By
Carmen L. Morano, Ph.D.
Associate Professor – Hunter College School of
Social Work
This presentation was developed in
cooperation with Emily Saltz of Elder
Resources, Boston MA
Define Hoarding
Discuss factors associated with onset of Hoarding
Provide overview of Hoarding Research
Provide a strategy for overcoming engaging
resistant (fearful) clients
◦ Increase knowledge of intervention strategies
◦ Discuss practical and ethical dilemmas
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◦ Collecting is a normal and common phenomenon in
children
◦ Collecting in adulthood can be a pleasurable activity
◦ Collector acquires and discards
◦ Hoarders just acquire and rarely discard
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Falls somewhere in between collecting and
hoarding
Lacks the organization usually associated
with collectors
Lacks the “mass” or “volume” associated with
hoarding
Doesn’t interfere with daily functioning
◦ 1) The acquisition of, and failure to discard a
large number of possessions that appear to be
useless or of limited value.
◦ 2) The living spaces in the home are sufficiently
cluttered so as to preclude activities for which
those spaces were designed.
◦ 3) There is generally significant distress or
impairment in functioning caused by hoarding.
DSM-IV
lists hoarding of “worn out or
worthless objects even when they have no
sentimental value” as a symptom of
obsessive-compulsive personality disorder
(OCPD).
Frost & Steketee; Cognitive-Behavioral Model of
Compulsive Hoarding; Frost & Steketee; 1998
◦ Estimated at 700,000 to 1.4 million people in U.S.
◦ Underreported problem –only five percent of
cases come to attention of authorities
◦ Prevalence among patients with obsessive
compulsive disorder is approximately 20-30%
◦ Prevalence among patients with dementia is
approximately 20%
◦ Typical age of onset was during childhood or
adolescence
◦ Strong familial link – 80% of hoarders grew up in
house with someone who had hoarded
◦ Most hoarders are female, live alone, and are
unmarried
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Sentimental value
Difficulty with decision making
Difficulty organizing
Feelings of responsibility
Control/perfectionism
Fear of forgetting
Shrines
Frost & Steketee; Cognitive-Behavioral Model of
Compulsive Hoarding; Frost & Steketee; 1998
◦ Stems from a desire to control how objects are used
◦ A desire to control the environment
◦ A sense of responsibility for the proper use and
well-being of objects
◦ An inflated sense of responsibility for object and
environment
Furby, L. (1978) Possessions: Toward a theory of their meaning and function throughout the life cycle.
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INFORMATION PROCESSING #1
Overestimate the need to remember or keep
records ‘I need . . . to remember’
Catastrophic assessment of consequences of
forgetting information – ‘I just know once I get
rid of . . . I will need it to . . . ’
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Fear of making wrong decision – ‘If I only knew
for sure . . . ’
◦ Attachments to possessions
 Objects as extensions of oneself – ‘All of this is a part
of who I am’
 Emotional ‘hyper-sentimentality’ to possessions –
‘When I look at . . . It reminds me of when . . . ’
 Attachments are associated with beliefs about
meaning and importance of possessions – ‘You know
as soon as I get rid of this paper, I will need it’
 Instrumental Savings
◦ Erroneous or distorted beliefs about the nature and
importance of possessions.
 Perfectionism – ‘I want to make the right decision’
 Need for control – ‘I am in control and could get rid of
this if I wanted to’
 Responsibility – ‘If not me, who?’
 Emotional comfort – ‘This helps me to feel
comfortable’
◦ Age-related illnesses are not primary cause of
hoarding.
◦ Hoarding can be a common symptom in
dementia patients.
 Memory loss: inability to discriminate between
relative importance of articles in home.
◦ Forty percent (40%) of hoarding complaints to
local health departments involved elder
service agencies.
◦ Self-neglect associated with hoarding.
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Genetic Factors
◦ Different inheritance pattern than OCD
 Autosomal recessive inheritance pattern
 Genetic Markers on Chromosomes 4, 5, & 17
2002)
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(Zang et al.,
Brain Patterns differ from those with OCD
◦ Lower metabolism in posterior cingulte gyrus &
occipital cortex
◦ Lower metabolism in dorsal anterior cingulate gyrus
& thalamus (Saxena et al., 2004)
“Hi, I’m a hoarder. Please
help me clean my home.”
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Pending eviction
Landlord harassment
Problems with neighbors
Complaints from the health or fire dept.
Rejection by a home care agency because of
the need for heavy duty cleaning that the
client refuses.
Referred by neighbor, family, clergy
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Requesting home delivered meals
Referred by an outside source (e.g. hospital
discharge planner) for housekeeping services,
not knowing that the situation is way beyond
housekeeping.
Requesting assistance in applying for
entitlements and having difficulty locating
documents.
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Capacity
Resources
Family involvement
Other agencies/professionals
Finances
Physical variables
◦ Physical frailty of the client
◦ Logistics (e.g. walk-up apartment, etc.)
Precontemplation
Relapse
Contemplation
Maintenance
Determination
Action
Termination
Synonyms
Determination = Preparation
Termination = Exit
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Ask initial question about client reason for
seeing you
Listen carefully and non-judgmentally
Ask follow-up question until you can form an
assessment of what stage the client is in
Set short-term goal of moving stage by stage
until you get to the Action Stage
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Engage client before you engage the problem
◦ Membership Theory
 Constant Connectedness
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Practice Patience - You can’t force
engagement
◦ Think ‘Bank Account’
 Deposits have to be made before you can make a
withdrawal
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Start with Deep Breathing Exercise
◦ Have client practice during and after sessions
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Advance to Visualization
◦ Visualize ‘Time Before Hoarding’
 What do they see? How do they feel?
◦ Anchor feeling
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Discuss client’s reaction
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What are they seeing now
◦ Ask for details to stimulate emotional reaction
◦ Help them understand what ‘it’ represents?
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What are the consequences to what they see?
◦ Ask them for specific examples
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“The Magic Wand”
◦ What would they ‘really’ like?
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What did your client like to do, that they are
no longer doing?
Start with something Easy and Pleasurable
◦ Moving from determination to action requires a
belief that change is possible
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Contract for 1 behavior/activity
Assess capacity/desire to do it?
◦ This will inform treatment plan to remove clutter
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Client just doesn’t know where to start
Start with ONLY 1 problem
What are some solutions
Pros
Cons
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Effort
Time
Money
Emotional Impact
Involving Others
Effort
Time
Money
Emotional Impact
Involving Others
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Contract for Action Plan
◦ Document tasks completed
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Contract for Daily Pleasant Activity
◦ Rate how Satisfied activity made you feel
 0 = Not at all 10 = Extremely
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Follow-Up Visit
◦ Rate how you felt with effort
 0 = Not at all
10 = Extremely
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7-Principles
1. Client
is Unique
2. Client has ‘Their Special Way’ of reaching goals
3. There are Exceptions of every problem that can be
created by client and you to build solutions
4. Clients are ALWAYS cooperative
5. Only clients can change self
6. Change is occurring all the time
7. CLIENT and YOU are BOTH experts
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5-Principles
1. Externalizing
Problem-Shift focus from person to
problem
2. Explore origin, consequence
3. Deconstruct Problem Story
4. Landscape of Action Question
1. Creating an alternative life story
5. Create landscape of Meaning Questions
1. Make meaning of the sequence of events-values-beliefs
Frost & Steketee; Cognitive-Behavioral Model of
Compulsive Hoarding; Frost & Steketee; 1998
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Treatment Goals
◦ Explore irrational thought patterns and replace with
rational thoughts
◦ Improve decision-making skills
◦ Reduce accumulation of new possessions
◦ Translate cognitive change into behavioral change
(excavation)
◦ Reinforce – Reframe – Reinforce Again
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Treatment Rules
◦ Therapist can’t touch or throw away anything
without permission
◦ All decisions are made by client
◦ Possessions are categorized before handling them
◦ Treatment proceeds slowly and systematically
◦ Flexible and creative strategies are a must
◦ “OHIO” rule: Only Handle it Once
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Working toilet and sink
Adequate walking paths in rooms used on a
regular basis
Safe walkway
No infestations of insects or rodents
No excessive accumulation of garbage
Access to all required means of egress
(doors, fire escapes, etc.)
Working electrical outlets
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Preparation
Allow client as much control as possible
Explain in advance what the cleaning will
entail, how and why it is being done
Allow the client to set aside valuable items
that he/she wishes to keep
Negotiate, negotiate, negotiate
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The Organizational Plan is set and Client
Agrees to Rules
Keep – Sell – Donate - Trash
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Client understands that all decisions belong
to them
◦ Start from outer perimeters
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What did the item represent to client when
it was acquired?
◦ What does it represent now?
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Only Handle it Once - OHIO
All heavy duty clean-outs are
traumatic and risk psychiatric
decompensation.
Make sure to have psychiatric
back-up in place
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Negotiation
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Collaboration
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Extreme reorganization
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Use of commercial storage spaces
BEFORE
AFTER
Professional Ethics and Working with
Hoarders
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Working with Hoarders requires a significant
investment
Start Slow; Go Slow; Finish the Job
Multidisciplinary approaches work best
Be open to compromise
Focus on the war, not the battle
Good Luck!