Challenges in Treating Hoarding

in Midlife and Older Adults

Gail Steketee, PhD, MSW, AASWSW
Boston University School of Social Work

Catherine R. Ayers, Ph.D., ABPP

Research Service, Psychology Service,
VA San Diego Healthcare System &
Department of Psychiatry, UCSD
Manifestations of Hoarding
Acquisition

Saving

Disorganization
DSM-5 Criteria
for Hoarding Disorder (HD)
An OC Spectrum Condition
 A. Persistent difficulty discarding or parting with
possessions, regardless of their actual value.
 B. This difficulty is due to a perceived need to save the
items and distress associated with discarding them.
 C. The symptoms result in the accumulation of possessions
that clutter active living areas and substantially
compromise their intended use. If living areas are
uncluttered, it is only because of the interventions of third
parties (e.g., family members, cleaners, authorities).
Hoarding Disorder Criteria
 D. The hoarding causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning (including maintaining a safe environment for self
and others).
 E. The hoarding is not attributable to another medical condition
(e.g., brain injury, cerebrovascular disease, Prader-Willi
Syndrome).
 F. The hoarding is not better accounted for by the symptoms of
another disorder (e.g., obsessions in Obsessive-Compulsive
Disorder, decreased energy in Major Depressive Disorder,
delusions in Schizophrenia or another Psychotic Disorder,
cognitive deficits in Dementia, restricted interests in Autism
Spectrum Disorder).
Hoarding Disorder Criteria
Specify if:
 With Excessive Acquisition: If symptoms are accompanied by excessive
collecting or buying or stealing of items that are not needed or for
which there is no available space.

 Good or fair insight: The individual recognizes that hoarding-related

beliefs and behaviors are problematic.
 Poor insight: The individual is mostly convinced that hoarding-related
beliefs and behaviors are not problematic despite evidence to the
contrary.
 Absent insight (i.e. delusional beliefs about hoarding): The individual is
completely convinced that hoarding-related beliefs and behaviors are
not problematic despite evidence to the contrary.
Reasons for Saving
 Sentimental –
“This represents my life. It’s part of me.”
 Instrumental –
“I might need this. Somebody could use this.”
 Intrinsic –
“This is beautiful. Think of the possibilities!”
 Compulsive Acquisition
 Compulsive Buying
 Retail/discount
 E-bay
 Home shopping network
 Acquisition of Free Things
 Advertising flyers/handouts
 Give-aways
 Trash - dumpster diving
 Stealing/Kleptomania
Prevalence, Onset and Course
(Ayers et al., 2010; Grisham et al., 2006; Samuels et al., 2008; Tolin,
Meunier, Frost & Steketee, 2010)

 Hoarding occurs in 2-5% of adults

 Hoarding onset starts early adolescence - 68% of
onsets before age 20
 Course tends to be chronic with very few reports of
spontaneous remission
 Late onset hoarding is rare
 Results mixed if hoarding symptoms increase with age
Percent with Moderate to Severe
Hoarding Worsens over Time
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

Tolin DF, et al. Depress Anxiety. 2010.

Frequency of Hoarding
in Older Adults
 15% of nursing home residents and 25% of community day
care elder participants hoarded small items (Marx & Cohen-
Mansfield, 2003)

 Rate of hoarding among elders in private and public

housing is unknown, but some frequency counts are
available:
 Elders at Risk Program, Boston 15%
 Visiting Nurses Association., NYC 10-15%
 Community Guardianship, NC 30-35%

 Some of the worst cases are reported among elderly people

Is Hoarding a subtype of OCD? No, but…
OCD = 135 Hoarding = 217

OCD Both Hoarding

= 96 = 39 = 178

Frost et al. (2010)

Comorbidity in 217 with Hoarding
60

50

40

30

20

10

0
Major Dep. GAD Social Phob PTSD Sub. Abuse ADD
Frost, Steketee, Tolin et al., 2011
Frost et al. (2010)
 Hoarding Consequences
in Older Adults
 Chronic and age-related medical illnesses
(Ayers et al., 2010; Ayers et al., in submission).

 Medication and dietary mismanagement leading

to a worsening of medical conditions (Ayers, Schiehser, Liu, &
Wetherell, 2012a; Diefenbach, DiMauro, Frost, Steketee, & Tolin, 2012; Kim et al., 2001).

 Significant impairment in activities of daily living

(Ayers et al., 2012a; Diefenbach, et al., 2012; Steketee, Schmalisch, Dierberger, DeNobel, & Frost, 2012).

 ability to move within the home, find important

items, eat at a table, use the kitchen sink,
prepare food, and sleep in a bed (Ayers et al., 2012)
 Premature relocation to senior housing or
eviction (Whitfield, Daniels, Flesaker, & Simmons, 2011)
Percentage of Appliances not Useable
(N = 62 older adults, Case Worker Interview)
60%
50%
40%
30%
20%
10%
0%

Steketee et al., Health Soc Wk 2001; 26:176-184

Hoarding related Consequences
 Social isolation (Ayers et al., 2010; Kim et al., 2001)
 Strained relationships (Tolin et al., 2008)
 Family, friends
 Landlords, neighbors
 Legal and financial problems
 Credit card debt
 High expenses – buying, storage unit fees
 Property damage - loss of home investment
Community Challenges
 Increased social service provider load for:
 Public health departments
 Housing and inspection services
 Housing managers & landlords
 Elder service agencies
 Mental health department
 Health care organizations
 The time and money required to resolve serious
hoarding cases strains agency resources
Special concerns and barriers in
working with late life hoarding
 Possible cognitive impairment
 Impaired activities of daily living (ADLs)
 Activities of caring for and moving the body
 Walking, bathing, dressing, toileting, brushing teeth,
eating
 Impaired instrumental activities (IADLs)
 Activities that support independent living
 Cooking, cleaning, driving, communication via phone or
computer, shopping, tracking finances, managing
medications
Special concerns and barriers in
working with late life hoarding
 Not familiar/comfortable with psychiatric
treatment
 Role of family members and other social supports
 Limited/fixed income
 Multiple medications/multiple medical providers
 Possible negative life events (i.e., death of spouse)
 Risk of losing independent living status
Recommended Assessment
 Diagnostic battery
 SCID, ADIS, MINI
 Hoarding Interview (Steketee & Frost, 2007)
 Measures of Hoarding Severity
 HRS
 SI-R
 CIR
 UHSS
 Hoarding Rating Scale (HRS)
0 1 2 3 4 5 6 7 8
Not at all Mild Moderate Severe Extremely
Difficult Difficult
1. Because of the clutter or number of possessions, how difficult is it for you to
use the rooms in your home?
2. To what extent do you have difficulty discarding (or recycling, selling, giving
away) ordinary things that other people would get rid of?
3. Do you currently have a problem with collecting free things or buying more
things than you need or can use or can afford?
4. To what extent do you experience emotional distress because of clutter,
difficulty discarding or problems with buying or acquiring things?
5. To what extent do you experience impairment in your life (daily routine, job /
school, social activities, family activities, financial difficulties) because of
clutter, difficulty discarding, or problems with buying or acquiring things?

Tolin, D.F., Frost, R.O., & Steketee, G. (2010).

Psychiatry Research, 30, 147-152.
 Saving Inventory – Revised (SI-R)
 23 items; excellent reliability and validity

 3 subscales:

 Compulsive Acquisition

 Difficulty Discarding

 Clutter
 Clutter Image Rating
 Select the picture that is closest to the clutter
in your living room, kitchen, bedroom.
 Pictures ranked from 1-9
 Rate the following rooms:
 Living Room
 Kitchen
 Bedroom
 Dining Room
 Hallway
 Garage
 Car
 Other
Recommended Assessment Battery
 ADL-Hoarding (ADL-H)

Activities affected by clutter Can do little moderate great Unable

or hoarding problem easily difficulty difficulty difficulty to do

1. Prepare food 1 2 3 4 5
2. Use refrigerator 1 2 3 4 5
3. Use stove 1 2 3 4 5
4. Use kitchen sink 1 2 3 4 5
5. Eat at table 1 2 3 4 5
6. Move around in home 1 2 3 4 5
7. Exit home quickly 1 2 3 4 5
8. Use toilet 1 2 3 4 5
15. Find important things
1 2 3 4 5
(bills, tax forms, etc.)
Recommended Assessment Battery
 Additional geriatric specific assessments:
 Depression and anxiety measures normed for use with
older adults
 Geriatric Depression Scale
 Geriatric Anxiety Scale
 Neurocognitive measures (Montreal Cognitive
Assessment, Delis-Kaplan Executive Functioning System)
 Additional Functional Measures (Functional Disability
Index)
Why do people Hoard?
 Vulnerabilities
 Evolutionary, biological, genetic, early experiences (attachment),
core beliefs

 Information processing deficits

 Meaning/value assigned to possessions

 Positive and negative emotional reactions

 Reinforcement of acquiring and saving behaviors

(Steketee & Frost, 2007)
 Cognitive Processes:
Vulnerabilities:
Decision-making, Attention,
Genetic, Family,
Memory, Problem solving
Early Experiences

Beliefs & Meanings: Identity, Value,

Responsibility, Memory, Control

Emotions
Negative
Negative Positive
Positive
Reinforcement Reinforcement

Saving &
Acquiring
 Emotions
 Positive Emotions  Negative Emotions
 Pleasure  Grief/loss
 Excitement  Anxiety
 Pride  Sadness
 Relief  Guilt
 Joy  Anger
 Fondness  Frustration
 Satisfaction  Confusion
 Functional Analysis:

What actually happens in real time?

 54-year-old woman
 Lives w/ husband & son, age 16
 Moderate to severe hoarding in living areas
 Hoarding began in high school & increased later
 Mild acquisition problem
 Her father collected items from others’ trash
 Her mother didn’t allow clutter in home
 Acquiring and saving
cosmetic samples & shampoo bottles
 Vulnerabilities
 Father modeled hoarding; “Waste not, want not”
 Perfection & completeness
 Organization, distraction
 Meaning of possessions
 Utility; frugality; waste
 Feelings
 Responsibility, guilt
 Saving items was negatively reinforced by
reduction in discomfort
 Clutter
 Son’s toys
 Vulnerabilities, core beliefs
 Am I a good mother?
 Childhood deprivation
 Beliefs & meaning
 I have to give my son what I didn’t get.
 Feelings
 Guilt/Anxiety/Sadness
 Saving is negatively reinforced
 Clutter
 Card from mother
1. I’ll waste it.
Guilt

2. This card represents my mother.

Ambivalence/Resignation
Grief (Loss of a dream)

3. This poor card.

Empathy
Functional Analysis of
Compulsive Shopping: Janet
 40 year old professional woman
 Husband & 12 year old son
 $27,000 credit card debt
 Clothes buying compulsion
 Serious hoarding problem
Compulsive
Buying
Episode
Specialized CBT for Hoarding
 Education and case formulation
 Determine values, set goals
 Motivational enhancement
 Skills training for organizing, problem
solving, decision-making
 Practice discarding & non-acquiring
 Evaluate thoughts and beliefs
 Maintain new behaviors
Treatment Format for Adults
 26 sessions takes about 1 yr, sometimes more in
severe cases
 Individual or group
 Office and in-home sessions
 Practice in acquiring locations
 Family consultation
 Assistance from a coach if available
 Cleanouts with trained staff/coach if necessary for
extensive clutter
Psychoeducation
 Education about cognitive-behavioral model of
hoarding
 Discussion of treatment and its effects
 Personalized model-building
 Developing a Model to Explain
Client’s Hoarding Behavior
 Start with client’s explanation
 Add features based on interview and
experimentation
 Identify feelings, beliefs, core beliefs
 Connect these to acquiring and saving behavior
and clutter
 Link vulnerabilities to feelings, beliefs and
behaviors
 Do functional analyses of individual features
 Susan’s Cognitive Challenges
Susan’s Vulnerabilities:

Susan’s Beliefs about Possessions

Susan’s Emotions
Avoidance
Negative Positive Attraction to
objects
behaviors

How Susan saves &

acquires
Establish Personal Goals and Values
 Values
 What does the client care most about? - family,
friends, honesty, achievement…
 Personal goals
 What does the client most want to do in the
remainder of his/her life?
 Refer to personal goals and values
throughout treatment to clarify ambivalence
and increase motivation
Example: Susan’s Goals
 To enjoy my instruments again
 To create breathing space, order, and beauty in
my bedroom (esp. in front of the closet)
 To have a living room that a friend or family
could enter
 To have a safe kitchen with working surfaces
 To take a bath
 To remove bagged items
Stages of Change
Preparation

Action Contemplation

Precontem-
Maintenance
plation
Motivating Change in Hoarding
 Recognize ambivalence

 Enhance ambivalence

 Resolve ambivalence

 Reinforce change talk and action

Rules for Clinicians and Coaches
 Ask permission before touching items
 Help clients decide on rules for acquiring,
keeping and discarding
 Help clients learn to make decisions
 Resist the urge to choose for them but do help
by providing information
 Develop a plan that moves systematically by
room or type of spaces and/or objects
Skills and Plan for Organizing
 Categorize and organize wanted items
 Identify categories for types of items
 Select locations for item categories
 Discuss storage locations and furnishings
 Select interim locations during sorting
 Categorize unwanted items
 Trash, recycle, donate, sell; few undecided
 Develop action plan for removing items
Skills to Manage Attention
 Determine usual attention span
 Help client reduce and/or delay
distractibility
 Use timer
 Control visual field (cover distracting areas)
 Discuss ways to create structure
 Regular appointments for sorting
 Establish priorities
 Divide projects into manageable steps
Treating Acquiring Problems
 Identify acquiring problems
 Develop a hierarchy from easier to harder
 Modify beliefs about acquiring
 Practice not acquiring
 Drive-by non-shopping
 Walk-through non-shopping
 Browsing and picking non-shopping
 Coping with empty space
Acquiring Hierarchy
 Driving past a store 10
 Standing outside store 25
 Walking into store 35
 Seeing something you want 50
 Touching object you want 65
 Putting object back 75
 Walking away from item 80
 Walking out without the object 85
Acquiring Questions and Rules
 Do I have an immediate use for this?
 Can I get by without it?
 Do I want it taking up space in my home?
 Is this truly important or does it just seem so
because I am looking at it?
 What are the advantages and disadvantages of
acquiring this?
 Develop personal rules for acquiring - must
have:
 An immediate use for it
 Time to deal with it appropriately
 Money to afford it
 Space to put it
Treating Difficulty Discarding
 Bring box of things from home to sort in the office
 Start with easier items
 Ask client to talk aloud about decision-making
 Gradually reduce assistance with decisions
 Practice sorting at home on most important areas and
easiest items first
 Move sorted items to destination or out IMMEDIATELY –
no looking back
Cognitive Restructuring
 Socratic questioning helps clinician and client
understand the logic
 Identify and correct cognitive distortions
 Downward arrow” technique
 Advantages/disadvantages (pros & cons)
 Taking another perspective
 Behavioral experiments
 Value of time
Identify Beliefs
 Fears of Mistakes/Decisions
 “Need” vs. “Want”
 Responsibility (guilt) for objects and people
 Opportunity
 Memory (memory aid, poor memory)
 Identity – I am what I have
 Uniqueness / one of a kind
 Completeness and perfectionism
 Need for control – it’s mine; no one can touch
Questions to Help Think it Through
 How likely is the feared outcome?
 What evidence is there to support the belief?
 How catastrophic would this be?
 How well could you cope with not having this?
 How much distress would you feel?
 How long would the distress last?
 Can you tolerate the feeling?
 Is your thinking coming from sometime or someone in
your past?
Socratic Questioning for Son’s toys
 How about getting rid of this toy from your son’s (son is
now 16)?
 That would be hard.
 What is the hard part?
 I’d feel like I was getting rid of something he might
want in the future. Maybe for his own kids.
 O.K. What condition is this toy in?
 Well, it’s sort of worn, probably not very good
condition.
 If you tried to sell it, would someone pay money for it?
 No, I don’t think so, it’s dirty and broken.
 O.K., I agree it seems unlikely anyone would buy it. Do
you think your son would want to give his kids a dirty
broken toy?
 No, I guess not.
Socratic Questioning - 2
 You sound unsure. Is there something else you are
thinking that makes you want to keep this? Maybe
some ideas in the back of your head?
 Yeah, I’m feeling like I didn’t help him take care of this
toy. I should have been better at protecting his things.
 OK, so you are thinking you’d have been a better
mother if you’d helped him take better care of his toys.
Do you believe that good mothers make sure their kids
keep their toys in good condition?
 No, I know that isn’t true. Kids have to play with their
toys and toys get worn and broken.
 So actually, it’s OK that this toy is worn and broken. Is
that what you believe?
 Yes, I do. But somehow I still feel guilty. Maybe I’m
feeling bad for the toy.
Socratic Questioning - 3
 Oh, bad for the toy. Do you think the toy has feelings?
What’s it made of?
 Just plastic. I know it doesn’t make sense.
 But the idea is there, so we need to examine that belief that
the toy might have feelings. What do you think?
 I know it doesn’t really have feelings.
 Are these feelings coming only from you? You said you felt
guilty. What do you think the guilt is about?
 I feel that I need to provide my son with things I didn’t have
as a child. My own childhood was hard and I didn’t have
many toys. Throwing this out seems wasteful.
 Um hmm. Let’s take a hard look at whether it is truly
wasteful. How would you decide that? When is it wasteful
to get rid of something, and when is it o.k.?
 Well, it’s bad to get rid of stuff that’s still useful but o.k. to
get rid of worn out things.
Socratic Questioning - 4
 What about this toy? Does it meet the definition of worn out?
You said you thought it was dirty and broken. Does that
qualify as worn out?
 Yeah, it’s really worn out. I need to get rid of this.
 What about your guilt feelings?
 I just need to let this go. He doesn’t want the toy, I know that.
I just have to figure out why I feel so guilty.
 I agree with you that it makes sense to get rid of this toy and it
seems like your guilt isn’t really about the toy itself. Maybe it
will become clear to you, but for now, shall we put it in the
trash bin?
 Yeah. I’ll get used to it.
 How about I ask you in a few minutes how guilty you feel.
What is it now at the start - on a 0-100 scale where 100 is the
most guilty you’ve ever felt?
 It’s a 60 I think.
 O.k., I’ll ask again in a little while to see if you feel better.
Open Trial: Clutter Image Rating
14 entered; 10 completed
4.5
4 Pre
*
3.5
*
3
2.5
2
1.5
1
0.5 Post
0
Pre Mid Post

Tolin, Frost, & Steketee (in press), Behav Res Ther

CBT Outcomes: Waitlist Controlled Trial
of Hoarding (Steketee et al., 2010)
CBT WL
(n=23) (n=23)

12 wks 12 wks
(n=19) (n=21)

26 wks 26 wks CBT

(n=19) (n=18)
37 Controlled Trial Completers
 78% Women
 89% White
 Mean age = 55 (range=42-66)
 40% Married or living with partner
 67% College Ed. or higher
 32% Unemployed
 46% MDD; 35% GAD; 24% Social Phobia

Steketee et al, (200). Depression & Anxiety;27:476-484.

CBT > Wait List at 12 Weeks
25%

20% CBT
WL
% Reduction SI-R

15%

10%

5%

0%
Clutter Difficulty Discarding Acquiring
SI-R Symptom

Steketee, Frost, Tolin, Rassmussen, & Brown, Depression & Anxiety 2010;27:476-484.
CBT Improvement at Wks 12 and 26
30%
Clutter
25% Difficulty Discarding
% Reduction

20% Acquiring
15%
10%
5%
0%
Session 12 Session 26
SI-R Symptom

Steketee et al, (2010). Depression & Anxiety;27:476-484.

Controlled Trial Responders
100%
% Responder

81%
71%
46%

0%
much or v.much much or v.much clinically
improved- improved-client significantly
therapist improved

Steketee et al., 2010, Depress & Anx, 27, 476-484

Alternative treatment methods
 Group CBT
 With in-home case management
 Structured CBT support groups - lay facilitated
 Buried in Treasures Workshops
 Professional organizers
 Assistance from coaches and/or family members
 Community task forces
 For involuntary cases
 Brookline
Flexible CBT for Hoarding
(modified from Steketee & Frost 2007 manual)

 Alternating home and office visits

 1.5 – 2 hour sessions
 ~40 sessions over ~ 12 months
 Treatment team included agency
clinicians and BA staff member hired and
trained to provide hoarding treatment
 Flexible application of skills training,
exposure practice and basic cognitive
strategies
Turner, Steketee, & Nauth (2010). Cog. & Behav. Pract., 17, 449-457.
Brookline Study Recruitment
 Excluded pts. with dementia, problem personality
features
 9 began; 6 completed
 5 women, 1 man
 Mean age = 72, range = 56 - 86 years
 Comorbidity: None = 1; depression = 5; PTSD = 1,
ADHD = 1
 5 lived alone; 1 with roommates
 Physical health comorbidity:
 Diabetes, overweight, arthritis
 Chronic bronchitis, glaucoma, Parkinson’s
Turner, Steketee, & Nauth (2010). Cog. & Behav. Pract., 17, 449-457.
Engagement Strategies
 Humor and inspirational quotations
 Schedule sorting times
 Listen to music while sorting
 Review progress via before and after photos
 Review life goals, esp. as priorities change with
declining health
 Reward self for work done - but not with new items!
 Balance homework with leisure

Turner, Steketee, & Nauth (2010). Cog. & Behav.

Pract., 17, 449-457.
 Reduction in Clutter
CIR %
Elderly Clients Reduction
1 17%
2 20%
3 25%
4 29%
5 36%
6 46%
Mean 28%

Turner, Steketee, & Nauth (2010). Cog. & Behav. Pract., 17, 449-457.
Successes with CBT for Elders
 High satisfaction with focused practical treatment
 Compulsive acquiring improved quickly
 Reduction in clutter took 1 year or more
 Structured assignments (esp. sorting) with daily
goals and scheduling worked best
 In-home coaches were especially helpful
 Therapy provided good social support – how to
promote this when therapy ends?
But Older Age Complicated Tx
 More health problems and safety risks – falling,
fire
 Low insight, limited motivation and ambivalence
requires strong relationship building
 A history of deprivation contributed to some
clients’ worries about necessities and urges to save
 Downsizing homes provokes special challenges:
 Who should receive cherished objects
 How to physically remove items
 Cognitive therapy less useful for those with
cognitive decline
CBT for Older Adults with Hoarding
Ayers et al. 2011; funded by IOCDF

• Open trial of 12 participants

• Mean age 73.6 (SD=6.5)
• 7 women; 5 men
• 26 sessions on individual CBT, supervised by
experienced clinician (C. Bratiotis)
• included 20-25% home visits
 Results
• No attrition
• Statistically significant changes in hoarding
severity (~15 - 20%; ) and depression (~50%)
• But only 3 of 12 were treatment responders
• Homework compliance was related to
decreases in hoarding severity
• Patient feedback – cognitive therapy
techniques difficult (Ayers, Bratiotis, Saxena, Wetherell, 20011)
 A closer look at outcomes
Outcome SI-R UCLA Hoarding
Severity Scale
N (% change) N (% change)

Got Worse 1 (2% increase) 2 (10% increase)

Same or slight 8 (12% decrease) 7 (16% decrease)

improvement
Improved 3 (60% decrease) 3( 59% decrease)
Conclusions & Implications
 Standard CBT for hoarding less effective
for older adults
 Older adults can tolerate 26 sessions of
hoarding-focused behavioral treatment
 Homework compliance is important
 Negative impact of neurocognitive
deficits on treatment?
 (Ayers et al., 2011; Ayers et al., in press, Mackin et al., 2011)
 Why poor the response?
Neurocognitive functioning is poorer in older HD versus Controls
(non-anxious/depressed) covaried by age, gender, and education

Measure HD Ps Controls p
(n=42) (n=25)

WCST Total Errors 33.1 (20.5) 21.0 (10.7) 0.022

WCST Perseverative
Errors 16.3 (12.8) 11.2 (6.1) ---

WCST Non-perseverative
Errors 16.7 (11.2) 9.8 (5.1) 0.017

WCST Conceptual
Level Response 49.2 (22.5) 61.0 (20.4) 0.009
 Neurocognitive Skills
Necessary for CBT
Intervention Sample Neurocognitive
Skills Necessary
Case formulation Develop new set, organization
of information
Skills training Categorization, organization
(organizational & of information, problem
problem-solving) solving, procedural learning
Exposure Inhibit response
 Neurocognitive Skills
Necessary for CBT
Intervention Neurocognitive Skills Necessary

Cognitive Therapy Largely Executive Functioning

(e.g. flexibly applying concepts,
abstract reasoning, hypothesis
generation)
Motivational Initiation, shifting set, decision
Interviewing making
Relapse Prevention Delayed recall, planning, problem
solving
Homework Initiation, organization, planning
How to enhance treatment for
older adults with hoarding?
1. Emphasis on behavioral approach (exposure)
2. Teach skills to support/improve:
 Cognitive functioning
 Planning, preparation, organization, abstract
reasoning, cognitive flexibility, problem solving
skills
 In-session and homework compliance
 Prevent relapse back to old habits
Cognitive Rehabilitation and Exposure/Sorting Therapy Session
Outline
1. Introduction and Psychoeducation
2. Calendar Use
3. Linking Tasks, Using a "to do" list
4. Problem Solving
5. Thinking Flexibility and Planning
6. Discarding Preparation
7. Organizational and Exposure Preparation
8. Introduction to Exposure Therapy
9 - 20. Exposure
21. Advanced Exposure (longer home visit with team)
22. Advanced Exposure
23. Relapse prevention and maintenance
24. Relapse prevention and maintenance
 Comparison of Adult and
Older Adult Treatments
General Adult Older Adult
(Steketee & Frost 2007) (Ayers et al., 2012)

Assessment 2-3 sessions 1 session

Case Formulation 2 sessions 0
Skills Training (organizational,
problem solving) 2-3 sessions 6-7 sessions*
Exposure and Cognitive Therapy 15-20 sessions 0
Exposure Therapy 0 15-16 sessions
Motivational Interviewing throughout throughout
Relapse Prevention 2 sessions 1-2 sessions
* Also includes prospective memory and cognitive flexibility rehab modules
 Selected Modules from
CogSmart program
Twamley et al., 2008
 Compensatory strategies target cognitive domains:
 Prospective memory & planning (i.e., organization
skills, calendar use, to-do lists, etc.)
 Cognitive flexibility and problem solving (i.e., executive
functioning)

http://www.mirecc.va.gov/docs/visn6/Cognitive-Therapies-mTBI-Workshop-at-
National-MH-meeting-July09.pdf
Theoretical basis for cog. rehab
(COGSMART; Twamley et al., 2008)

Cognitive compensation
 “Working around” deficits (e.g., using a cane to support a
weak leg)
 Taking advantage of cognitive strengths
 By using different strategies

 By using different brain areas

Habit learning
 Habits –good or bad –are hard to break and are particularly
resistant to forgetting
 Relies on intact neostriatalpathways rather than declarative
memory systems
Prospective memory
 Strategies
 Calendar systems and programming calendar use
 Daily checking
 Weekly planning
 Entering both events and reminders prior to events
 Linking tasks (new task linked to automatic task)
Prospective Memory cont.
 Automatic places (keep items in same place)
 Using to do lists and sticky notes with calendars
 Short-term prospective memory strategies
 Write on hand
 Leave self a message
 Use visual imagery
 “Can’t miss” reminders
Problem Solving
 Emphasis on making decisions, creating steps,
finding solutions
 Follow the 6 step method:
1. Define the problem
2. Brainstorm solutions to the problem
3. Evaluate each solution in terms of ease of
implementation, costs and benefits,
and likely consequences
4. Select a solution to try
5. Try the solution
6. Evaluate the solution: Did it work? If not, go
back to step 4.
 Practice in session & then give as homework
Cognitive Flexibility Cont.
Brainstorming
Strategy verbalization
Hypothesis testing by
looking for
disconfirming
evidence
Set shifting/
maintenance
Standard Organizational Strategies
Like those in Steketee and Frost 2007

 Categories to keep & discard

 Filing system
 Places to discard & plan for discarding
 (Amvets, Goodwill, Recycle)
 Adequate storage
 Items for sorting (containers, files, shredder, etc)
 Developing rule system – like with like
 Everything has final resting place – if none, discard
 Staging areas
 Maintenance system
 Keeping cleared areas clean
Discarding and Acquiring Practice
• Most emphasized portion of treatment
• Rationale based on process of habituation &
distress tolerance
• Expose to triggers: simply making a distressing
decision about an object and/or reason for saving
(utility, sentimental value, fear of making wrong
decision/not feeling right, loss of information)
Exposure Therapy in Session
 Discuss role of avoidance in maintaining hoarding problems
 Explain the process of habituation
 Exposure directly combats avoidance
 Develop a hierarchy
 Establish rules to use during exposure (e.g. therapist may not
touch any possessions)
 Repetition of exposure treatment rationale necessary
 Use SUDS ratings
 Wrap up exposures with “lessons learned”
 SUDS Ratings
Time SUDS Ratings (0-10)
0 Minutes
5 Minutes
10 Minutes
15 Minutes
20 Minutes
25 Minutes
30 Minutes
35 Minutes

What lessons did you learn from your exposure?

Example:
1. That I can let go of items.

2. Keeping things does not help me with my

hoarding.

3. I get deal with distress from discarding.

Initial Pilot Study Ayers et al., in press

 N=11 (9 women, 2 men

 Mean age 66, range =60-85
 24 wks individual therapy by 3 licensed
psychologists
 First 6 sessions on executive functioning
 Next 16 sessions on exposure for discarding and
acquiring
 Approximately 12-25% home visits
 Final 2 sessions on relapse prevention
Results
 Significant main effects of time on hoarding
severity measures with large effect sizes
 Results are significant when depression or
anxiety symptoms are covaried
 Clinical Global Improvement (CGI) = “much
improved” to “very much improved” at post-
treatment
 CGI Severity moved from “moderately ill” to
“mildly ill”
Treatment responders
 8 of 11 = treatment responders
 3 = partial responders.
 Partial responders
 narrowly missed full response criteria
 3 had comorbid MDD; 2 had OCD.
 Highest SI-R ratings before treatment (SI-
R = 75, 71, 67).
Hoarding Severity Changes
% Change from
Baseline to Post-
Measure Treatment
n=11
SI-R 38%

UHSS 41%

CIR 26%
Hoarding Severity Changes
M = 59.90(10.17)

M = 54.66(12.27)

M = 37.50(14.78)

M = 27.30(5.67)

M = 22.77(7.17)

M = 16.60(8.16)
Conclusions
 Cognitive rehabilitation + exposure is feasible,
acceptable, and promising for geriatric HD
 Treating neurocognitive deficits in older patients
with HD appears to enhance response to CBT
 CR + E doubled the improvement rates for CBT
 Patients with comorbid disorders and severe
hoarding may require more intensive or longer
treatment
 Limitations - small sample size, no control group,
no follow-up
 Case example
Eleanor responded to a flyer for hoarding treatment
because she “knew she had a problem but didn’t know
there was help for such a thing until now.” Over 65% of her
home was cluttered with objects, making most rooms
unusable. She slept in a reclining chair and showered once
a week at a senior center.
Problem solving techniques targeted barriers to treatment:
1. heavy objects in the way  selected solution: 2 church
volunteers to assist
2. difficulty focusing on exposure exercises  selected
solution: asked former colleague to assist during
homework to keep on track).
 Case example
With help of therapist, she improved her discarding by
linking practice to an established routine (nightly news).
Through repeated practice, she learned to push through
avoidance and that she could tolerate distress of letting go
of possessions. At session 18, she completed an “advanced”
exposure by leading a team of student volunteers in
discarding exercises in her home for two 4-hour sessions.
After 24 sessions, she reduced clutter in her living room by
50%, bedroom by 50%, and could complete most basic
functions at home. Hoarding symptoms decreased by
approximately 40% on clinician administered and self-
report measures.
Future Treatment Directions For
Geriatric HD Treatment
 Randomized controlled trial (coming soon!)
 33 (18 complete) participants enrolled
 22 women; 11 men
 mean age 68; 12% ethnic minority
 16 assigned to TAU (case management)
 (2 refused final assessments; 1 hospitalized for psychiatric
symptoms)
 17 assigned to CREST condition (cog. rehab.)
 No participants dropped out
 Real world effectiveness
[email protected]

[email protected]
Resources
 Hoarding and Acquiring: Therapist Guide and
Workbook (Steketee & Frost, 2007; 2014)
 Cognitive Symptom Management and Rehabilitation
Therapy (CogSMART) for Traumatic Brain Injury
Individual Manual (Twamley et al., 2008)
 Cognitive Rehabilitation and Exposure/Sorting
Therapy for Compulsive Hoarding (Ayers et al., 2012)
 General hoarding information:
http://www.ocfoundation.org/hoarding/