Hoarding – clinical approaches

This page focuses on some of the findings from focus groups, literature and lived experiences about clinical approaches for hoarding.

What is hoarding?

Hoarding is defined as:

  1. "Accumulation of and difficulty discarding objects, regardless of their actual value
  2. which results in excessive clutter in living spaces, restricting their use
  3. creating significant risk, distress, or impairment of function."1

One New Zealand study estimated that in a group of 50-year-olds, approximately 2.5% of them have pathological hoarding2. Another New Zealand study that used a collection of questions from existing InterRAI assessments rather than a specific hoarding measure estimated that 3.5% of this more frail group may have hoarding issues.3 

These studies may have underestimated the prevalence of hoarding in New Zealand as people who hoard may be isolated and lack insight, making identification of the issue difficult. 

How is hoarding diagnosed and treated?

The following image outlines how hoarding is diagnosed and the next steps. 


Image credit: Enabling Spaces Canterbury DHB, NZ

Hoarding is best treated by a multidisciplinary approach. Studies of clinical treatments have consistently high dropout rates,4 which emphasises the importance of support services and the relationship between individuals and support workers. Intervention such as one-time forced clean-ups that remove the clutter also prove unsuccessful,5 as this sort of intervention only removes the physical manifestation and not the underlying problem. This can cause a recurrence of hoarding behaviour. 

Researchers have shown the most effective treatment for hoarding behaviour currently is a multi-component treatment protocol based on the cognitive behavioural therapy (CBT) model of hoarding developed by Steketee and Frost.6,7 This protocol has been shown to reduce hoarding severity,7,8,9 and is especially helpful in overcoming the difficulty in discarding objects.10 This CBT model can be used in individual therapy, group therapy, self-help books or resources, and webcam-based therapy. 

To support people who hoard, it is important to:

  • understand what hoarding means to the individual
  • establish a relationship and trust with the individual
  • understand the policies and resources available to help you support the person.

Below are some findings from focus groups and literature that show these 3 key things that help support people who hoard. 

 

Description

Understanding the individual

Your support of the individual/your client needs to be based on an understanding of hoarding for them.

Examples of the ways hoarding can arise include:

  • compulsive hoarding
  • hoarding disorder
  • non-purposeful accumulation
  • controlled hoarding. 

For example, if your client or patient has compulsive hoarding, and the need to acquire or to avoid discarding certain things is caused by obsessions or compulsions, then OCD therapy will be useful for them. 


It has also been shown that it is useful to understand why it is hard for people to give up objects. Some common reasons include:

  • attachment
  • vulnerabilities
  • identity
  • security
  • avoiding waste.

As a support person, it is also useful to understand what impact hoarding has had on the individual and others. Some impacts of hoarding include:

  • risks such as social isolation, falling and limited access to bathroom or kitchen facilities, increased risk of fire and damaging homes especially rental properties
  • disability or functional impairment to perform important activities
  • distress or substantial negative emotions for the individual or others.

Consider the following steps to help minimise risk, disability and distress:

  • A Hoarding Assessment tool (Appendix C)1 which has been used by Christchurch City Council can be used by other agencies with guidance about when and how a referral for council support would be recommended. 
  • Clutter Image Rating Scale (CIR) can be useful to provide photo cues to rate clutter, however is not used as a standalone assessment and outcome measure. It can be used to celebrate and reinforce progress to the individual by showing an album of photos across time. 
  • The Savings Inventory Revised (SI-R) is a tool to measure hoarding-related distress and impact. Guidance of thresholds for recommending referring or funding to stepped care CBT treatment options can be potentially included. 

Read more about understanding the individual Enabling Spaces, Canterbury DHB, NZ

Understanding the relationship

Findings from both the literature and focus groups found that establishing trust with the person who hoards helps them to be more open and able to accept help from others. Some of the components to help to establish trust include:

  • being non-judgemental
  • making a connection
  • pacing 
  • supporting autonomy
  • building motivation.

Steps to consider going forward to help establish trust and relationship include:

  • facilitating awareness of online resources
  • developing local person-centred practice resources
  • recording video resources
  • training home-based support workers
  • establishing a hoarding specialist role. 

Read more about understanding the relationship Enabling Spaces, Canterbury DHB, NZ

Understanding policies

A supportive resourcing and policy environment helps you as a support person to support people in challenging living environments. 


It is shown that most hoarding services don't have enough long-term resources for ongoing support and that the resources are inflexible. Therapy resources such as the multi-component CBT has been proven to be effective in supporting people who hoard. A stepped care model was also suggested in one focus group and by some researchers. 


Hoarding is also recognised internationally to be best managed by a multidisciplinary team,11,12,13,14 as hoarding has a multifaced nature and impacts many areas of life. A multidisciplinary team can integrate different services and provide support in different areas such as psychological, emotional, medical or safety-oriented support.

Examples of services include:

  • emergency services
  • mental health services
  • social workers
  • home-based support services
  • public health agencies
  • city council 
  • non-governmental organisations in housing, mental health.

Steps to consider going forward for a supportive policy environment include:

  • facilitating coordination such as establishing protocols and pathways, gaining traction on a central point of contact and simplifying information sharing and referrals. 
  • funding hoarding support as a longer-term commitment.

Read more about understanding policies Enabling Spaces, Canterbury DHB, NZ

Learn more

Enabling Spaces Canterbury DHB, NZ
What is hoarding disorder? American Psychiatric Association, US
Hoarding disorder NHS, UK
Hoarding fact sheet International OCD Foundation

References

  1. Enabling Spaces Canterbury DHB, NZ
  2. Spittlehouse, J. K., Vierck, E., Pearson, J. F., & Joyce, P. R. (2016). Personality, mental health and demographic correlates of hoarding behaviours in a midlife sample PeerJ, 4, e2826.
  3. Barak, Y., Leitch, S., & Greco, P. (2019). Identifying hoarding disorder in the elderly using the interRAI Archives of Gerontology and Geriatrics, 80, 95-97.
  4. Stineman, M. G., Xie, D., Pan, Q., Kurichi, J. E., Zhang, Z., Saliba, D., ... & Streim, J. (2012). All‐cause 1‐, 5‐, and 10‐year mortality in elderly people according to activities of daily living stage Journal of the American Geriatrics Society, 60(3), 485-492.
  5. Thompson, C., de la Cruz, L. F., Mataix-Cols, D., & Onwumere, J. (2017). A systematic review and quality assessment of psychological, pharmacological, and family-based interventions for hoarding disorder Asian Journal of Psychiatry, 27, 53-66.
  6. Steketee, G., & Frost, R. O. (2007). Compulsive hoarding and acquiring: Therapist guide Oxford University Press.
  7. Frost, R. O., Steketee, G., & Grisham, J. (2004). Measurement of compulsive hoarding: saving inventory-revised Behaviour Research and Therapy, 42(10), 1163-1182.
  8. Burns, B. (2014). Coping with hoarding Kai Tiaki: Nursing New Zealand, 20(10), 26-27.
  9. Muroff, J., Bratiotis, C., & Steketee, G. (2011). Treatment for hoarding behaviors: A review of the evidence Clinical Social Work Journal, 39(4), 406-423.
  10. Tolin, D. F., Frost, R. O., Steketee, G., & Muroff, J. (2015). Cognitive behavioral therapy for hoarding disorder: A meta‐analysis Depression and Anxiety, 32(3), 158-166.
  11. Roane, D. M., Landers, A., Sherratt, J., & Wilson, G. S. (2017). Hoarding in the elderly: a critical review of the recent literature International Psychogeriatrics, 29(7), 1077-1084
  12. Koenig, T. L., Spano, R., Leiste, M. R., Holmes, R., & Macmillan, K. R. (2014). Multidisciplinary teams’ practice strategies with older adult clients who hoard Social Work in Mental Health, 12(1), 81-97.
  13. Frank, C., & Misiaszek, B. (2012). Approach to hoarding in family medicine: Beyond reality television Canadian Family Physician, 58(10), 1087-1091
  14. Firsten-Kaufman, E., Broker, K., & Hildebrandt , C. (2017). What are effective interventions for hoarding?: Rapid review Ontario, Canada: Evidence Exchange Network for Mental Health and Addictions. Retrieved from https://www.eenet.ca/resource/what-are-effective-interventions-hoarding-0.