Treating Compulsive Hoarding by Dr. Renae Reinardy

Recently I’ve invited several of the doctors, from A&E TV’s, “Hoarders,” to answer a question (or two) about hoarding, from their perspective.

Dr. Renae Reinardy

Dr. Renae Reinardy

This week my guest blogger is Dr. Renae Reinardy and my question to her is, “Viewers want to know why are many homes of hoarders so filthy? Are they lazy or are (some) hoarders truly unable to wash dishes and laundry, take out the trash and clean up after their pets?”

Dr. Reinardy told me she had co-written an article that addresses this topic and agreed to let me share it with you; so, here it is.

Roadblocks To Successfully Treating Compulsive Hoarding

By Renae Reinardy, Psy.D., and Charles S. Mansueto, Ph.D.

Although problems associated with hoarding are likely to have existed throughout time and across cultures, hoarding has only recently been the subject of scientific scrutiny. While known to be associated with a broad range of psychiatric conditions, in today’s diagnostic system, hoarding is categorized as a symptom of obsessive-compulsive personality disorder (OCPD). It is commonly viewed as related to obsessive-compulsive disorder (OCD). While it has been viewed from a variety of psychological and medical perspectives, cognitive-behavioral perspectives have stimulated research on hoarding and generated current treatment approaches. The impetus provided by the pioneering work of Drs. Randy Frost, Gail Steketee, and their colleagues has resulted in a greatly clarified view of the nature of hoarding and of essential elements for effective treatment.

Compulsive hoarding is a complex problem involving problematic patterns of acquisition, organization, and retention of items of questionable value. Compulsive hoarders often acquire excessive quantities of items, live in cluttered and disorganized circumstances, and fail to dispose of items in a reasonable and timely manner. The predominant treatment for compulsive hoarding is cognitive behavior therapy. (CBT) that employs exposure (e.g., practice in discarding hoarded items), response prevention (e.g., forgoing opportunities to add items to the cache of hoarded items), and cognitive restructuring (e.g., correcting distorted beliefs relating to hoarding). Pharmacologic treatment has also been applied to hoarding. While there is little research on treatment outcome, it is believed that hoarding is strongly predictive of a poor treatment outcome. It is widely held that these individuals are often difficult to engage in treatment, lack motivation to change and are resistant to therapeutic interventions. Thus, among the so-called “obsessive-compulsive (OC) spectrum disorders,” hoarding is viewed as an OC variant that is particularly hard to treat. This article will consider the various factors that make this so.

Personal Factors: The Hoarding Individual

Some research has focused on the personal characteristics of hoarders. It is not unusual for hoarders to have personality features that can work against their successful treatment. Many hoarders are perfectionistic and have rigid beliefs about saving and discarding possessions. Decisions about retaining or disposing of hoarded items can be excruciating and time-consuming for these individuals. Organizing or discarding such items may involve catastrophic thoughts and deep fears of making the mistake of discarding a needed item or not properly organizing it in the appropriate way. Instead the choice is often to retain items and defer decisions until a later time thus perpetuating the hoarding problem.

Research suggests that some hoarders have deficits in cognitive functioning. These are memory and decision making. Many may develop and maintain strong emotional attachments to items they hoard. It is not unusual for hoarders to maintain erroneous or exaggerated beliefs regarding their possessions and their utility. Such as, “It would be unbearable if I needed this information at some later date” or “I will find a proper use for every one of these items.” Such beliefs can support the retention of innumerable items and encourage the hoarder to avoid confronting the problem in a constructive way. Despite the many negative consequences associated with compulsive hoarding, many, if not most, hoarders lack adequate intrinsic motivation to change. They resist efforts of others who try to influence them to change.

Emotions play a powerful role in maintenance of hoarding patterns. Often the hoarder is frightened and angered by the prospect of others being involved in the handling of their possessions. They have difficulty acknowledging the impact that their hoarding has on their life and the lives of others, they often use denial, rationalization and minimization to defend their hoarding and resist therapeutic efforts. The strongly held values about possessions and the emotions they engender in many hoarders also work against resolution of the problem. Many hoarders view their hoarding in positive terms, such as reflective of environment consciousness, or example, or consistent with a “waste not, want not” ethic. These individuals could be called “righteous hoarders” because they view their hoarding behaviors as morally or ethically sound.

Social and Environmental Factors: The Hoarder’s World

Other factors complicating hoarding treatment are found in the physical and social environment of the hoarder. Hoarding behavior is usually a well-established pattern of behavior that has occurred for many years by the time an individual is identified. Hoarders are often homeowners who tend toward degrees of social isolation. Their behavior goes undetected for years. They have little internal motivation to change. Many hoarders do not receive treatment until there is a medical emergency. Situations like interventions by public agencies for health or fire code violations, or other circumstances that act as catalysts for intervention. The shortage of competent treatment providers is a reality that must be faced for the minority of individuals who are open to receiving treatment. Even when the hoarder is willing and proper treatment is available, other “nuts and bolts” issues can impede a successful outcome. The sheer magnitude of the problems can be overwhelming. Some individuals can possess thousands of items and thousands of pounds of accumulated mass. Even if the hoarder is a willing participant in the process, sorting and disposal of items can be a monumental task. In the more likely scenario where the intervention is not fully voluntary, the prospects for a smooth and successful operation become remote.

Even individuals who choose freely to participate in CBT may progress at excruciatingly slow rates and may find it difficult to follow prescriptive therapeutic measures when not under direct supervision by their therapist. Because independent efforts to dispose of relatively inconsequential items can produce intolerable discomfort for many hoarders, avoidance of disposal and reversion to characteristic hoarding patterns. These are common occurrences during the course of therapy.

Thus, a variety of factors are involved. The physical effort required to deal with the volume of collected materials, the patience and knowledge required to sort out truly valuable items from the junk, the practical solutions that must be found for appropriate disposal of items, etc. can tax the physical energies, the financial resources and the emotional reserves of the most treatment-receptive hoarder. For the resistant, isolated, elderly economically disadvantaged individual in poor health with decades of unchecked hoarding behaviors, the picture is exceedingly grim.

Non-OC Hoarding and Comorbid Conditions

Much of the discussion thus far has focused on hoarders who closely match the “OC hoarder” model. These individuals whose hoarding patterns constitute the primary elements of the symptom picture. In fact, hoarding behaviors frequently coexist with other psychological disorders. They are rarely seen in the absence of symptoms resulting from the hoarding itself. Besides OCD and OCPD, hoarding has been associated with psychosis, anorexia nervosa, organic mental disorders, such as, Alzheimer and senile dementia, Prader-Willy syndrome, attention-deficit disorder (ADD), depression, social phobia, addictive disorders, retardation, physical disabilities and others. Obvious complications can result when hoarding emerges in these contexts. For example, psychosis can produce hoarding of unusual items such as urine and feces. ADD sufferers may lack the attention span and/or organizational abilities necessary for the task of uncluttering. Physically impaired individuals may lack the physical strength or prowess necessary to address the excavation process and dementia can render the individual incapable of comprehending the nature of the problems he or she faces.

Psychological problems secondary to hoarding may complicate treatment. Hoarders may be too depressed by the magnitude of their dilemma to generate sufficient energy for change. They may be too embarrassed by the state of their living environment to allow others to see it firsthand. Thus, they may become socially anxious, isolated, eccentric and beyond the reach of potential helpers. All of these possibilities can greatly complicate the potential for effective therapeutic intervention.

Hope for Hoarders

While it is important to understand these and other possible impediments to the successful treatment of hoarding, the situation is certainly not completely bleak. More has been learned about hoarding in the past ten years than was ever known before. Efforts are underway to increase our understanding of hoarding and to enhance the effectiveness of available treatments. Researchers throughout the country have joined the campaign.

Diverse resources including researchers, clinicians, social services providers, public funding sources, and community judicial, police, health and fire services and national organizations, such as, the Obsessive Compulsive Foundation, have become increasingly aware of the scope of the problems associated with hoarding. They are communicating and cooperating as never before. Therapy for hoarding is now more effective than it ever has been and, no doubt, will become increasingly effective as the nuances of hoarding yield to modern tools of scientific investigation.

Here are some more articles that may be of interest to you.

Comments

  1. L says

    I cannot comprehend the DSM classification criteria: Observation of these folk , including communicative style, information processing, self-awareness and reality-orientation suggest overwhelmingly that, with few exceptions, compulsive hoarding is a form of psychosis, not an anxiety spectrum disorder. Indeed, their reality orientation seems to be more of a semiotic artifact than genuinely grounded in cogent object relationship, and the fierce sophistication of defense more closely recalls the tenor of schizoid or schizophrenic defensive strategy than either addictive or anxiety strategies. Only this accounts for the overwhelming resistance to treatment and recidivism. I suspect that antipsychotic treatment will yield better results than depression treatment, notwithstanding the well-known “backlash” exhibited by patients who’ve been subjected to forced intervention. I hate to even suggest it, because psychopharmacology is still the redheaded step-child of big-pharma (all glowing TV ads to the contrary), but I’m persuaded that a good course of haloperidal or risperdal might have better long-term effects than the current standard of prozac/patience/compassion and CBT/DBT.

    • says

      This is a great question and it is important to conceptualize hoarding as a symptom rather than a diagnosis. There are currently committees working on the question of “where does hoarding belong in the DSM?” Indeed, some people who struggle from hoarding do suffer from a psychotic thought process and their treatment may (and often does) include antipsychotic medications. Compulsive hoarding and acquisition can also result from depression, physical conditions, anorexia, dementia, head injury, OCD, trauma and ADD. Often the hoard does serve as a protective mechanism for that individual (i.e. control, attachment, security). This helps to understand the intense emotion many hoarders experience when emergency interventions take place. Every client is different and the psychological treatment of this symptom is dependent on a good conceptualization and treatment plan of the core problem. It is easy for many therapists and helpers to get blinded by the clutter and totally miss the true cause of the hoard. Television programs like Hoarders have done a great job of increasing awareness of this problem, however very little therapy is shown to the audience. Therapists on the show are there for crisis management and it is not an appropriate setting to open up to much of that individual when we can only be there for them for a few days. As experts in hoarding, we start to create a conceptualization of that person and refer them to the most appropriate aftercare professionals following the show. No doubt about it, hoarding is a multifaceted problem. That being said, with the hundreds of hoarding clients that I have worked with over the past 12 years they are also some of my favorite people.

  2. Anonymous says

    My mother is a hoarder and her health and safety loom in my mind every second of the day.
    I can’t afford professional help to organize and she refuses to seek help and that blocks any progress
    . Sometime I wish she were alcoholic as well so I could get her in some kind of rehab.

  3. Geralin says

    You are not alone!

    I hear this all the time from adult-children of hoarders. It’s one of the most frustrating things about this disorder–the hoarder usually isn’t hurting anyone except themselves so action can’t be taken. (That being said, renters who hoard are another story because some can’t afford to clean/repair the damages caused by hoarding.)

    But, the truth of the matter is that it is very hurtful for family members who feel helpless.
    Thanks for your note and check back for next week’s post which will be about addiction and compulsion written by Dr. Marla Deibler.

  4. Anonymous says

    Hey I am a student at James Benson Dudley High School. I was wondering if you would answer a couple qeustions for me. I am Doing Compulsive Hoarding for my Senior Project. I need to interview a doctor or some one in this field of work.

    Q: Is compulsive hoarding a mental or physical problem?

    Q: Is it something that can be cure able?

    Q: Does the state board need to be involved at this point of compulsive hoarding?

    Q: Does this affect the soical life of the hoarder?

    IF you could get in contact with me that would be perect. miller_jametrice1@yahoo.com

    Thank You, Jametrice Miller

  5. Anonymous says

    1. Hoarding can be either/both a physical or mental problem. We are learning that our emotional experiences can be due to factors outside of our brain, experiences and neurotransmitters. Everyone is different and hoarding can be a symptom of many different things. This is why a thorough behavioral analysis is so important to successful treatment.
    2. Hoarding can be successfully treated.
    3. Sometimes it is necessary to involve local city or state agencies to ensure a safe environment for children, adults and animals.
    4. Many hoarders experience significant impairment in their social lives due to this problem. It makes it difficult to start new relationships and keep the ones they already have. Many people do not understand hoarding and think that it is as simple as “just throw it out”. This causes problems when friends and family try to help.

    Hope this is helpful. Best, Dr. Renae Reinardy http://www.lakesidecenter.org

  6. Anonymous says

    Can you tell me where I can find information on the ethical guidelines for therapists working with hoarders?
    If we enter a house and clearly see that there is a public health issue are we required to report it to the health department? What about a situation in which exits are blocked etc…? What about self-neglect in clients that are over 65 years of age?

    Thanks for any assistance you can offer.

  7. Anonymous says

    Each state is a little different. You would have to contact your state licensing board to see what your local ethical guidelines include.
    Best,
    Dr. Renae Reinardy