Treatment Of Obsessive-Compulsive Hoarding
In An Intensive Treatment Setting

Karron Maidment RN, M.A.

Program Coordinator/Behavior Therapist
UCLA OCD Intensive Treatment Program

In this article, I'm going to discuss how our group at the OCD Intensive Treatment Program at UCLA treats hoarding. The intensive treatment program for hoarding at UCLA is a six-week program that runs five days a week, Monday through Friday, from 9 a.m.-1 p.m. Much of the treatment for obsessive-compulsive hoarding that is done in this program is based on the work of Drs. Randy Frost and Gail Steketee (see: "Compulsive Hoarding: New Developments in Treatment and Research," Winter 2003 OCD NEWSLETTER).

At the UCLA program, treatment begins with a thorough assessment of:

  • Amount and type of clutter.
  • Beliefs about the loss of clutter.
  • Level of functioning: 84% of the people with the hoarding problem in our program were unable to work as a direct result of their hoarding.
  • Level of support from friends and family.
  • Medication compliance.
  • Comorbidity.
  • Motivation for treatment.
  • Level of insight and understanding of the disorder.

Education is a very important component of the UCLA treatment program. Patients learn to conceptualize their hoarding in terms of problems with:

  • Information processing.
  • Beliefs about and attachments to possessions.
  • Emotional distress associated with possessions.
  • Avoidance behaviors designed to limit the experience of distress (see: "New Developments" article for more extensive discussion).

The next major component of treatment is exposure and response prevention (E&RP). That is, patients gradually expose themselves to the objects or situations that cause them anxiety (having to throw something away, or make a decision about what to do with a specific object). They are then supported as they resist the urge to respond in their usual way (by keeping something or avoiding making a decision) until the anxiety diminishes. With repeated practice, E&RP will extinguish the fear of losing something important and increase a person's ability to resist the urge to keep things.

Treatment may take place in the patient's home, or, if they live too far away, treatment can just as effectively be carried out in the therapist's office. Before any treatment can begin, the patient must provide baseline photographs of the hoarding area.

When treatment is carried out in the home, patients are asked to pick one room on which they would most like to work. When they have picked a room, they systematically work their way around the room, discarding and organizing items as they go. They should not move on to another room until the first is completely cleared of clutter. Patients who live too far away to make home visits feasible and who are, therefore, doing treatment in the therapist's office, will work out a system with the therapist whereby boxes of "clutter" from a specified room at home are brought into the office. Patients often need the help of friends or family members whom they trust to help them with this.

Behavioral treatment for hoarding focuses on four main areas: discarding, organizing, preventing incoming clutter, and introducing alternative behaviors.

Discarding

Patients spend a significant amount of treatment time learning how to discard things in an effective manner. Patients go through every single item of clutter and make a decision about its worth before they move on to the next item. There are several ground rules to discarding. The first is that the person must pick up the first item that comes to hand in his pile of clutter. He should not "sift through" his clutter. Secondly, he must make a decision about that item before he moves on to the next. Patients have three choices when they are making a decision about an item: they can discard it, keep it, or recycle it. Obviously, the preferred option is for patients to choose to discard the item and they are actively encouraged to provoke their anxiety by throwing as many items away as possible. Patients may decide that they just have to keep an item. They then work with their therapist on where the item will go at home and how it will be organized. Some patients like to recycle things and this is fine, with the caveat that the recycling options are limited to two places only. Patients may recycle "recyclables," e.g., plastic, paper, etc.; and they may choose one other option, such as, Goodwill or a charity shop. Patients are not permitted to save things for all their friends and family members.

When patients throw something away, they typically become anxious for awhile. Patients are asked to rate their anxiety -- Subjective Units of Distress (SUDS) -- and then monitor it as it decreases over time. The anxiety may stay for a few minutes or even a few hours but it does decrease. It seems to decrease faster when the patient does not see the discarded item once it is thrown away. The discarding process helps the patient in two ways. First of all, it forces the patient to make decisions, rather than postpone them. The results in a decrease in the anxiety associated with making decisions. Secondly, it helps the patient to see that nothing terrible happens when they throws things away that feel valuable. This directly addresses the patient's obsessive fears of losing valuable or necessary items.

To help patients throw things away, they are prompted to cognitively reframe their obsessive fears about discarding things. They are asked:

  • What's the worst thing that would happen if you didn't have this item?
  • What do you think other people do with similar items?
  • If you needed this information later, how could you access it if you threw this away now?

This process is essential. People who hoard need assistance in learning how to think differently about their possessions. When patients are asked to think about the consequences of throwing away their clutter, they are challenging their erroneous beliefs that dire consequences will occur if they throw something away.

Organizing

Many people with hoarding problems have as much difficulty organizing their stuff as they do discarding it. Frequently, they have piles of stuff on the floor, in walkways, on counters, chairs and tables, all in plain view. Many people dislike putting things away in a cupboard or drawer because they are afraid they will "forget about it." Another problem with organizing is that people with hoarding problems frequently have difficulty with "categorizing." Instead of putting a pair of shoes in the closet or on a shoe rack, hoarders want to put one pair of shoes by the front door, "... because I might wear them next week." Then they want to put other pairs in the den because they need to polish, re-heel or fix them. Other shoes go in a box somewhere because they don't fit right now, but they might later. The hoarder has difficulty categorizing things in a simple or efficient manner. They tend to "over-categorize" and this leads to confusion and increased clutter. To address this problem, there are several ground rules that must be established (just as for the discarding problem). When patients decide that they have an item that they have to keep, they are asked to immediately identify a specific space at home to put that item and designate a time frame by which it will be done. For example, someone who chooses to keep a one-year old bank statement will decide to put it in a manila folder labeled "bank statements" which goes in her desk, in her den. She agrees to do this within two days. The assumption is that if she is not able to do this in the designated time-frame, then the item is not important enough to keep. Patients often need the help of friends or loved ones to make sure that they follow through on daily assignments to put "saved" items away in their designated spaces at home after each session.

Another rule is that once an area is cleared of clutter, it has to be maintained. Patients are encouraged to use the cleared area for its intended purpose. For example, if they have cleared off their couch, they should get used to sitting on the couch during their leisure time. If they have cleared the kitchen counter, they should start preparing food on the counters. Also, patients must empty the trash after every session. They also have a homework assignment to empty the trash at home every day.

Prevent Incoming Clutter

Clutter should not be coming in as fast as it is going out. Therefore, patients must not only work on discarding and organizing their clutter; but they also have to work on resisting the urge to acquire new items or keep accumulating clutter. Patients are asked to keep a daily log of every item that they have accrued each day. The goal is that the overall number of items accrued each day should decrease. Patients are encouraged to discontinue many of their subscriptions to magazines and newsletters (not the OCF newsletter, of course!). If a patient has difficulty going into stores without buying things, they receive graduated assignments to go to stores and resist the urge to buy things. They may need to surrender their credit card to a trusted friend or family member until they feel this compulsion is under better control.

Introduce Alternative Behaviors

Hoarding is a full-time occupation. It is important to replace hoarding behaviors with more adaptive, healthy behaviors. This is done in several ways. First, although many people with the hoarding problem dislike the idea of schedules, they do, however, benefit from structure in their day. Obviously, their participation in this program will mean their days are structured: but when they leave, this structure needs to be maintained. A common problem that these patients have is that they tend to stay up very late at night and then sleep late in the day. It is important for patients to get back on to a regular sleep/wake cycle. (This may also improve their depression). Another problem is that, with this rather chaotic and unstructured lifestyle, many patients are not taking their medications regularly. With a more structured day, it becomes easier to get into the regular habit of taking medications as prescribed. This too will help with treatment and also improve mood and concentration.

It is important to incorporate recreational time into each day. People with the hoarding problem often report that they never have time to relax or pursue all the hobbies that they express an interest in. They frequently have an "all-or-nothing" mind set. They spend all day shuffling, and rearranging their clutter; or they get so overwhelmed by it that they stay in bed all the time. Patients need help creating balance in each day, a balance of work and recreation and rest. Patients are frequently asked to create a realistic schedule of activities for each day that will include the chores and homework assignments that they have to do, and also a recreational activity and a reasonable time to go to bed.

As part of a structured day, there are several "baseline activities" that patients are required to do on a regular basis. These are activities that many of us routinely do but for people with hoarding problems, these are often overlooked. Each day patients are asked to empty the trash, do dishes and sort mail. Patients are also encouraged to designate a specific day and time each week to do laundry and pay bills.

Finally, patients need to start working towards more permanent long-term structure. This might mean doing part-time work, volunteer work, or signing up for some classes. Whatever form of structured activity patients choose, they should be assisted in getting it set up and in place before their hoarding treatment program is completed. We do this at our program.

Ending Treatment

It is absolutely essential that patients have follow-up behavior therapy and medication management on at least a weekly basis after they have completed an intensive treatment for hoarding. We provide for this at the UCLA program. It is not an exaggeration to say that if patients do not follow up with ongoing treatment, they will not maintain the gains they have made in any intensive treatment program.

Because hoarding is such a difficult problem to treat, many patients benefit from doing this type of intensive program a couple of times. At UCLA, a patient's return to the program is contingent on several factors: first, that they are in outpatient therapy and second, that they have been able to maintain the gains made in the program.

It is highly motivating at the end of treatment to have "after" photos of the area the patient has been working on. When placed next to the "baseline" photos, they enable the patient to really appreciate the progress that they have made and provide a visual reminder of the benefit of all their hard work.

In conclusion, it would be unfair not to point out that the treatment of compulsive hoarding is extremely difficult. Success will depend on a high degree of motivation and commitment on the part of the patients. However, there is no denying that treatment is also highly effective. The major components of this treatment (education, E&RP, cognitive restructuring) will leave patients with a set of organizational and decision-making skills that they will have forever.