Mental Health Academy course collection, Motivational Interviewing in Theory and Practice.
Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST) and compensatory cognitive training
CBT and MI both depend on a client being able to weigh up how things are currently as opposed to how they might be in future and commit to sorting possessions and then discarding some. But what if the client has neurocognitive dysfunction as well as hoarding disorder? A new therapy, an off shoot of CBT, called Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST) was developed to assist individuals who have some cognitive impairment.
Individuals with hoarding disorder report difficulties in organising, sorting, paying sustained attention, and remembering things. CREST aims to address those challenges by removing the cognitive restructuring and substituting a component of what is called compensatory cognitive training, a practical intervention which includes exercises for cognitive flexibility, categorisation, problem-solving, and memory (see below). A small randomised clinical trial with participants between ages 60 and 80 who had moderate hoarding at baseline compared results from receiving CREST treatment with equivalent participants receiving standard geriatric case management care; the CREST group got significantly better results (O’Neill, 2024).
What is involved in compensatory cognitive training (CCT)?
CCT is a brief, patient-centred, holistic/comprehensive, multi-modal, behavioural intervention which includes cognitive training, psychotherapeutic techniques, and lifestyle techniques and teaches individuals skills to address attention, memory, and executive function problems. It also incorporates day planner/calendar training, brief mindfulness-based stress reduction exercises to improve cognition and general health, and brief motivational interviewing techniques to increase healthy lifestyle behaviours associated with improved cognition. CCT is associated with significant improvements in objective cognitive performance, subjective cognitive complaints, and subjective everyday functioning (O’Neill, 2024).
Compassion-focused therapy (CFT)
In an earlier article, we identified four major factors said to influence hoarding development: dysregulated emotional attachment, information-processing deficits, unhelpful beliefs about possessions, and behavioural avoidance. We noted the high proportion of people diagnosed with hoarding disorder who also had childhoods with little nurturing or other adverse childhood experiences (ACEs), and/or who had comorbid disorders of anxiety, depression, or PTSD. We note how those with hoarding disorder frequently suffer from shame and stigma regarding the state of their homes, and often have low self-esteem.
While the therapies we have been discussing so far have been developed to treat most of the above factors, they have not generally emphasised the first one: dysregulated emotional attachment and the corresponding emotional turmoil that accompanies hoarding disorder. While there have been successes with the above-described therapies, they have not benefitted all participants. For some clients, the cognitive restructuring aspects of CBT may trigger shame, anger, and despair rather than a neutral awareness which can then be modified.
Pilot study using CFT in hoarding disorder
Thus, one investigation addressed not the cognitive aspects but the underlying emotional dysregulation and emotional attachment that accompany hoarding disorder. It used compassion-focused therapy, the idea behind it being that, as human beings, we evolved in a social context, and we are thus physiologically hard-wired to respond to social stimuli, particularly positive, caring stimuli. CFT uses a variety of techniques to address emotions that may arise in therapy and inhibit progress: techniques such as imagery, mindfulness, breathing exercises, emotion regulation training, and work on self-compassion to deal with the shame (Gilbert, 2014; Mathews, 2021).
The study compared participants receiving CFT to those receiving a second round of CBT. Most of the CFT group persisted until the end of the study, compared to fewer than half of the CBT group, and 100% of the CFT group rated the treatment as “excellent” or “good”, compared with 79% of the CBT group. The researchers concluded that CFT is feasible and acceptable (because so few dropped out). Moreover, it was found to have promising effects in addressing hoarding-related factors that may not have been sufficiently addressed by CBT (Chou et al, 2020).
Who may benefit from CFT for hoarding disorder?
CFT has particular potential as a treatment for hoarding disorder for those who do not respond well to CBT. That said, any client with issues of shame and/or low self-esteem is likely to benefit.
Acceptance and commitment therapy (ACT)
ACT aims to maximise human potential in order to create a rich and meaningful life, while accepting the pain that inevitably goes with it. It teaches those practicing it to accept things that are out of their control without evaluation or attempts to change them (unlike in CBT), while committing to taking action that enriches one’s life. ACT therapy achieves this by:
- Helping people to clarify genuinely important and meaningful values
- Teaching psychological skills, such as mindfulness skills, for handling painful thoughts, feelings, and memories such that they have less impact on the person. Developing a new mindful relationship with such experiences frees the ACT practitioner to take action consistent with their values (Eppingstall in Cooke, 2021; Good Therapy, 2018; Newcastle Psychology and Health, n.d.).
Who can benefit from ACT?
Looking at hoarding disorder through the lens of avoidance behaviours, we can see that ACT is a therapy made-to-order for hoarding disorder. By accepting (making room for) the feelings, thoughts, sensations, and memories that have heretofore been too painful to acknowledge (and not trying to change them, as with CBT), the person can discover the function of the hoarding behaviours. Therapist and client alike can come to understand how substituting possessions for the missing nurturance and relational satisfaction has been a process of avoiding, including the avoidance of genuine emotional regulation. ACT targets cognitive and behavioural processes rather than symptoms, and its main processes are defusion (disidentification), acceptance, present-moment awareness, perspective-taking, committed action, and valued living.
ACT may be particularly helpful for those with comorbid diagnoses of anxiety, depression, and even psychosis, where evidence is emerging that ACT is a viable treatment (Eppingstall, in Cooke, 2021). For more on ACT, refer to the Mental Health Academy course, Acceptance and Commitment Therapy.
Self-help techniques: EFT and mindfulness
In addition to the above therapist-guided techniques, we note that, once taught the techniques, individuals can enact both emotional freedom technique (EFT, or tapping) and mindfulness techniques to alleviate hoarding disorder distress (to take a deeper dive into EFT, refer to the Mental Health Academy micro-credential, Clinical Applications of EFT).
This article has listed the chief assessments and treatment modalities that are most effectively used to deal with hoarding behaviours. If you have also read the earlier articles in this series, you know that hoarding disorder is a challenging condition in many ways, but knowledge about how to treat it is ever evolving and individuals diagnosed with it can learn to manage the thoughts, urges, and behaviours to acquire and not discard which would otherwise keep them from living a healthy, satisfying life.
Hoarding disorder training
This article was adapted from Mental Health Academy’s hoarding disorder training course, Helping Clients with Hoarding Disorder. In this 6-hour course, you’ll learn the epidemiology, aetiology, and neurobiology of hoarding disorder; how and why hoarding impacts individuals and communities; the co-morbidities of those who hoard; and how to assess and treat hoarding disorder.
Note: Mental Health Academy members can access 500+ CPD/OPD courses, including those listed above, for less than $1/day. If you are not currently a member, click here to learn more and join.
Key takeaways
- The best instrument to screen/assess for hoarding disorder varies according to the purpose for which it is being used, with different tools being appropriate for general screening; diagnostic assessment; or assessment of symptom severity, functional impairment, or intensity of irrational beliefs/poor insight.
- The modalities so far shown to be most effective at treating hoarding disorder include CBT, MI, CREST (with CCT), CFT, and ACT, with EFT and mindfulness as useful self-help techniques (once the skills are learned).
References
- Chou, C.Y.; Tsoh, J.Y.; Shumway, M.; Smith, L.C.; Chan, J.; Delucchi, K.; Tirch, D.; Gilbert, P.; & Mathews, C.A. (2020). Treating hoarding disorder with compassion-focused therapy: A pilot study examining treatment feasibility, acceptability, and exploring treatment effects. Br J Clin Psychol. 2020 Mar; 59(1): 1-21. doi: 10.1111/bjc.12228. Epub 2019 Jul 4. PMID: 31271462.
- Cooke, J. (2021). Understanding hoarding: Reclaim your space and your life. London: Sheldon Press.
- Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology (2014), 53, 6-41. Retrieved on 15 May 2024 from: https://self-compassion.org/wp-content/uploads/publications/GilbertCFT.pdf
- Good Therapy. (2018). Acceptance and commitment therapy. GoodTherapy.org. Retrieved on 15 July, 2013, from: https://www.goodtherapy.org/acceptance-commitment-therapy.html
- Mathews, C. (2021). Recognizing and treating hoarding disorder: How much is too much? New York: W. W. Norton & Co.
- Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing. Preparing people for change. 2nd ed. New York: The Guilford Press.
- Miller, S., & Rollnick, W.R. (1995). What is motivational interviewing? Behav Cogn Psychother, 23,325-334.
- Newcastle Psychology and Health. (n.d.). Embracing your demons: An overview of Acceptance and Commitment Therapy. Author. Note: this article is a reprint of one by Russ Harris published in Psychotherapy in Australia, 2006. Retrieved on 16 May 2024 from: https://www.nph.net.au/project/embracing-your-demons-an-overview-of-acceptance-and-commitment-therapy/
- O’Neill, M. (2024). Compensatory cognitive training research program. Oregon Health and Science University: School of Medicine Psychiatry Research. Retrieved on 15 May 2024 from: https://www.ohsu.edu/school-of-medicine/psychiatry-research/compensatory-cognitive-training-research-program-cctrp
- Prochaska, J. & DiClemente, C. (1986). Towards a comprehensive model of change. In: Miller, W.R., Heather, N., editors. Treating addictive behaviours: processes of change. New York: Pergamon.
- Saxena S., Ayers C.R., Dozier, M.E., & Maidment, K.M. (2015). The UCLA Hoarding Severity Scale: development and validation. J Affect Disord. 2015 Apr 1;175:488-93. doi: 10.1016/j.jad.2015.01.030. Epub 2015 Jan 22. PMID: 25681559; PMCID: PMC4352402.
- Tolin, D.F., Frost, R.O., & Steketee, G. (2010). A brief interview for assessing compulsive hoarding: The Hoarding Rating Scale-Interview. Psychiatry Res, 178(1), 147-152. https://doi.org/10.1016/j.psychres.2009.05.001