Hoarding disorder (HD) is a complex condition that affects approximately two to five percent of the population. Hoarding disorder is included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM5) and is characterized by: 1) persistent difficulty discarding or parting with personal possessions, even those of apparently useless or limited value, due to strong urges to save items, distress, and/or indecision associated with discarding; 2) symptoms result in the accumulation of a large number of possessions that fill and clutter the active living areas of the home, workplace, or other personal surroundings (e.g., office, vehicle, yard) and prevent normal use of the space; and, 3) symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). Because hoarding behavior occurs in a number of medical conditions (e.g., brain injury, cerebrovascular disease) and other mental disorders (e.g., restricted interests in Autistic Disorder, food storing in Prader-Willi Syndrome), clinicians must rule out these conditions in order to diagnosis an individual with HD.
HD is a difficult problem to treat. However, researchers have developed a special form of cognitive-behavior therapy that is promising for the treatment of the condition. Cognitive-behavior therapy for HD includes motivational interviewing to engage and to re-engage the client in the treatment process, cognitive interventions that target the beliefs and assumptions clients hold regarding the acquisition and discarding of possessions, behavioral interventions that decrease the client’s emotional response to discarding possessions and limiting acquiring, and training in a variety of organizational, problem solving, and time management skills. Typically, treatment is 26-weekly sessions with a portion of those sessions conducted in the client’s residence.
In spite of the availability of CBT for HD, few people seek treatment for the condition and often refuse treatment when offered to them. At the same time, many of these individuals who refuse treatment risk serious injury or eviction because they live in a highly cluttered and often unsanitary environment. Furthermore, certain hoarding situations present public health risks that precipitate community responses that are expensive and often repeated. For this reason, communities have undertaken harm reduction approaches that strive to resolve the public health problem while assisting the individual to live safely in his or her residence. Harm reduction is a set of pragmatic strategies to decrease the harmful consequences of high-risk and low-insight problem behaviors and is appropriate when the individual consistently refuses treatment for the problem and yet continues to engage in activities or behaviors that place his health and well-being and the health and well-being of others at risk. Harm reduction for HD is not a treatment in the way we usually think of treatment of a mental health condition. Primarily, the goals of harm reduction and treatment are different. In harm reduction, the primary goal is to manage symptoms to decrease risk whereas in treatment, the goal is to eliminate or minimize symptoms to decrease distress and impairment. Clinicians in collaboration with the client who hoards and other team members create a plan to minimize the risks associated with hoarding behaviors. A harm reduction plan identifies what must be done to the living environment to bring it to a minimum level of safety; what interventions would increase the psychological, social, and physical capacity of the client that enhance his safety and wellbeing; who will do the work and how will they go about doing this; and, who will monitor adherence with the plan and how.
In conclusion, we now have a moderately effective cognitive-behavioral treatment for clients with HD who are open to treatment. At the same time, clinicians may wish to consider harm reduction for clients who refuse treatment and yet face serious health and safety risks associated with the condition.
Tompkins, M. A., & Hartl, T. L. (2009). Digging out: Helping your loved one manage clutter, hoarding, and compulsive acquiring. Oakland, CA: New Harbinger Publications.
Tompkins, M. A. (2014). Clinician’s guide to severe hoarding: A harm reduction approach. New York: Springer Publications.