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Cognitive and Behavioral Practice 17 (2010) 449–457 www.elsevier.com/locate/cabp
Treating Elders With Compulsive Hoarding: A Pilot Program
Kathy Turner, Brookline Community Mental Health Center Gail Steketee, Boston University
Laura Nauth, University of Chicago
1077 © 20 Publ
Hoarding among elderly clients can have serious health and safety consequences, including death. Because medications and standard behavioral treatments have yielded limited benefits for people with serious hoarding problems, we employed a specialized cognitive behavioral treatment (CBT) based on Frost and colleagues’ model of hoarding problems. Of 11 elderly clients who met screening criteria for hoarding at a community mental health center, 6 completed an average of 35 sessions of therapy administered by a B.A.-level therapist trained and supervised in CBT methods. Treatment consisted of weekly home visits that included motivational interviewing, organizing and decision-making skills, cognitive therapy regarding hoarding and related beliefs, and practice sorting, discarding, and not acquiring. Modest improvement was evident in ratings of clutter, risky situations in the home, and functioning. Clients were generally satisfied with treatment. Challenges in treating hoarding in elderly clients include health and safety risks as well as reduced physical capacity that required problem-solving strategies.
HOARDING is characterized by excessive clutter thatimpairs the use of living spaces, difficulty discard- ing items, excessive acquiring of new items, and signifi- cant distress or impairment in functioning due to hoarding (Steketee & Frost, 2007). Common accompani- ments to hoarding include difficulty making decisions, keeping attention on tasks, perfectionism that interferes with task accomplishment, and concurrent problems such as depression, social anxiety, and worry. Recent epidemi- ological studies suggest that clinically significant hoarding occurs in 2% to 5% of adults (e.g., Iervolino et al., 2009; Samuels et al., 2008). Among elderly patients, 15% of nursing home residents and 25% of community-dwelling day care participants hoarded small items (Marx & Cohen-Mansfield, 2003), although this behavior may not be typical of clinical hoarding described in other studies of adults. Hoarding has been associated with low insight, more severe illness, difficulty initiating or completing tasks, indecision, social phobia, and generalized anxiety disorder (Samuels et al., 2002; see Pertusa et al., 2010). Other studies also confirm substantial comorbidity among people who hoard (e.g., Farchione et al., 2004), which may contribute to the limited success of treatment approaches.
Among elderly people who hoard, deterioration in physical health and safety, as well as psychological,
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emotional, and social well-being, is not uncommon (e.g., Kim, Steketee, & Frost, 2001; Thomas, 1998). Hoarding can lead to impairment in everyday activities like cooking, cleaning, bathing, and sleeping (e.g., Damecour & Charron, 1998), and severe hoarding can be especially dangerous for elders at risk for falling and those with chronic health conditions like emphysema because of dust and other allergens, as well as insect and rodent infestation. In addition, age-related reductions in social support networks can increase psychological and physical risk. Further, the risk of homelessness increases for elderly hoarders when landlords seek eviction due to unsafe conditions. Serious hoarding also poses significant problems for community service staff in health depart- ments, housing authorities, and social service agencies, and can strain the financial resources of communities (Frost, Steketee, & Williams, 2000).
The limited number of studies of interventions for hoarding indicate that pharmacological and behavioral treatments have typically yielded benefits below those reported for obsessive-compulsive disorder (OCD), with which hoarding has been most closely associated (e.g., Mataix-Cols et al., 1999; Mataix-Cols et al., 2002; see review by Pertusa et al., 2010). Modest success in treating hoarding has been achieved through specialized cognitive and behavioral interventions based on a model of hoarding (Steketee & Frost, 2007). Motivational inter- viewing combined with behavioral and cognitive techni- ques directed at hoarding symptoms was tested in a pilot study (Tolin, Frost, & Steketee, 2007) and a wait-list
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controlled trial (Steketee, Frost, Tolin, Rasmussen, & Brown, 2009). It produced moderately good success in 10 pilot cases and for 36 patients who completed 26 sessions of this targeted therapy. After treatment, approximately two thirds of the sample was considered much or very much improved on therapist-rated clinical global im- provement. Using similar methods, an elderly woman with a serious hoarding problem was successfully treated by Cermele, Melendez-Pallitto, and Pandina (2001). Among factors the authors considered important in her success was establishing a trusting client-therapist rela- tionship and empowering the client to make decisions whenever possible.
Although formal studies are lacking, clinical evidence suggests that service providers face substantial challenges in treating hoarding among elderly clients. Because hoarding typically begins in childhood or adolescence (Grisham, Frost, Steketee, Kim, & Hood, 2006) and increases gradually with age, elderly hoarders are likely to have ingrained behavior patterns and substantial clutter. Treating hoarding becomes even more challenging in the face of preexisting mental health problems, normal age- related mental and physical decline, reductions in living space, losses of friends and family members, and financial stress for many. Social service agencies often employ a fragmented treatment approach, marked by occasional interventions prompted by acute health or safety con- cerns, often followed by relapse (Damecour & Charron, 1998; Thomas, 1998).
In the face of these concerns, the Brookline Commu- nity Mental Health Center (BCMHC) in collaboration with the Brookline Housing Authority and the Council on Aging obtained funding from Springwell Elder Services (a Massachusetts Aging Access Service Point) to develop and deliver an intervention for elders with hoarding, based on an evidence-based manual of CBT for hoarding (Steketee & Frost, 2007). A flexible number of sessions delivered by caseworkers and mental health clinicians trained in CBT methods were expected to produce reductions in clutter and related hoarding problems among community- referred elderly clients. Modifications to the standard protocol to address age-related concerns were made to achieve improvement in this broad community sample.
The treatment team consisted of three licensed master’s-level social workers (including the first author, KT), three bachelor’s-level counselors (one, LN, hired specifically for this project), an agency psychiatrist, and a doctoral-level social worker experienced in CBT for hoarding (GS). Treating clinicians attended three 2- hour training sessions and received monthly group supervision with phone consultation as needed. The
inclusion of several clinicians was intended to reduce potential staff burnout as hoarding cases can be time- consuming and frustrating. However, of the starting six clinicians, two left the agency (unrelated to this study) and three had clients who were unable to continue in therapy for hoarding (one had a psychiatric hospitaliza- tion, one died, and a third required immediate treatment for depression). Thus, only LN, who was hired for this project, was able to complete treatment for the six clients described in this paper.
Referring therapists were asked to maintain contact with their clients to provide ongoing emotional support and intervention for comorbid conditions during their hoarding treatment. Five clients saw their nonstudy clinician approximately weekly, and the sixth client who had Parkinson’s disease maintained contact with her case manager for in-home personal care services (see case descriptions below).
All clients signed standard privacy rights disclosure forms agreeing to assessment and service delivery from BCMHC; all data for this paper were analyzed without identifiers to protect client confidentiality. The project was approved by the Boston University human subjects review board.
Fourteen referrals for the project came from a community mental health agency (n=9), elder housing site (n=4), and a private therapist (n=1). Individuals were included if they had ratings of 4 (moderate) or greater on a pictorial measure of clutter and/or at least moderate difficulty discarding objects (see Measures). As the agency’s mission was to serve a broad range of community members, exclusion criteria were flexible for this hoard- ing intervention program. Thus, we included 1 client with a past history of schizophrenia who had been stable for more than 1 year. Three people were excluded, 1 for dementia that was evident during the initial interview (no formal cognitive assessment was conducted for this or other clients), and 2 because of severe personality features (e.g., aggression) deemed problematic for in- home treatment.
Of 11 clients who began the intervention, 1 discon- tinued due to psychiatric hospitalization for psychosis and another withdrew to seek treatment for body dysmorphic disorder. Nine clients completed assessment and began treatment, but 2 discontinued when their therapists left the agency and 1 died of causes unrelated to hoarding. The remaining 6 people (1 man, 5 women) completed at least 26 sessions of treatment (consistent with Steketee and Frost’s 2007 treatment protocol) and provided posttreatment measures. Their average age was 72.3 years (range 56 to 87). Five lived in subsidized rental
451Treating Elders Who Hoard
units requiring yearly inspections and 5 lived alone. Four clients reported taking antidepressant medications at study outset. Two had been on stable doses for at least 1 year (one on 20 mg of citalopram; one on 75 mg amitriptyline plus 25 mg fluoxetine). A third client began 20 mg of citalopram 2 weeks prior to the study. All 3 of these clients remained stable on medication throughout the study period. A fourth began an antidepressant of unknown type during the project to address depressed mood. Thus, CBT effects may have been influenced by medications, particularly for these last 2 clients.
Clinician consensus based on agency case records (but no formal diagnostic interview) was used to estimate comorbid conditions as follows: major depression (3), dysthymia (3), PTSD (1), attention deficit disorder (1). Only one client had no suspected mental health comorbidity. Clients also displayed a range of physical problems that included Parkinson’s disease, chronic bronchitis, peripheral neuropathy, arthritis, glaucoma, and obesity. The youngest person had chronic diabetes and a recent toe amputation that left her with limited mobility. Mobility problems were evident in three cases and two others reported low energy due to physical problems and/or depression.
According to a semistructured hoarding interview (available in Steketee & Frost, 2007) administered early in treatment, this group included a range of ages of onset (see case descriptions below). Two clients had lifelong hoarding beginning in childhood, with histories that included childhood deprivation and loss of a parent. Two clients developed symptoms in their mid 30 s, possibly triggered by the death of a family member (mother, daughter). Two people had late-life onset, possibly because of life changes that included moving to senior housing after a history of alcoholism and homelessness and downsizing to a smaller apartment, coupled with increasingly decreased mobility due to a degenerative medical condition.
The clinician completed pretest assessments within the first two therapy sessions and posttest measures ranging from Session 28 to 41. The therapist was trained (by GS) in using the assessments but reliability was not assessed.
During a walk-through of each participant’s home, the therapist rated the extent of clutter using the Clutter Image Rating (CIR; Frost, Steketee, Tolin, & Renaud, 2008), a set of nine photos of the kitchen, living room, and bedroom in stages of clutter (from 1=no clutter to 9= severe clutter). The average of the three main rooms served as the total score. In some cases, one room served dual purposes and the total score was based on only two rooms. This instrument has demonstrated good reliability and validity for both therapist and client ratings.
The clinician completed the Activities of Daily Living (ADL) scale by rating the participant’s degree of difficulty in carrying out 16 common in-home tasks using a scale from 1 (can do easily) to 5 (unable to do). The total score was the average of all relevant tasks (maximum=5.0). In addition, the clinician also rated the extent of safety concerns within the home (averaged across 5 items scored from 1 to 5). This instrument provides clinically useful information about clients’ capabilities within the home and has been used previously (e.g., Grisham, Frost, Steketee, Kim, & Hood, 2006). Reliability and validity are under study.
The therapist also rated clients on typical hoarding symptoms during the initial interview and repeated these ratings at the end of treatment. The first three items were drawn from the Hoarding Rating Scale (HRS; Tolin, Frost, & Steketee, 2010a), for which clinician ratings have shown good internal consistency and reliability across time, context, and raters. These ratings on scales ranging from 0 (none) to 8 (extreme) covered (a) difficulty using rooms (“Because of the clutter or number of possessions, how difficult is it for you to use the rooms in your home?”); (b) difficulty discarding (“To what extent do you have difficulty getting rid of [discarding, recycling, selling, giving away] ordinary things that other people would get rid of?”); (c) excessive acquiring (“To what extent do you currently have a problem with collecting or buying more things than you need or can use or can afford?”). A fourth item, problems organizing (“To what extent do you have difficulty organizing the things in your home?”), was added. These scales provided useful information about the severity of initial symptoms and progress following treatment.
Treatment included some office visits and mainly in- home sessions scheduled approximately weekly for 1.5 to 2 hours over a period of 11 to 13 months. In this flexible treatment, the number of sessions ranged from 28 to 41 with a mean of 35.3. Treatment was terminated when study funding ended. At that time, the therapist provided recommendations for follow-up care. At the outset of therapy, each client received a large notebook to keep educational materials and homework papers. With client consent, the therapist took digital photographs of the home to plan treatment and evaluate progress.
Treatment followed guidelines by Steketee and Frost (2007), but no formal therapy adherence measures were collected. Initial sessions included motivational interview- ing (MI) based on work by Miller and Rollnick (2002), reviewing personal values and goals, and building a CBT model to help clients understand their problem. As all clients struggled with ambivalence, MI techniques were used throughout treatment. Apparent reasons for low
452 Turner et al.
motivation included preoccupation with other pressing issues such as health care, finances, housing and legal problems, and anxious and depressed mood. Working on hoarding problems was typically accorded lower impor- tance until other concerns abated or outside pressure increased.
Most sessions were spent sorting, organizing, and categorizing. As they advanced in problem-solving and decision-making skills, clients recognized the overabun- dance of types of objects and were more willing to remove them. The therapist used cognitive strategies to reduce perfectionist standards about finding the “right” location, and clients began to rely on their organizing plan instead of their memory to find items. Two participants focused first on discarding, because organizing seemed too overwhelming. One participant found the questions for hoarding (“When was the last time you used it? Do you really need it?”) helpful and was able to discard many items without categorizing them. Problem-solving skills helped participants generate coping strategies for a variety of situations.
As clients increasingly tolerated discomfort about organizing and putting objects out of sight, the therapist used cognitive methods to facilitate discarding. These included Socratic questioning for decisions about dis- carding, downward arrow to identify underlying beliefs, and behavioral experiments to test the validity of these beliefs. One participant’s behavioral experiment tested the effectiveness of his organizing system against the Internet and archives at the local library, proving wrong his theory that keeping reading materials at home was the best way to ensure he could find it. His discarding increased substantially after the experiment. Strategies to control acquiring included reviewing disadvantages and advantages and gradual exposures to resisting acquiring with written rules for allowing themselves to acquire. Metaphors and quotations added humor and inspiration, and listening to music helped reduce tedium and frustration while working. Reviewing photos helped participants notice their progress.
Table 1 Scores for 6 Completers on the Clutter Image Rating and the Activities of
Participant CIR Pretest
CIR Change ADL Functioning Pre
A F P
1 4.67 3.33 -1.34 (29%) 2.14 1 2 3.67 2.00 -1.67 (46%) 1.29 1 3 5.50 3.50 -2.00 (36%) 2.50 1 4 2.50 2.00 -0.50 (20%) 1.33 1 5 6.00 5.00 -1.00 (17%) 1.56 1 6 5.33 4.00 -1.33 (25%) 2.67 1 Mean 4.61
(SD=1.31) 3.31 (SD=1.17)
-1.31 (28%) 1.92 (SD=.60)
The therapist made several modifications to standard treatment for these older clients. Encouraging client- initiated discussions about the end of life helped clients become more realistic about the available time and the value of their possessions. For two participants, discussion of their increasing health problems helped them reorder their priorities, increase their discarding, and lower perfectionist expectations so they could enjoy more of the present. In addition, several older participants benefited from establishing a balance of therapy work and leisure time (rewards for work), as this appeared to ensure continued motivation, especially in the face of an uncertain future that made them hesitant to work hard on their hoarding problem. Because physical sorting and moving objects was more difficult for this older group, the therapist encouraged clients to extend their sorting time but take more breaks. On several occasions, once clients made decisions, the therapist was able to enlist help from neighbors, friends, and building managers to help move and remove objects. However, none of these clients was able to identify a “coach” for regular assistance.
We first examined pretest scores for the 6 treatment completers and the 5 clients who discontinued. CIR data were not available for this comparison. No significant differences were found on measures of hoarding symp- toms (HRS items) or functioning (ADL) according to t tests (all psN .16).
Hoarding Outcomes for 6 Treatment Completers
Individual severity scores for the 6 completers on the CIR and ADL at pre- and posttreatment are provided in Table 1. Mean scores were calculated across all com- pleters to provide an index of overall response. A repeated-measures t test indicated significant improve- ment in CIR-rated clutter, t(5)=6.139, p= .002. As evident from Table 1, before treatment 1 client reported only
Daily Living Before and After Treatment for Hoarding
DL unctioning ost
ADL Functioning Change
ADL Safety Pre
ADL Safety Post
ADL Safety Change
.64 -0.50 (23%) 2.83 1.83 -1.00 (35%)
.14 -0.15 (12%) 1.50 1.17 0.33 (22%)
.79 -0.71 (28%) 2.17 1.50 -0.67 (21%)
.13 -0.20 (15%) 0.00 0.00 0.00
.38 -0.18 (12%) 2.34 2.17 -0.17 (7%)
.66 -1.01 (38%) 1.67 1.50 -0.17 (10%)
-0.46 (24%) 1.75 (SD=1.36)
453Treating Elders Who Hoard
mild clutter (this resulted from averaging the uncluttered kitchen with the moderately cluttered bedroom/living room); 3 clients scored above the midpoint, indicating moderately severe clutter, with the remaining 2 in the moderate range. After treatment, average scores reduced to the mild/moderate range, with a mean reduction of 1.31 representing an average 28% reduction in clutter (range 17% to 46%). Living room clutter reduced by 1 to 2 points on the CIR, as did kitchen clutter (excepting 1 client whose kitchen was not cluttered before therapy began). Bedroom clutter reduced slightly less. These changes reflected clients’ preferences for clearing rooms in their homes.
With regard to daily activities on the ADL, pretest scores indicated that 3 clients showed little difficulty, and the remaining 3 had moderate problems (see Table 1). Reductions following treatment were statistically signifi- cant, t(5)=3.218, p= .024, and represented 24% improve- ment in ability to function. Three clients’ apartments had moderate safety concerns at the outset (scores from 2.17 to 2.83), mainly with regard to fire, and 2 had minor problems (scores of 1.5 and 1.67); 1 client had no safety concerns. Overall, safety conditions improved significant- ly, t(5)=2.548, p= .05. Four of the 5 clients who had such problems improved 10% to 35%, whereas 1 client continued to have significant fire hazard (score of 2.17) even after treatment.
Table 2 illustrates mean scores on therapist ratings of hoarding problems (0–8 scales) for the 6 treatment completers. Substantial reductions of 2 points or more were evident for excessive acquiring and difficulty discarding (reductions of 54% and 34%, respectively), but pre-post reductions were not significant according to t tests, psN .11). Difficulty using rooms in the home improved slightly (14%) but, surprisingly, organizing did not show improvement. T-tests indicated no change on these measures (psN .22).
Progress was uneven both within and across the 6 clients who are described briefly below. Methods that were helpful for all clients included goal setting and goal review, behavioral cues, scheduling times to work/sort for homework and reviewing progress with photographs.
Table 2 Average Pre- and Posttreatment Scores and Average Change on Intervie
Difficulty using rooms due to clutter 6.00 (SD=1.67) Difficulty discarding 5.83 (SD=1.60) Excessive acquiring 4.33 (SD=1.37) Organizing problems 4.83 (SD=2.79)
Several strategies seemed especially helpful. The therapist spent time in the first 2 to 4 sessions getting to know the client in order to build a trusting relationship with this older group who seemed more than usually cautious about engaging in new behaviors. Several clients with physical limitations required lengthy therapy sessions to help them move and remove items or find trusted others from whom they would accept help. The therapist found it helpful to post homework assignments, reminders and questions to challenge hoarding beliefs on the walls as memory aids for forgetful clients.
Client 1 was a 67-year-old woman who had major depression and posttraumatic stress disorder. Her acquir- ing, discarding, and clutter began at age 12, following reported extreme deprivation as a child that contributed to a lack of trust in others and herself. She viewed her possessions as a source of comfort, protection from loneliness, and in some cases, as a stabilizing force that helped her manage. For example, her mild heart problem led her to save numerous articles on heart disease and prevention, believing that throwing them out could jeopardize her health and/or her ability to help herself. She lived alone in senior housing where management was pressuring her to clear her apartment. Moderately active socially, she went out daily with friends, but was not close to her family. Her obesity, diabetes, and depression tired her easily during her 39 therapy sessions. Helping her find a way to sit comfortably during sorting sessions greatly increased her time on this activity. CBT methods that worked well for her included considering the pros and cons, problem-solving techniques, and imagined exposures for discarding and acquiring. Cognitive strat- egies of taking another perspective and downward arrow were not helpful because, although she could easily identify an error in judgment, she still wanted to keep the item. Her organizing improved, but moderate acquiring continued, although she became more aware of this over time. Acquiring and discarding exposures worked well initially, but required frequent repetition. She came to believe that she deserved a livable apartment and reported continuing to engage in sorting several times a week at the end of treatment. Her moderate clutter reduced by nearly 30% as she improved in discarding, especially old newspapers, as well as daily functioning (23%) and safety problems (35%). After her second
w Measures of Hoarding
Mean Post Mean Change
5.16 (SD=2.32) -.83 (14%) 3.83 (SD=2.48) -2.00 (34%) 2.00 (SD=2.10) -2.33 (54%) 5.00 (SD=2.10) +.16 (-3%)
454 Turner et al.
housing inspection showed nearly two-thirds reduction in clutter, she began to invite people into her apartment.
Client 2, a woman of 87 with Parkinson’s disease, had no evidence of psychiatric comorbidity. She described a normal and happy childhood living with a mother who kept her house “perfectly clean until she died.” Like Client 1, she lived alone and was under pressure from management to reduce clutter, which appeared to have developed later in life. She believed her things were useful and beautiful and helped distract her from feelings of loss and concerns about aging. She had very limited mobility and was mostly housebound, although she did socialize with some residents in her housing community. Her 38 treatment sessions began with removing papers from the floor due to fire safety issues and extreme fall hazard. She learned to part with old magazines, calendars, clothing, and empty boxes. Improvements in organizing slipped after she entered a rehab facility for her neuromuscular problems but improved again over time. Mild acquiring problems also improved slightly. CBT methods that worked well included Socratic questioning, enhancing beliefs about coping, evaluating perfectionism on a continuum (e.g., making a “good enough” decision instead of a “perfect” one), and considering the value of her time, especially after she was hospitalized. Her degenerating health helped her focus on not wanting to keep and sort so many things and reduced her underestimation of the time required to clear clutter. She began to accept help from her home health aide, whom the therapist trained to help with physical sorting. By the end of treatment, her moderate clutter reduced substantially (46%) and mild functioning problems improved slightly (12%), as did safety concerns (22%).
Client 3, a woman of 87, had dysthymia and chronic respiratory problems. She lived alone in senior housing where management insisted she clear her home. This client’s mother had died when she was 5, and she noticed a problem with excessive acquiring and clutter early in her life (around age 10). She had downsized recently from a house to a small studio apartment, requiring her to give up many of her furnishings and other possessions. Active in her community and church, she socialized and engaged in various hobbies. In her view, her possessions represented her life achievements and held great sentimental value and usefulness. Treatment focused first on safety problems identified by the housing inspector, especially papers cluttering walkways, blocked fire exits, and a tilting bookcase. Like other clients, she had difficulty moving large objects and sorting for sustained periods. Problem-solving strategies helped her identify items of least importance for discarding and generated a good solution for the bookcase (having a repairman fix it), while also strengthening her confidence in the clinician. Examining the continuum to reduce
perfectionism, reflecting on personal goals, using photos to replace objects, and self-rewards worked well for her. Also helpful were enquiries about previous successes in making positive changes as this increased her belief in herself (self-efficacy). She began treatment with substan- tial clutter and after 41 sessions reduced this by 36%, getting rid of boxes, clothing, and many items she hadn’t used in a year. She also improved in daily functioning (28%) and safety (31%). She stopped all excessive acquiring but continued to have moderate difficulty discarding and organizing the home, although her ability to make decisions improved.
Client 4, a woman of 75 with dysthymia, had previously lived in a homeless shelter following serious alcohol problems 15 years earlier. Her hoarding was identified at age 69 when she moved to a senior housing complex where she lived alone. She had many strong telephone relationships with friends and attended AA meetings regularly. Her things held mainly sentimental value as reminders of her struggles and losses. This client tired easily during treatment work and began taking antide- pressants at the beginning of her 29 sessions of treatment. She began using a filing system as she slowly emptied boxes and drawers and shredded old bills and papers. Her history of eviction, homelessness, and shame about her past alcoholism played an important role in her avoidance of sorting/discarding because many of the papers reminded her of that painful time. Acknowledging these feelings in therapy and the use of thought records helped reduce her avoidance. Other helpful treatment methods included goal setting, problem solving, considering advantages/disadvantages, Socratic questioning to evalu- ate beliefs, reflecting on her coping skills, and cultivating new resources and supports. Exposure to organizing and discarding increased her tolerance for both of these activities. Her mild clutter improved modestly (20%), as did her mild functioning problems (15%). This client had no safety problems. She improved greatly in her ability to discard and organize, and she stopped her excessive acquiring completely.
Client 5 was a 64-year-old man who lived in an apartment with two roommates, one of whom tolerated the clutter, whereas the other planned to move out soon. The client’s mentally ill mother died when he was in his early 20s; his hoarding reached onset in his middle 30s. He reported a period of homelessness after eviction by a landlord who discarded all his possessions just prior to hoarding onset. He exhibited symptoms of major depression and possible attention-deficit disorder, as well as occasional cannabis use; there were no physical disabilities. Client 5 reported having several friends; he attended some community gatherings, and worked occasionally. Regarding his possessions, he considered them to be useful and wanted to avoid wasting them; in
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addition, he regarded other possessions as beautiful, sentimental reminders of unrealized hopes and ideals. He completed 37 sessions of treatment. The most effective methods for this client were use of a perfectionism continuum, considering the value of his time, setting goals and rewarding himself when these were achieved, reviewing progress in photos, and finding resources outside his house (library, community groups, and worthy causes to whom he could donate). Behavioral experi- ments (i.e., determining the effects of discarding items from basement) were helpful and appeared to boost his confidence, but he sometimes became overwhelmed by his failure to do more, to improve his life, or to arrive at appointments on time. Socratic questioning, downward arrow, and considering advantages/disadvantages were less helpful as he turned these into theoretical discussions or became annoyed by requests for information about his thinking. His severe clutter improved somewhat (17%), as did mild functioning difficulties (12%), but moderate safety problems improved only slightly (7%). He im- proved in his ability to get rid of duplicates and to recycle old newspapers. Although he established a filing system, he was unable to use it effectively so his severe organizing problems improved little. Similarly, he curbed the acquiring of newspapers but continued to bring large furniture items into the home. His tolerance for sorting possessions and his perfectionism seemed to improve.
Client 6 was 56 and had recently downsized from a 2- to a 1-bedroom apartment where she lived alone, also pressured by management to clear her home. She had symptoms of major depression and physical problems, including diabetes, peripheral neuropathy, arthritis, and glaucoma. These and recent surgery on her leg limited her mobility and left her nearly housebound, although she kept active in her religious community via phone contact. She reported deprivation in her childhood (running out of food and supplies) and an abusive relationship with her husband in her early adulthood. Her hoarding began after her daughter’s death when the client was in her mid 30s. For her, possessions meant comfort and protection from loneliness, and, like other clients, she found objects useful and pretty; she also wanted to avoid wasting things. Helpful treatment methods included uplifting quotes and metaphors, valuing her time, and taking another perspective. For example, asking, “Would you expect your friend to keep this item if you had given it to her?” proved very effective. Goal setting, problem solving, and rating objects on a “need versus want scale” also helped, as she discarded half of her 80 bottles of nail polish by considering her “need” for them compared to other items in her life. This client used rational discussion to temper her symptoms, but she found the downward arrow technique confusing and unhelpful. With a goal of being able to invite people into
her home, she resisting acquiring new items, especially excessive food items on sale. As she realized that many of her items were no longer useful to her, her discarding improved and she was able to clear and give up her storage space. During 28 sessions of treatment she gained confidence in her ability to help herself, proudly noting her ability to quit smoking. Her substantial clutter improved by 25%, functioning improved by 38%, and mild safety concerns improved slightly (10%).
Clients completed a Satisfaction Survey of 8 questions inquiring about quality and type of service desired, extent to which needs were met, whether clients would recommend the program to a friend, satisfaction with amount of help, usefulness of services for dealing with hoarding problems, overall satisfaction and willingness to return for the services provided if needed in future. Questions were scored on 4-point scales from very dissatisfied to very satisfied (possible range=8 to 32). Satisfaction scores ranged from a low of 23 to high of 32 with a mean of 27.2, indicating high satisfaction.
The present study presents outcomes for 6 of 11 clients with hoarding problems from a community-based agency that provides services to elders. We included 1 client with a past history of severe mental illness, but this client required hospitalization for a recurrence of psychosis and had to be dropped from the protocol. Four other clients refused or dropped out of the therapy protocol for a variety of reasons, a relatively high rate of attrition in this community sample. In a wait-list controlled research trial using a similar proto- col, only 10% (4 of 41) of those assigned to CBT dropped out (Steketee et al., 2009). The broader inclusion criteria for this project may have led to more dropout as psychiatric and health comorbidity interacted with limited commitment to resolve hoard- ing. While we do not recommend restricting the client sample for such community-based service delivery, we do suggest educating clients at the outset regarding therapy methods and procedures. Even with such efforts, however, community clients, especially low- income elders with significant hoarding and comorbid- ity, will be difficult to engage and retain in therapy. In fact, limited insight among hoarding clients is well documented (e.g., Kim et al., 2001; Tolin, Fitch, Frost, & Steketee, 2010b), such that motivational enhance- ment methods form a part of the recommended treatment protocol (Steketee & Frost, 2007).
Our sample included clients with lifelong hoarding, as well as those with later-onset hoarding triggered by life changes (e.g., moving from a larger residence to a smaller
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one) or loss (e.g., death of a family member, recent illness). The extent of the stressful early life events they reported (deprivation, abuse, death) seems typical of hoarding samples in other studies (e.g., Tolin, Meunier, Frost, & Steketee, in press). These difficult histories may play out during the therapy. For example, two clients (Client 1 and Client 5) with extremely complicated parental relationships had very little trust in their own ability to positively affect their lives and both seemed to have more difficulty than other clients in making changes in their behavior. Deprivation in childhood and adult- hood contributed to two clients’ (Client 1 and Client 6) fears that they would be unable to replace necessities like toilet paper, shampoo, or even food if they ran out.
The 6 clients who continued in treatment all responded to the CBT intervention, if somewhat unevenly. The positive significance tests on this small sample must be viewed cautiously given the very small sample size. Further, most clients were also taking medications, rendering it possible that benefits may have been due to pharmacological treatments or their combination with CBT, although previous research calls this into question (e.g., Mataix-Cols et al., 1999; Winsberg, Cassic, & Koran, 1999). Consistent with findings from other research (e.g., Steketee, Frost, Wincze, Greene, & Douglass, 2000; Tolin et al., 2007), excessive acquiring improved most, but clients also improved considerably in their ability to discard. Clients varied considerably in their initial severity of clutter, and although the clutter was reduced in all cases, the extent of reduction for those with the most serious problems varied: one client (Client 3) benefitted substantially, with a 36% reduction, and two others (Client 5 and Client 6) improved moderately at 25% and 17% improved. Other studies of adult hoarding (Steketee et al., 2009; Tolin et al., 2007) indicate that those who begin with severe clutter often have considerable remaining work to do after treatment to make their home truly livable. In fact, two clients (Client 5 and Client 6) still had so much clutter remaining after therapy that their posttreatment scores showed more severe clutter than some clients at the start of therapy.
The wide range of outcomes evident in Table 2 may also reflect greater awareness (insight) about their hoarding symptoms at the end of treatment than at the beginning, when clients tend to deny or minimize the severity of their behavior. Thus, in some cases, symptoms appeared to worsen according to clients’ self-report, whereas the therapist saw clear improvement. Although we did not have both therapist and client data on the CIR, we suspect that this problem with variable self-report of severity is less likely to occur on a pictorial measure than on other rating scales. For this reason, we recommend multimethod assessment of hoarding problems.
We encountered a number of treatment challenges that required modification of standard CBT hoarding treatment. Assessment took at least four sessions, with interview questions about the hoarding history and current behavior blending with relationship building and MI. Another important concern was the safety of the home for elderly clients with more limited physical capacity. Fire and fall hazards were identified by referral sources, and in these cases, the clinician needed to focus first on clearing papers from the floor, stove, and furnace areas before permitting the client to select other areas for sorting. Another concern was the mental and physical capacity of clients working alone at home. Several clients had difficulty standing and sorted sitting down with the worker helping to move items, and one client’s arthritis made sorting and filing challenging. Because of the multiple problems clients faced, problem-solving skills were especially necessary and a number of clients mentioned the benefits of learning these skills.
As is typical in treating hoarding, motivation problems recurred regularly, necessitating MI strategies through- out therapy for all clients. Useful techniques included joining with the client and rolling with resistance, understanding their experience through empathic ques- tions about the meaning of saved items, listing the advantages and disadvantages of saving and discarding, and asking for elaboration about how clutter took up their time. Taking the negative side of an argument (devil’s advocate), in which the therapist asked clients, “Why do this anyway?” provided an opportunity for clients to talk about their original goals. We recommend that clinicians establish a clear working time frame for the therapy as a whole and for homework assignments. When we were unclear with clients about expectations, they tended to perform more poorly.
While we recommend that those who treat hoarding have mental health training in CBT and in hoarding problems, the complex health and mental health (Axis I and II) comorbidities that often accompany hoarding can easily sidetrack treatment. In fact, the bachelor-level clinician (LN) who lacked formal training in CBT was able to provide effective treatment with regular supervi- sion. Given the complexity of these cases, two providers who focus on specific areas (e.g., hoarding and case management) may be most helpful for this client population. We recommend that service agencies identify one or two staff members able to obtain specialized training (preferably with close supervision for initial cases) in order to focus intervention closely on the hoarding problems. These clinicians can rely on other staff members to meet the clients’ other service needs. The agency should also permit clinicians to spend more than 50-minute sessions with clients, especially during home visits. Future research on hoarding treatment
457Treating Elders Who Hoard
should include larger samples of elderly clients with a goal of determining effective modifications that accommodate aging clients and identifying factors that affect therapy engagement and outcomes.
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This project was funded by a grant from Springwell Elder Services in Watertown, MA, awarded to the first author.
Address correspondence to Gail Steketee, Ph.D., Boston University School of Social Work, 264 Bay State Rd., Boston, MA 02215; e-mail: firstname.lastname@example.org.
Received: January 3, 2009 Accepted: April 13, 2010 Available online 21 April 2010
- Treating Elders With Compulsive Hoarding: A Pilot Program
- Pretreatment Comparisons
- Hoarding Outcomes for 6 Treatment Completers
- Client Descriptions
- Client Satisfaction