Compulsive Hoarding

and Acquiring:
Therapist Guide

Gail Steketee
Randy O. Frost

OXFORD UNIVERSITY PRESS

Compulsive Hoarding and Acquiring
--

David H. Barlow, PhD


 

Anne Marie Albano, PhD

Jack M. Gorman, MD

Peter E. Nathan, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

Compulsive
Hoarding and
Acquiring
T h e r a p i s t G u i d e

Gail Steketee • Randy O. Frost

1

1
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Cataloging-in-Publication Data available from Library of Congress.

Library of Congress Cataloging-in-Publication Data

Steketee, Gail.
Compulsive hoarding and acquiring : therapist guide / Gail Steketee,
Randy O. Frost.
p. cm.—(Treatments that work)
Includes bibliographical references.
ISBN- ----; ISBN ---X
ISBN- ----; ISBN --- (pbk.)
. Obsessive-compulsive disorder. . Compulsive behavior. I. Frost,
Randy O. II. Title. III. Series: Treatments that work.
[DNLM: . Compulsive Behavior—therapy—Case Reports.
. Behavior Therapy—methods—Case Reports. . Impulse Control
Disorders—therapy—Case Reports. WM  Sc ]
RC.S 
.⬘—dc 

        

Printed in the United States of America

on acid-free paper
About TreatmentsThatWork ™

Stunning developments in health care have taken place during the last
several years, but many of our widely accepted interventions and strate-
gies in mental health and behavioral medicine have been brought into
question by research evidence as not only lacking benefit, but, perhaps,
inducing harm. Other strategies have been proved effective using the
best current standards of evidence, resulting in broad-based recommen-
dations to make these practices more available to the public. Several re-
cent developments are behind this revolution. First, we have arrived at a
much deeper understanding of pathology, both psychological and phys-
ical, which has led to the development of new, more precisely targeted
interventions. Second, our research methodologies have improved sub-
stantially, such that we have reduced threats to internal and external va-
lidity, making the outcomes more directly applicable to clinical situa-
tions. Third, governments around the world and health care systems and
policymakers have decided that the quality of care should improve, that
it should be evidence based, and that it is in the public’s interest to en-
sure that this happens (Barlow, ; Institute of Medicine, ).

Of course, the major stumbling block for clinicians everywhere is the ac-
cessibility of newly developed evidence-based psychological interven-
tions. Workshops and books can go only so far in acquainting responsi-
ble and conscientious practitioners with the latest behavioral health care
practices and their applicability to individual patients. This new series,
TreatmentsThatWork™, is devoted to communicating these exciting
new interventions to clinicians on the frontlines of practice.

The manuals and workbooks in this series contain step-by-step detailed

procedures for assessing and treating specific problems and diagnoses.
However, this series also goes beyond the books and manuals by provid-
 ing ancillary materials that will approximate the supervisory process in
assisting practitioners in the implementation of these procedures in their
practice.

In our emerging health care system, the growing consensus is that evi-
dence-based practice offers the most responsible course of action for the
mental health professional. All behavioral health care clinicians deeply
desire to provide the best possible care for their patients. In this series,
our aim is to close the dissemination and information gap and make that
possible.

This therapist guide and the companion workbook for patients address
the puzzling and difficult problem of compulsive hoarding. This disorder,
characterized by a profound inability to discard material items that are
no longer useful, can result in severe disruption of interpersonal rela-
tionships, threats to health, and even death in some extreme cases from
the dangerous accumulation “clutter.” Although we know relatively little
about compulsive hoarding, the best estimate at this time is that this
problem afflicts as many as  to % of the population, who seldom pres-
ents for treatment until late middle age when, evidently, patients have
had sufficient opportunity to accumulate overwhelming clutter.

The treatment program presented in this therapist guide and accompa-

nying workbook represents the first attempt to treat compulsive hoard-
ing with any systematic evidence of efficacy. This program, originated by
world-renowned widely acknowledged experts in this area, leads to sub-
stantial improvement in most patients. In the most recent study, a group
receiving treatment achieved close to a % reduction in hoarding sys-
tems—far superior to the group not receiving treatment. Although we
have much to learn about the nature and treatment of compulsive
hoarding, this program represents the best hope for this intractable con-
dition at the current time.
David H. Barlow, Editor-in-Chief,
TreatmentsThatWork™
Boston, Massachusetts

vi
Acknowledgments

We are grateful to our families for tolerating our constant work and end-
less deadlines. Gail thanks her husband, Brian McCorkle, for his under-
standing and helpful comments. Randy thanks his wife, Sue Frost, for
her support and encouragement.

This book would not be possible without the participation of many

people who have sought help from us for compulsive hoarding problems
during the past decade. They are too numerous to name, but stand out
because of their compelling stories and their willingness to participate in
our research studies. We have learned a great deal from them and have
much more to learn. A special thanks is due the members of the H-C list
who have communicated with us in various ways over the years, and in
particular to Paula Kotakis for her dedication to helping people with this
problem and helping us sort out how therapists can help. We would like
to thank our collaborator, Dr. David Tolin; and our research team mem-
bers and therapists, Christiana Bratiotis, Ancy Cherian, Diane Cohen,
Amanda Gibson, Krista Gray, Scott Hannan, David Klemanski, Danielle
Koby, Terry Lewis, Nicholas Maltby, Suzanne Meunier, Matt Monteiro,
Jessica Rasmussen, and Cristina Sorrentino; as well as Robert Brady and
Stefanie Renaud, our research assistants; for the insights they have pro-
vided in developing this treatment.

Finally, we would like to thank our editors, Mariclaire Cloutier and

Cristina Wojdylo, for their tireless efforts to bring this manual to life.

vii
This page intentionally left blank
Contents

Chapter  Introductory Information for Clinicians 

Chapter  Assessing Hoarding 

Chapter  Case Formulation 

Chapter  Treatment Planning 

Chapter  Enhancing Motivation 

Chapter  Skills Training for Organizing and Problem Solving 

Chapter  Exposure Methods 

Chapter  Cognitive Strategies 

Chapter  Reducing Acquiring 

Chapter  Preventing Relapse 

Appendix A Assessment Instruments 

Appendix B Clinical Session Form 

References 

Readings and Resources 

About the Authors 

This page intentionally left blank
Chapter 1 Introductory Information for Clinicians

Background Information and Purpose of This Program

Throughout much of the developed world, the number of personal pos-

sessions owned by ordinary people has exploded during the last  years.
Modern civilizations are based on the commerce of consumption, and
they thrive when people are accumulating belongings. For most people,
managing their possessions is not difficult and often it is pleasurable. We
buy what we need, sometimes more, and we discard, recycle, give away,
or sell what we don’t. Almost all of us keep some things we don’t need
and don’t use. When these unneeded objects impinge on our living space,
we no longer want them and usually get rid of them. But for people who
suffer from compulsive hoarding, this process is not so easy. For them,
possessions never “feel” unneeded or unnecessary, and trying to get rid
of them is an excruciating emotional ordeal. For some it is easier to di-
vorce a spouse, sever ties with children, and even risk life and limb. This
manual is the culmination of more than  years of work on under-
standing this compulsive hoarding problem and building an effective in-
tervention to address its myriad components. The intervention program
is the result of a treatment development project funded by the National
Institute of Mental Health.

The intervention relies on collaboration between clinicians and clients

to achieve a shared understanding of the client’s hoarding problem. Al-
though the  chapters in this manual suggest a sequence of intervention
strategies, we do not provide session-by-session instructions, but instead
adopt a modular approach because of the many features that contribute
to clients’ hoarding symptoms. We strongly recommend that clinicians
read all chapters before starting. After completing a basic assessment and
case formulation, decide what aspects of hoarding to focus on first and

1
 what methods to use. Understanding clients’ hoarding problems fully
will help you empathize with their struggle to overcome very powerful
emotional attachments and strong beliefs as they make steady, often un-
even, progress toward the goal of ridding their homes of debilitating
clutter.

This manual first describes compulsive hoarding in sufficient detail to

enable clinicians to understand the problem and answer clients’ and fam-
ily members’ basic questions. We consider this crucial information to
dispel misunderstandings about hoarding behavior before trying to pro-
vide effective intervention. The next several chapters prepare clinician’s
to conduct the intervention. Chapter  covers methods for assessing the
problem, along with illustrations of several forms for this purpose. In
chapter , clinicians collaborate with clients to formulate a model for
understanding how the client’s hoarding symptoms develop and occur
in real time. Chapter  focuses on treatment preparation and planning
to select intervention methods based on the case formulation. Chapter 
addresses a major problem in hoarding: ambivalence about change. It
includes methods to enhance motivation, drawing from motivational
interviewing methods originally developed for substance abuse problems.

The next four chapters cover the core cognitive and behavioral inter-
ventions for organizing, saving, and acquiring problems. In chapter ,
clinicians train clients in skills for making decisions and organizing pos-
sessions, and how to solve problems that inevitably arise during this pro-
cess. Chapters  and  cover exposure methods to habituate discomfort
while sorting, and cognitive strategies for restructuring problematic beliefs
and automatic thoughts. Chapter  focuses on cognitive and behavioral
methods for reducing acquiring. The final chapter (chapter ) provides
tips on preventing relapse. Throughout these chapters we illustrate the
use of various forms for use during assessment and intervention to gauge
clients’ symptoms and progress. Blank copies of these forms are available
in the accompanying client workbook, as well as on the TreatmentsThat
Work™ website at www.oup.com/us/ttw.

2
The Problem of Compulsive Hoarding

Three features define compulsive hoarding: () the accumulation and

failure to discard a large number of possessions that appear to most people
to be useless or of limited value, () extensive clutter in living spaces that
precludes activities for which the rooms were designed, and () signifi-
cant distress or impairment in functioning caused by the hoarding (Frost
& Hartl, ). This definition distinguishes hoarding from collecting,
in which individuals maintain collections of objects that are generally
considered interesting and valuable. Descriptions of unusually severe cases
of compulsive hoarding, including the Collyer brothers in New York
City, can be found on several Internet sites. The behavior can result in
serious and even life-threatening pathology (Frost, Steketee, & Williams,
), and severity appears to increase with age (e.g., Grisham, Frost,
Kim, Steketee, & Hood, ). The average age of people who seek help
for hoarding is about  years.

Acquiring

People who hoard often acquire excessively in the form of compulsive

buying (usually considered an impulse control disorder) and acquiring
free things, such as extra newspapers, advertisements, promotional give-
aways, and discarded items from street trash or dumpsters (Frost & Gross,
; Frost, Kim, Morris, Bloss, Murray–Close, & Steketee, ). Oc-
casionally, acquisition includes stealing and kleptomania. Acquiring is
often associated with positive feelings and even euphoria, which rein-
force the behavior and make it difficult to curtail. Compulsive acquiring
is also sometimes associated with dissociated states and may be used to
soothe negative moods (Kyrios, Frost, & Steketee, ), colloquially
reflected in the phrase “retail therapy.”

Difficulty Discarding

A principal feature of hoarding is the failure to discard objects judged by

observers (but not the person who has collected them) to be worthless
or worn out. Most people who hoard view their possessions as having

3
 sentimental (emotional), instrumental (useful), or intrinsic (aesthetic)
value in excess of their worth in most people’s eyes. These reasons for
saving are no different from most people, but these values are applied to
a much larger number and wider range of possessions. People who hoard
are often able to discard some items, but the process of doing so is so
elaborate and time-consuming that the number of newly acquired items
easily exceeds removed ones, so the home gradually fills with things.

Clutter

Excessive acquisition and difficulty discarding possessions are not suffi-

cient to be considered compulsive hoarding unless these behaviors are
accompanied by significant clutter. The presence of clutter probably re-
flects a deficit in the ability to organize possessions (Wincze, Steketee, &
Frost, ). In severe cases, clutter prevents very basic activities like
cooking, cleaning, walking through the house, and even sleeping. The
interference with these functions can make hoarding a dangerous prob-
lem, putting people at risk for fire, falling, poor sanitation, and health
problems. Elderly clients may face particular challenges because of the
clutter in their homes (Damecour & Charron, ; Steketee, Frost, &
Kim, ; Thomas, ).

Special Features

Occasionally, hoarding occurs in squalid conditions that constitute a

public health problem that threatens occupants of the home. In such
cases, public health officials or other agencies may become involved. An-
other serious variant of hoarding is animal hoarding, defined as the ac-
cumulation of a large number of animals, typically in excess of , that
are not intended for the purpose of breeding or sale. The owner fails to
provide an adequate living environment for the animals, as indicated by
overcrowded or unsanitary living conditions, inadequate veterinary care
and/or nutrition, and the unhealthy condition of the animals. Even
when they are clearly unable to provide adequate care, most people who
hoard animals are reluctant to place the animals in the custody of oth-
ers. Animal hoarding is often identified through complaints by neigh-

4
 bors to legal authorities such as animal control agencies. This manual is
not designed to address animal hoarding, because there is currently in-
sufficient research to indicate what causes this problem and how to treat
it. For further information about animal hoarding, contact the Hoarding
of Animals Research Consortium at their website (www.tufts.edu/vet/
cfa/hoarding) and see the Angell Report published by this organization.

Relationship to Other Psychiatric Disorders

Hoarding behavior has been reported in a variety of axis I disorders, in-

cluding schizophrenia (Luchins, Goldman, Lieb, & Hanrahan, ),
organic mental disorders (Greenberg, Witzum, & Levy, ), eating
disorders (Frankenberg, ), brain injury (Eslinger & Damasio, ),
and various forms of dementia (Finkel, Costa, Silva, Cohen, Miller, &
Sartorius, ; Hwang, Tsai, Yang, Liu, & Lirng, ). Hoarding is
also considered one of eight symptoms of obsessive–compulsive person-
ality disorder (OCPD) (American Psychiatric Association, ), but its
role in OCPD has not been well studied.

Whether hoarding is a symptom of obsessive–compulsive disorder

(OCD) remains open to debate. In studies of adult OCD clients,1 the
frequency of hoarding ranges from  to % (Frost, Krause, & Steketee,
; Rasmussen & Eisen, ; Samuels, Bienvenu, Riddle, Cullen, Gra-
dos, Liang, Hoehn–Saric, & Nestadt, ; Sobin, Blundell, Weiller,
Gavigan, Haiman, & Karayiorgou, ). Hoarding was the primary
symptom in % of a large sample of OCD clients of Saxena and col-
leagues (). Supporting an association of hoarding to OCD symp-
toms is the excessive doubting, checking, and reassurance seeking before
discarding possessions, which appear similar to compulsive rituals (Ras-
mussen & Eisen, , ), and the moderately frequent cooccurrence
of hoarding and other OCD symptoms in psychiatric patients and com-
munity samples (Frost & Gross, ; Frost et al., ; Frost, Steketee,
Williams, & Warren, ; Samuels et al., ). On the other hand,

1Most studies of hoarding have recruited clients through OCD clinics rather than soliciting
them from community or independent sources. This introduces a bias in favor of finding OCD
symptoms among those with hoarding. It is necessary to recruit people with hoarding prob-
lems directly from the community to understand best the symptoms of hoarding and how they
relate to other psychiatric disorders.

5
 people who hoard often view their symptoms as reasonable, in contrast
to most people with OCD symptoms, who view them as senseless and are
greatly disturbed by them. Five of six recent studies of OCD subtypes
have identified hoarding as a separate symptom category (Abramowitz,
Franklin, Schwartz, & Furr, ; Calamari, Wiegartz, & Janeck, ;
Leckman, Grice, Boardman, Zhang, Vitale, Bondi, Alsobrook, Peterson,
Cohen, Rasmussen, Goodman, McDougle, & Pauls, ; Mataix–Cols,
Rauch, Manzo, Jenike, & Baer, ; Summerfeldt, Richter, Antony, &
Swinson, ; but see Baer, ). Research by Saxena and colleagues
() suggests that cerebral metabolic patterns observed in hoarding
are different from those seen in OCD. Whatever the relationship of
OCD and hoarding, we recommend assessing the presence of other
symptoms of OCD and determining their role, if any, in compulsive
hoarding. For example, contamination fears and checking problems may
exacerbate or even generate clutter problems and complicate treatment.

Prevalence, Course, and Family Patterns

Formal prevalence estimates for compulsive hoarding are not yet available.
Frost and associates () reported a five-year prevalence of hoarding-
related complaints to public health departments of  per ,, but
this figure undoubtedly seriously underestimates the number of people
with compulsive hoarding problems, many of whom have not had a
public complaint filed against them. In view of our own recent finding
that % of clients seeking treatment in our program for compulsive
hoarding did not have other OCD symptoms (Steketee, Frost, Tolin, &
Brown, ), together with reports indicating that approximately %
of OCD clients (who represent –% of the population) have hoarding
problems (Steketee & Frost, ), our own guess is that approximately
 to % of the population has hoarding problems. Of course, this requires
confirmation from epidemiological researchers.

Existing case reports suggest that compulsive hoarding runs a chronic

and unchanging course, beginning in childhood. When we assessed onset
and course of hoarding using a retrospective timeline to facilitate accu-
rate recall, hoarding symptoms (acquisition, difficulty discarding, clut-
ter) began around age  years on average (Grisham et al., ). In some

6
 cases, trauma precipitated the hoarding, usually at a later age of onset.
The course of hoarding tended to be chronic, with very few participants
reporting improvement after onset. Currently we have no evidence that
chronic cases do not respond to intervention, although some entrenched
patterns of behavior may require more effort to change.

Hoarding appears to run in families, according to several studies (Samuels

et al., ; Winsberg, Cassic, & Korran, ), and may have a genetic
component (Zhang, Leckman, Pauls, Tsai, Kidd, Rosario–Campos, &
Tourette Syndrome Association International Consortium for Genetics,
). This suggests that many of those seeking help will have family
members who condone and engage in hoarding behavior. This has
proved problematic for some clients when only one family member is in-
terested in reducing hoarding behaviors whereas the others see no reason
to change and resent the intrusion of clinicians. The low rate of marriage
among people who hoard is another striking finding (Samuels et al.,
; Steketee et al., ) and may be related to the greater social anxiety
and schizotypal features of those who hoard (Frost et al., ; Samuels
et al., ; Steketee, Frost, Wincze, Greene, & Douglass, ). Clients
who live alone may have difficulty with motivation to change their hoard-
ing, because no one at home is encouraging them to change.

Insight and Motivation

Many people who hoard do not consider their behavior unreasonable

(e.g., Frost & Gross, ; Frost et al., ), and this may be particu-
larly true among elderly people (Hogstel, ; Steketee et al., ;
Thomas, ). A study of complaints made to health departments about
hoarding indicated that less than one third of those identified in the
complaint willingly cooperated with health department officials, and only
half recognized the lack of sanitation in their home (Frost et al., ).
This lack of insight may also contribute to the high rates of dropout and
poorer treatment outcomes observed for compulsive hoarding (e.g.,
Black, Monahan, Gable, Blum, Clancy, & Baker, ; Mataix–Cols et
al., ). This problem can be particularly troublesome for family
members seeking help and for service providers. Even those who seek
help for their hoarding become ambivalent when faced with decisions

7
 about removing clutter. For this reason, chapter  includes specialized in-
terviewing techniques for motivational problems.

Comorbidity

Social phobia has been associated with compulsive hoarding (Samuels et

al., ; Steketee et al., ), and social isolation has been reported
among elderly hoarding clients (Steketee et al., ). Such clients may
rely on hoarding to shield themselves from social interaction. Several
studies have reported a high frequency of depressed mood among hoard-
ing sufferers (Frost et al., ; Samuels et al., ). This may merely
be a side effect of severe clutter that seems overwhelming, but can also
deplete the energy needed to work on clutter during treatment. Symp-
toms of attention deficit hyperactivity disorder (ADHD) appear to be a
relatively common accompaniment to hoarding (e.g., Hartl, Duffany,
Allen, Steketee, & Frost, ), contributing to difficulty staying on task
while sorting and to general disorganization. Assessment of these com-
plicating comorbid conditions is important for planning the interven-
tion and preventing relapse.

Acquiring problems may manifest as compulsive buying, which is con-

sidered an impulse control disorder (ICD) (McElroy, Keck, & Phillips,
). Indeed, researchers have speculated about a compulsive–impulsive
spectrum of disorders linked to OCD and other anxiety disorders (e.g.,
Black & Moyer, ; McElroy et al., ; McElroy, Keck, Pope, Smith,
& Strakowski, ; Schlosser, Black, Repertinger, & Freet, ). Hoard-
ing has also been associated with a greater frequency of ICDs such as
trichotillomania, skin picking, and gambling (Frost, Meagher, & Riskind,
; Samuels et al., ). At issue here is whether acquiring behaviors
associated with hoarding reflect broader impulsivity problems that will
require specialized intervention to enable clients to cope with strong im-
pulsive urges.

Hoarding is associated with frequent personality problems (e.g., Frost et

al., Mataix–Cols, Baer, Rauch, & Jenike, ; Samuels et al., ), the
most common of which are perfectionism, indecisiveness, dependency, and
compulsive personality traits. We have also observed avoidant, schizo-
typal, and paranoid traits among some of our clients. The treatment pro-

8
 gram outlined here includes cognitive and behavioral strategies to reduce
perfectionistic standards and rigid rules for saving and discarding, and to
reduce dependency on others to make decisions. When clients exhibit para-
noid personality traits, clinicians must work harder to gain clients’ trust,
and interventions move more slowly to accommodate these concerns.

Diagnostic Criteria for Hoarding

There are no currently accepted diagnostic criteria for compulsive hoard-

ing in the Diagnostic and Statistical Manual for Mental Disorders, Fourth
Edition, Text Revision (DSM-IV-TR) (American Psychiatric Association,
). We propose the following diagnostic criteria currently being tested
by our research group:

. The client accumulates a large number of possessions that clutter

the active living areas of the home (e.g., living room, kitchen, bed-
room), workplace, or other personal surroundings (e.g., vehicle,
yard) and are kept in a disorganized fashion. If disorganized clut-
ter is not present in these areas, it is only because of other’s efforts
(e.g., family members, authorities) to keep these areas uncluttered.

. The client has current or past difficulty resisting the urge to col-
lect, buy, or acquire free things that contribute to the clutter.

. The client is extremely reluctant to part with items, even those

with very limited monetary value or utility.

. The accumulation of clutter or difficulty parting with items causes

marked distress or interferes significantly with normal use of the
home, workplace, or other personal surroundings, occupational
(or school) functioning, usual family and social activities; poses
significant health or safety risks (e.g., blocked egress, cluttered
stairs, fire hazard); or causes significant conflict with family mem-
bers, neighbors, or authorities (e.g., work supervisors, landlord).

. The problem has persisted for at least six months and is not the
result of a recent move, repairs to the home, the accumulation of
many items resulting from the death of a family member, or other
temporary circumstances.

9
 . The clutter and the difficulty parting with items are not better
accounted for by another mental disorder such as OCD (e.g., fears
of contamination, checking rituals), dementia (e.g., cognitive im-
pairment that interferes with decision making and organizing),
major depressive disorder (e.g., diminished interest in normal
activities, fatigue, indecisiveness resulting from difficulty concen-
trating), schizophrenia (e.g., retention of items resulting from
delusions or hallucinations about objects, paranoia regarding per-
sonal information), or bipolar disorder (e.g., impulsive buying
sprees, distractibility that interferes with organizing). The distur-
bance is not the result of the direct physiological effects of a sub-
stance (e.g., drug abuse, medication) or a general medical condi-
tion (e.g., stroke, brain injury).

Specifiers

With poor insight: if for most of the time during the current episode,
the person does not recognize that the clutter, acquisition or difficulty
parting with items are excessive or unreasonable.

With unsanitary conditions: if condition of the home reflects squalor

(presence of human or animal waste, rotting food, insect infestation,
etc.) or if personal hygiene is poor (e.g., significant body odor, unkempt
appearance, dirty clothing, etc.).

Development of Hoarding Interventions

The intervention program described here grew out of our work with two
individual clients studied intensively in single case designs and six clients
who participated in  weekly group sessions followed by five group ses-
sions spaced two weeks apart for a total of  weeks; home visits were
scheduled every other week. An advanced doctoral student and two less
experienced students in clinical psychology treated that group while we
both observed from behind a one-way mirror. During the past few years,
this therapy has been tested on nearly  patients, a handful treated under
our own care, but most by our graduate students whom we have super-

10
 vised by listening to tapes of their sessions so we have firsthand knowl-
edge of the process and outcomes.

The clients who received treatment exhibited moderate to severe hoard-

ing behaviors and substantial comorbidity that included attention deficit
disorder (ADD), major depression, serious marital problems, and prob-
lematic personality traits. Some were highly functional in their employ-
ment and social lives, but were unable to make headway with severe clut-
ter that filled all living spaces and rendered the home useless for all but
bathing and sleeping. Others who were less functional with regard to
work, social, and family life also responded to intervention, but possibly
with less overall improvement, although we have not yet studied this.
Our experience in training relatively novice clinicians is that this treat-
ment is more easily delivered, and perhaps more effectively, in the hands
of more experienced clinicians able to field a range of personality traits
and motivational problems often evident in this group.

We have modified the manual to include some in-home sessions to en-

able hoarding clients to make progress that strongly reinforces their efforts.
Although the therapy content is similar to cognitive behavior therapy
(CBT ) methods for other conditions, its structure is atypical in that every
fourth meeting occurs in the client’s home, usually for extended periods
of . to  hours. The intractability of compulsive hoarding and the asso-
ciated motivational difficulties have led us to conclude that such methods
are necessary to successful outcomes in many, although undoubtedly not
all, cases. Clearly, effective intervention for compulsive hoarding will re-
quire more work throughout the coming years, but we believe we have
made a good beginning with the procedures described in this manual.

Evidence Base for CBT for Hoarding

In , Ball and coworkers suggested that clients in OCD clinics with
hoarding problems refuse and drop out of treatment more often than
OCD clients without hoarding and that CBT interventions were more
difficult to design for these individuals. Several studies support these
conclusions. In large sample trials of OCD treatment outcomes, Black
and colleagues () found that that hoarding symptoms strongly pre-
dicted nonresponse to CBT. Likewise, Mataix–Cols and associates ()

11
 found that more people with hoarding dropped out of exposure and re-
sponse prevention (ERP) treatment, and, among those who remained,
only % improved compared with % of nonhoarding OCD clients.
Early case studies are consistent with these findings (Chong, Tan, & Lee,
; Cole, ; Damecour & Charron, ; Frankenberg, ; Green-
berg, ; Herran & Vazquez–Barquero, ; Shafran & Tallis, ).
Christensen and Greist () also reported poor outcomes in a brief
computerized behavior therapy program (BT Steps) for three hoarding
clients, citing resistance to intervention, ego–syntonic symptoms, and
significant pressure from others to get help as complicating factors. They
described a pattern of passive resistance to therapy and concluded that
prognosis for hoarding was poor.

In contrast to the disappointing results of these investigations, more en-

couraging evidence has accumulated for the efficacy of CBT specifically
designed to treat hoarding and based on our cognitive behavioral model
of compulsive hoarding (Frost & Hartl, ; Frost & Steketee, ).
Hartl and Frost () reported a successful outcome in a single-case ex-
perimental design using the modified CBT approach for a -year-old
woman with a long-standing hoarding problem. Using similar methods,
Cermele and colleagues () reported a successful outcome for a -
year-old woman with chronic hoarding. We also reported modest bene-
fits for seven clients treated individually and in a group format using an
updated version of Hartl and Frost’s approach (Steketee et al., ). Of
these seven clients, all of whom also suffered from major depression
and/or social phobia, four improved moderately after  weeks ( ses-
sions) of intervention. Of the four who continued on in individual ther-
apy, three continued to improve at a one-year follow-up. Self-rated im-
provement was greatest in the areas of acquisition, confidence in their
ability to improve, and recognition of cognitive errors.

More recently, Saxena and colleagues () reported good success using
a combination of hoarding-specific CBT modeled after Hartl and Frost
() plus serotonin reuptake inhibitor medication in an intensive six-
week intervention program. As in other trials, OCD clients without hoard-
ing improved more than those with hoarding problems, but the latter
group showed significant reductions in Yale-Brown Obsessive Compul-
sive Scale (Y-BOCS) scores ( points on average) after intervention. They
concluded that multimodal intervention tailored to specific features of

12
hoarding led to clear improvement, and selective serotonin reuptake in-
hibitors (SSRIs) may help clients tolerate the CBT more easily.

Frost and coworkers () tested an earlier version of methods described

in this treatment manual in an open trial in which nine clients (all women)
with primary hoarding problems (mean age, . years; range, –
years) completed  sessions over a period of six to nine months, with
every fourth session held in the home (or occasionally in acquiring set-
tings). Therapists were graduate students with limited experience in
CBT methods who were trained by us. The clients showed significant re-
ductions (–%) in global measures of hoarding severity, in ratings of
clutter (% improved) and acquiring (% improved), and in observa-
tional measures of clutter in which clients rated themselves somewhat
more improved (%) than did therapists (%). In % of treatment
“completers,” both the therapist and the client rated the client as “much
improved” or “very much improved.” However, full remission of hoard-
ing behaviors and clutter was infrequent, and substantial residual symp-
toms remained in this preliminary test of CBT methods.

The treatment manual was revised prior to a second wait list-controlled

study in which we randomly assigned clients with primary hoarding prob-
lems of at least moderate severity to either treatment or a -week wait
list followed by treatment. Participants were excluded if they showed
significant cognitive impairment that would interfere with learning,
were on psychotropic medication, or were unable to participate consis-
tently in this relatively lengthy intervention. Doctoral students in psy-
chology and social work, trained and supervised closely by us, provided
 weekly sessions that followed the format described in this manual.
Treatment duration ranged from  to  months. Forty-three clients en-
tered the program and six (%) dropped out for various reasons, in-
cluding changing priorities, limited time to devote to the treatment, and
comorbid conditions needing more attention. Mean age for the clients
was . years (range, – years). At the time of this writing,  clients
who had completed the wait list period were compared with  clients who
completed  weeks of treatment. These  clients included nine men and
 women. Groups did not differ at pretreatment on a measure of hoard-
ing severity developed for this project and were rated after the diagnos-
tic interview. Treated clients showed significant reductions (p⬍ .) in
hoarding symptoms (%) even at week , outperforming wait listed

13
 patients who improved slightly (%), with an effect size (Cohen’s d ) of
. for this comparison. After  sessions, the  patients who com-
pleted treatment showed a % reduction in hoarding symptoms (p ⬍
.) with a very large effect size (Cohen’s d ) of .. These data indi-
cate very positive outcomes for this sample of clients based on the meth-
ods used in this manual.

Currently we do not have information on factors that predict outcome

from this intervention, nor is there sufficient information regarding its
generalizability to various populations with hoarding problems. Our
sample contains both men and women from various backgrounds (five
black clients, one Asian, and one Latina), but the sample is too small to
determine any differential effects by gender or ethnicity. It is our im-
pression that men and women did not differ in their outcomes, and that
our black clients did benefit, despite the presence of trauma histories
and comorbid problems in this subgroup.

CBT Model of Compulsive Hoarding

The cognitive and behavioral model of compulsive hoarding is based on

the limited research and clinical experience with this problem, and thus
must be considered a work in progress. The model presumes that prob-
lems with acquiring, saving, and clutter result from () personal vulner-
abilities that include past experiences and training, negative general
mood, core beliefs, and information processing capacities, which con-
tribute to () cognitive appraisals about possessions, which in turn result
in () positive and negative emotional responses that trigger () hoarding
behaviors of clutter, acquiring, and difficulty discarding/saving. These
behaviors are reinforced either positively through the pleasure gained
from saving and acquiring or negatively through the avoidance of nega-
tive emotions of grief, fear, or guilt. The overall model is depicted in fig-
ure .. This model is intended to depict many variants of hoarding ele-
ments seen across clients. In chapter  we provide a simplified version of
this model that is suitable for use with individual clients.

14
 Vulnerability Factors Beliefs/Attachment Emotional Reactions Hoarding Behaviors

Information processing:
Perception
Attention
Memory Clutter
Categorization
Decision-making Beliefs about possessions: Positive emotions:
Instrumental value Pleasure
Intrinsic beauty Pride
Sentimental value
Early experiences
Core beliefs
Beliefs about vulnerability: Acquiring
Unworthy
Unlovable Safety/comfort
Helpless Loss
Personality traits Beliefs about responsibility: Negative emotions:
Perfectionism Waste Sadness/grief
Dependency Lost opportunity Anxiety/fear
Anxiety sensitivity Beliefs about memory: guilt/shame
Difficulty
Paranoia Mistakes discarding
Mood Lost information saving
Depression Beliefs about control
Anxiety
Comorbidity
Social phobia
Trauma

Figure 1.1
Model of compulsive hoarding.

The components of this model are described further in chapter , which

describes how to assess vulnerability factors, beliefs about possessions,
emotions, and behaviors related to hoarding. Chapter  clarifies how to
construct idiosyncratic models for clients who hoard.

Risks and Benefits of CBT for Hoarding

There are few risks associated with the hoarding treatment program de-
scribed here, but we believe they are strongly outweighed by the poten-
tial benefits. Risks include encountering traumatic memories and un-
resolved grief reactions (e.g., past rape, childhood losses) that provoke
strong emotions requiring extra clinical time to help clients process their
feelings. Another risk is that clinicians will encounter a home environ-
ment that triggers mandated reporting because of abuse or neglect of
children or elders (including self-neglect for older clients). If the assess-
ment indicates that children or older adults are living in the home and

15
 that conditions may impair their health or safety, clinicians should warn
clients that they may have to report such problems to the relevant au-
thorities. In our experience, the investigative authorities can be cooper-
ative with the therapeutic efforts aimed at hoarding and may also pro-
vide a motivational “stick” to the clinician’s “carrot” of treating the
problem. A third concern is the extent of squalor present that may re-
quire clinicians to wear masks or protective clothing when in the home
or to request the aid of cleaning crews to remove waste that could cause
health problems.

The benefits of treatment are apparent in the earlier description of out-

comes following treatment in our recent studies. Treatment takes time
and clients may not be recovered (out of episode) at the end of the in-
tervention, but most experience significant reduction in clutter, diffi-
culty discarding, and excessive acquiring, and have gained many skills to
continue their work. The comprehensive intervention methods typically
have positive side effects of improving self-esteem, mood, and function-
ing, along with improvements in clutter.

Alternative Interventions

Currently, there are no alternative treatments that can be considered evi-

dence based. Standard exposure and blocking of rituals for OCD symp-
toms appear to work in some cases, but is generally less successful for
hoarding than for OCD symptoms. Many of our clients have experi-
enced forced “clean-outs” by authorities or relatives. Their strong angry
and hurt reactions and continuing struggle with hoarding indicate that
this is not an effective alternative.

The Role of Medications

Several investigators have reported poor outcomes with SSRIs in retro-

spective studies. In large samples, Black and colleagues () found that
that hoarding symptoms were the strongest predictor of nonresponse to
medication, and Mataix–Cols and associates () found that higher
hoarding scores predicted worse outcomes. Winsberg and coworkers ()

16
 also reported poor response to medication treatment among people with
compulsive hoarding. However, in a prospective study, Saxena and col-
leagues () reported that the SSRI paroxetine produced similar bene-
fits for both hoarding and nonhoarding OCD patients, although im-
provement was modest in both groups. Our own treatment studies have
not included clients receiving SSRI medications, so we cannot provide
useful information on combining medications with the CBT methods
described here. We would recommend that unless medications are needed
for other conditions such as attention deficit symptoms or severe de-
pression, hoarding clients can be treated without medication.

Outline of This Intervention Program

This cognitive and behavioral intervention program is designed for 

weekly sessions spaced over a period of approximately six months. How-
ever, the number of treatment sessions might vary from a minimum of
 for a case of mild hoarding to  or more spaced over a one-year pe-
riod. Duration of treatment will likely be related to motivational factors,
the amount of clutter, presence of comorbid conditions that slow progress,
and availability of cooperative assistants in decluttering the home. The
approximate number of sessions for various aspects of the CBT inter-
vention are as follows:

■ Assessment: two to three sessions at the beginning of treatment

■ Case formulation: two sessions after assessment

■ Skills training: two to three sessions, including organizational and

problem-solving skills, repeated as needed during other sessions

■ Exposure and cognitive therapy:  to  sessions, beginning with

exposure and adding cognitive methods immediately during all
sorting sessions and for acquiring problems

■ Motivational interviewing to address ambivalence and low insight:

portions of several sessions, especially early in treatment

■ Relapse prevention: two final sessions

17
 Three weekly clinic sessions alternate with one monthly home visit or a
visit to an acquisition site throughout treatment. The first two assess-
ment sessions may require approximately . hours each. Allow approxi-
mately one hour for each office visit, during which boxes or bags of items
brought from the home are used for sorting. In-home appointments will
typically last two hours. We have also had good success with two or three
“marathon” sessions of several hours in the home, or a “clean-out” for
which we enlisted the help of a closely supervised cleaning crew with the
client’s permission. These sessions produce substantial progress that en-
hances motivation, helps clients feel less overwhelmed, and helps clients
consolidate skills to work more independently on the remaining clutter.

The flow of the CBT methods varies considerably from client to client
as clinicians alternate their focus among the three problems of organiz-
ing, acquiring, and removing objects depending on the client’s immedi-
ate goals and needs. Developing an organizing plan and gaining control
over compulsive acquiring are usually more easily accomplished than re-
moving items. However, many clients are more strongly motivated to
clear their clutter because of outside pressure or because the clutter is the
most frustrating aspect of their symptoms. Skills are taught whenever
needed. Alternating among cognitive and exposure strategies for clear-
ing clutter will be necessary, because progress on sorting and removing
items depends on changing thinking and reducing distress. For example,
a clinician may begin by sorting items in the kitchen, using cognitive
strategies as problematic beliefs surface, and then switch focus to acquir-
ing as the client faces an immediate need to purchase a birthday present
for a family member and fears losing control.

Session Structure

Each treatment session follows a basic format outlined briefly here. Clients
use the Personal Session Form from the workbook to make notes during
and between sessions. These forms provide a record of what clients learned
during therapy and are used to facilitate recall of helpful treatment meth-
ods during relapse prevention. Clinicians check in briefly (five minutes)
to ask about mood, recent events, and important issues discussed during
the previous session, and then set the agenda for the session together

18
 with the client. Encourage clients to express their own wishes and, if the
agenda seems overly long for one visit, prioritize and hold less important
items until the next session. Be sure to discuss previous homework early
during the session to emphasize its importance.

Then, introduce agenda topics and intervention strategies to ensure that

important points are covered within the time available. After any seg-
ment with new information, ask clients to summarize what they learned
in order to consolidate new learning. New homework assignments for
the week can be developed during the discussion or devised at the end
of the session to fit the topics covered. Clients should write down the as-
signment on their Personal Session Form to prevent uncertainty and
minimize avoidance of homework. Sessions end with clients summariz-
ing what was covered. Then ask for feedback about the session (How did
you feel about today’s session? Is there anything I did or said that both-
ered you?), encouraging clients to be honest about their reactions. Clini-
cians should complete their own Clinician Session Form (see chapter )
to keep an accurate record for future reference.

Use of the Client Workbook

The accompanying client workbook contains brief information and in-

structions to clients that follow the format of this manual, as well as
blank versions of all forms used during treatment and for homework as-
signments. These include scales for assessment, a Personal Session Form
for recording notes and homework, various forms for recording thoughts
and beliefs as they occur naturally, case formulation, treatment goals, or-
ganizing plans, behavioral experiments, cognitive techniques, and a list
of interventions learned during treatment. Thus, the client workbook
reinforces what is learned during sessions and is a critical part of therapy.
Clinicians should advise clients which parts to read and which forms to
complete. Books are easily lost in the clutter at home, so it is critical to
refer regularly to the workbook so clients become accustomed to bring-
ing it to all sessions. Discuss where they will keep the workbook to avoid
losing track of it.

19
This page intentionally left blank
Chapter 2 Assessing Hoarding

(Corresponds to chapters 1 and 2 of the workbook)

Materials Needed

■ Camera for home visit

■ Clinician Session Form

■ Hoarding Interview

■ Saving Inventory–Revised

■ Clutter Image Rating

■ Saving Cognitions Inventory

■ Activities of Daily Living for Hoarding (ADL-H)

■ Personal Session Form

■ Reading: “What Is Hoarding?”

Outline

■ Complete assessment measures.

■ Conduct a home visit within the first four sessions.

■ Work with the client to choose a family member or friend for the
“coach” role.

This chapter walks the clinician through the components for assessing
hoarding symptoms and related problems before commencing the for-
mal intervention. This should require two to four sessions, depending
on the complexity of the case, although in some complicated cases with

21
 limited motivation, it can take more than four sessions. You will un-
doubtedly begin treatment before you understand all aspects of the client’s
situation, learning more about your client and the hoarding problem as you
go along. This is typical of most cognitive and behavioral interventions—
more understanding occurs as you actually do the treatment. Chapter 
helps clinicians build a model for understanding the client’s symptoms
based on the assessment.

As you begin assessing clients’ symptoms, ask them what terms they pre-
fer to use to describe their problem. Sorting and removing items may be
called dehoarding, decluttering, uncluttering, or other terms. Letting go,
removing, or getting rid of objects may be preferred over discarding, be-
cause the latter implies wastefulness to many clients and does not include
recycling, selling, or giving away—alternatives preferred by many clients.

Assessment Plan

If you have the flexibility, allow about  minutes for the first assessment
session in the office and . to  hours for the second appointment held
in the client’s home. Additional assessment sessions can be scheduled in
the office for about an hour. The home appointment can be postponed
if the client is very uncomfortable allowing the clinician to visit, but
should not be delayed beyond the fourth session because this would in-
terfere with beginning effective treatment. The home session can also in-
clude some discussion with adult family members living in the home, as
described later in this chapter.

During the first office visit, provide your client with the workbook con-
taining all forms and instruct him to bring it to each session. During this
and all subsequent sessions, clients can make notes on the Personal Ses-
sion Form found in the workbook about their agenda, points they want
to recall from the session, homework assignments, and any topics they
want to discuss next time. You’ll have to remind them to use the form at
times that seem especially helpful, so clients get in the habit of doing so.
You can also suggest that these forms provide a good record of the ther-
apy itself to facilitate recall of the treatment methods that were most
useful. Ask clients where they will keep their workbook at home so they

22
 can always find it. This question is especially important for clients who
report that they often misplace things in their clutter.

Use the blank Clinician Session Form on pp. – to guide each session
and to record any special information based on the session discussion. A
sample completed form is shown in figure .. You may photocopy the
blank form available in Appendix B or download multiple copies from
the TreatmentsThatWork™ website at www.oup.com/us/ttw.

Establish a collaborative agenda by indicating the type of information

you plan to collect about hoarding, including organizing problems, ac-
quiring, and getting rid of clutter. Inquire what topics the client wants
to include in this first session and record these items on the agenda.

During the assessment phase, try to allay clients’ fears about treatment,
especially about the prospect of having to get rid of hoarded items, by
listening closely to their responses to questions about their experiences.
Take care to communicate that clients are not to blame for their hoard-
ing behavior (or related symptoms) and that treatment is likely to be
successful but will require patience, time, and homework. Ask clients
about their expectations and concerns about the intervention and ad-
dress them as appropriate.

In-Office Assessment

Much of the assessment takes place in the clinician’s office and includes
interviews about hoarding symptoms and any comorbid problems. Sev-
eral formal measures can be completed by clients in your office, although
some should be done during the home visit.

Assessing Hoarding Symptoms

Questions from the Hoarding Interview (see the Appendix A: Assessment

Instruments) will occupy most of the first and part of the second ses-
sion. This interview provides a template for collecting detailed informa-
tion about clients’ compulsive hoarding symptoms, degree of impairment,

23
Clinician Session Form

Client: Session #: Date:

Basic Session Content:

Agenda:

Homework report:

Degree of homework compliance (1 to 6):

( ⫽ did not attempt;  ⫽ attempted but did not complete;  ⫽ did about %;  ⫽ did about
%;  ⫽ did about %;  ⫽ did all homework)

Symptoms and topics discussed during session:

Intervention strategies used or reviewed:

24
Clinician Session Form continued

Homework assigned:

Comments on client’s summary and feedback:

Goals for next or future sessions:

and general life situation. The information will help provide a basis for
developing a conceptual model for each client’s hoarding symptoms.

In addition to this interview, we recommend using the following standard-

ized questionnaires to assess the type and severity of hoarding symptoms:

■ The Saving Inventory-Revised (Frost, Steketee, & Grisham, )

is a -item scale with three subscales. These include the Acquiring
subscale to determine the extent of compulsive buying and the
acquisition of free things, the Clutter subscale to report the
amount of clutter and problems associated with it, and the Diffi-
culty Discarding subscale to measure discomfort about removing
the clutter. Typical total scores (summed across all  items) for
people with compulsive hoarding problems are more than 
points with an average of  points (table .), whereas those who
do not hoard have average scores of  points and a typical range
of  to  points. This scale can be found in the corresponding
client workbook.

■ The Clutter Image Rating (Frost, Steketee, Tolin, & Renaud, )
is a pictorial measure that includes nine pictures that vary in rating

25
Clinician Session Form

Client: PK Session #: 2 Date: 11/6.06

Basic Session Content: Assessment

Client’s mood and symptoms: Felt good about starting work on clutter, some anxiety during

past week, mild trouble focusing at work, no significant depression.

Agenda:

1 - Review self-report forms

2 - Finish hoarding interview

3 - Answer PK’s questions about her symptoms

4 - Discuss family issues if time

Homework report: PK read ‘What is Hoarding” and finsihed half of her questionnaires, made

note of a few questions

Degree of homework compliance (1 to 6): 6

( ⫽ did not attempt;  ⫽ attempted but did not complete;  ⫽ did about %;  ⫽ did about
%;  ⫽ did about %;  ⫽ did all homework)

Symptoms and topics discussed during session: Some acquiring this week—mainly clothing

for self and kids on sale.

Reviewed reasons for saving—mainly concerned about missing opportunities, sometimes

losing information.

Effects of acquiring, saving, clutter: financial problems, conflicts with husband about money

spent, electricity may be cut off, kids can barely sleep in beds because of clutter

Family history—mother saved but not this much, grandmother a neatnik

Serious clutter began after rape in current home 15 years ago—discussed trauma effects

Figure 2.1
Example of completed Clinician Session Form.

26
Clinician Session Form continued

Intervention strategies used or reviewed: Hoarding assessment and questions to clarify reasons

for saving and effects of hoarding symptoms, probed for severity (moderately severe),

questions to clarify motivation indicated some ambivilance, esp, giving up shopping

Homework assigned: Finish remaining questionnaires

Ask husband if he is available to meet for half an hour at end of home visit next week

Comments on client’s summary and feedback: Client happy with start of treatment, found

questionnaires and my comments on these interesting

Goals for next or future sessions: Complete assessment, maybe begin work on acquiring

depending on family meeting

Figure 2.1 continued

from  (no clutter) to  (severe clutter) for a kitchen, a living room,

and a bedroom. A rating of  points or more represents clinically
significant clutter characteristic of hoarding. Clients simply select
the picture that most closely matches their own room to provide a
rating of the amount of clutter in that room. This instrument is
very easy to use for the initial assessment of clutter and also helps
gauge progress during treatment. The measure works best when
printed in full color. We have included black-and-white samples in
Appendix A and the corresponding client workbook; however,
you may download color versions from the TreatmentsThatWork™

Table 2.1 Typical Saving Inventory-Revised (SI-R) Scores

Population n SI-R Total Clutter Discarding Acquisition

Hoarding clients  . (.) . (.) . (.) . (.)
Community control subjects  . (.) . (.) . (.) . (.)

SI-R, Saving Inventory–Revised.

Standard deviations are in parentheses.

27
Table 2.2 Saving Cognitions Inventory (SCI) Scores
Emotional
Population n SCI Total attachment Memory Control Responsibility

Hoarding clients  . (.) . (.) . (.) . (.) . (.)
Community control
subjects  . (.) . (.) . (.) . (.) . (.)

website at www.oup.com/us/ttw. Both clients and clinicians can

complete the measure.

■ The Saving Cognitions Inventory (Steketee, Frost, & Kyrios,

) is a -item self-report questionnaire that assesses beliefs and
attitudes clients experience when trying to discard items. Four
subscales focus on emotional attachment to objects, beliefs about
objects as memory aids, responsibility for not wasting possessions,
and the need for control over possessions. Typical scores for hoard-
ing clients and community members are given in table .. This
questionnaire can be found in the corresponding client workbook.

■ Activities of Daily Living for Hoarding (ADL-H, Frost & Steketee,

unpublished) inquires about how much the clutter interferes with
clients’ ability to complete ordinary activities like bathing, dressing,
and preparing meals ( items). Additional questions pertain to the
quality of living conditions (e.g., presence of rotten food, insect in-
festation—seven items) and safety/health issues (fire hazard, unsani-
tary conditions—six items). The ADL-H can be rated by clients
and by clinicians, and is useful in identifying particular problems
with the living environment. If the client rates himself or herself
significantly lower than the clinician on these measures, this may
indicate significant problems with insight. This measure is included
in Appendix A, as well as the corresponding client workbook.

Identifying Other Psychiatric Problems

If a diagnostic interview has been completed as part of the clinic intake

to assess psychiatric problems (Axis I) and personality disorders (Axis II),
clinicians can determine whether some comorbid conditions are present

28
 that might affect the therapy. Additional self-report measures can be
given to provide useful information about mood, psychiatric symptoms,
general functioning, and motivation. We use the following instruments,
but many others are available in the psychiatric and psychological as-
sessment literature. Of particular value are measures that indicate when
clients score well above the normative range, indicating that symptoms
may warrant clinical attention.

■ With the Beck Depression Inventory (Beck, Steer, & Brown, ),
a score of  points or more is considered severe, and a score in
the ⫹ points range is extreme. If item  (regarding suicidality)
is rated  or  points, probe for suicidal intention that may re-
quire immediate crisis management. This measure is available at
www.psychcorp.com.

■ The Obsessive Compulsive Inventory-Short Form (OCI-SF) (Foa,

Huppert, Leiberg, Langner, Kichic, Hajcak, & Salkovskis, ) is
a self-report measure of OCD symptoms. The -item short form
has six subscales for washing, checking/doubting, ordering, ob-
sessing, hoarding, and mental neutralizing. The optimal cut point
for diagnosing OCD using the OCI-SF total score is  points, al-
though the authors recommend using a score of  points on the
Obsessions subscale only because it better discriminates between
OCD and nonclinical control subjects. This measure is available
in the corresponding client workbook.

Planning the Home Visit

The home appointment helps confirm impressions gained during the

office interviews. It also determines the amount and type of clutter, and
can also be used to meet with family members at the point that seems
most appropriate. Schedule the home appointment within the first four
sessions of treatment. Our own preference is to arrange this for the
second session, unless clients are ambivalent about treatment and are
unwilling to agree to this “invasion” of their privacy until a stronger
therapeutic relationship is established. Assume your client is worried
and embarrassed about the first home visit and will find your walking
through the home and taking photographs intrusive. Many hoarding

29
 clients are isolated and have had no visitors for years and, in some cases,
relatives or local officials have removed their belongings against their
will. To allay their fears, describe the goals of the home assessment and
the procedures you will follow during the visit. Indicate that you will not
touch any items and that all photos are part of the client’s confidential
record. Language similar to the following may be helpful:

The home visit is very important for us to understand your thoughts

and experiences about the things you own. So far I’ve asked you a lot
of questions about the hoarding problem during this office visit. When
we are at your home, I’ll be asking how you feel and think about your
things as you actually look at them and also what you typically do at
home and how the clutter affects this. I’ll take pictures of your home to
use during treatment to decide on next steps and to track your progress.
The first home visit is especially useful for me to really understand
how you think and feel about your home and your possessions. Do you
have any questions about the process or about anything else so far?

In-Home Assessment

When entering the home for the first time, be careful not to react with
shock or dismay, regardless of the level of clutter or state of the home.
This avoids confirming clients’ worst fears that the clinician will judge
them harshly. As for all treatment sessions, begin the home visit by es-
tablishing the agenda, inquiring about reactions to the previous office
visit, and reviewing any homework assignments. The major agenda items
for this session are completing assessments of daily activities and the
amount of clutter, and beginning to plan the intervention with clients.
The clinician can complete the ADL-H as an informal interview during
the walkthrough, as well as the Clutter Image Rating pictorial measure.
As noted earlier, a mismatch in client and clinician scores may reflect a
lack of insight into the severity of the problem. The ADL-H helps es-
tablish treatment goals to improve functioning—goals that may later
prove useful when motivation wanes.

We recommend photographing all rooms to capture an accurate visual

portrayal of clutter and to provide a baseline assessment of the severity

30
 of clutter for reference during therapy to evaluate progress and decide on
next steps. We have found photos helpful to point out visible progress
when clients are discouraged during what can be a lengthy treatment
process. If clients live too far from the clinic, they can take the necessary
photographs themselves with a little training. Plan to take enough pho-
tographs per room to capture the full extent of the hoarding problem
and to provide information about items the client will eventually bring
to office sessions for practice during treatment. Try to devise a consistent
method that is easy to follow at the next picture-taking occasion to
match the first pictures. We suggest doing all photographing digitally,
printing the pictures, and storing them in a folder for easy reference in
subsequent sessions.

Deciding Where to Begin

At some point during the home assessment, decide with clients where to
begin to work on sorting, organizing, and removing clutter. This re-
quires a discussion about whether to proceed room by room or to use
some other system such as one based on type of item (e.g., gathering up
all paper items or all books from all the rooms and then sorting them).
We usually select rooms to work on, beginning with the easiest or the
one that will have the most immediate benefit for clients. For example,
some clients may prefer to begin with a hallway because it impedes ac-
cess to parts of the home they would like to use. Others might begin in
the kitchen because it is least cluttered and/or offers the most benefit in
terms of resuming important activities like cooking or eating. Other
considerations like reducing family members’ criticism or complying
with building codes may also contribute to this decision.

Help clients assemble a box or bag of typical saved items for use during
clinic appointments to learn and practice new skills. This box should
contain random clutter observed in the house, such as junk mail, news-
papers, magazines, small objects, receipts, notes, ticket stubs, clothing,
books, and so forth. These clutter items should be selected mainly from
the room in which treatment will begin.

31
Discussion With Family Members

When clients are living with family members whose lives are affected by
the hoarding, we strongly suggest arranging to meet with the client and
family members together for some portion of the first or second home
session, preferably after the clinician has first walked through the house
and completed the clutter assessment. We usually reserve the last  min-
utes of the session for this meeting, asking family members not to be
present for the earlier walkthrough with the client. Ask the client about
any special concerns or arrangements for meeting with family members
in advance and decide what topics to cover. The clinician may also wish
to speak to family members by phone before the meeting.

Introduce yourself and inquire about family members’ questions about

you, the treatment, or other matters related to hoarding. Ask whether
family members engage in behaviors that accommodate the client’s
hoarding. These might include doing sorting tasks for clients, throwing
out items clients would otherwise deal with, buying or saving things for
clients that they would not otherwise do, keeping the credit card to pre-
vent overspending, and so forth. Describe the treatment plan and ask
whether they would be willing to follow your directions to refrain from
doing things that might interfere with treatment progress or homework
assignments. We usually suggest that family members continue with their
usual behaviors unless the clinician or the client asks for changes based
on the treatment plan and recent progress.

Frequently, family members are highly critical of the client’s ineffective

efforts at reducing clutter. Discuss the importance of making positive
comments on progress and avoiding criticism of the slowness of change.
You can explain that change will take months because the client must
learn new ways of doing things and of thinking, and this takes time. You
can also ask family members how effective their criticisms have been so
far in changing the client’s behavior. If they haven’t been effective, would
they be willing to respond differently to improve the hoarding? Then
make specific suggestions about when to refrain from comments and
what to say when progress occurs.

Ask whether any family members living at home also have similar prob-
lems with acquiring, organizing, and removing possessions. Turf wars

32
 over space can erupt when clients reduce clutter only to have family
members fill the new space with their things. Some negotiation may be
needed to give the client appropriate control over some spaces in the
home. Questions about who has the right to handle belongings and to
control household spaces will need to be negotiated as the intervention
progresses. The final plan must ensure that clients use new skills in prob-
lem solving, decision making, and organizing, as well as evaluating their
own beliefs and managing their emotional reactions to not acquiring and
letting go. This will require family members to refrain from special ac-
commodations (making decisions, providing unnecessary reassurance,
and taking over duties like trash removal and controlling acquiring) that
prevent clients from learning new behaviors. After spaces are cleared,
rules about how to handle new clutter can be negotiated.

Coaching From Friends or Family Members

Family members or friends who are especially calm, thoughtful, and em-
pathic people can be enlisted as official coaches during the intervention.
Discuss this plan with the client first to determine whether anyone qual-
ifies for this role, and then include the coach in one or more treatment
sessions with the client to outline the rules for helping and provide guid-
ance. “Instructions for Coaches” from the workbook provides written
suggestions for this purpose.

Special Issues During the Home Visit

Severe hoarding problems may complicate home visit procedures. Al-

though it is difficult to know how severe the problem is, you may be able
to gauge this based on your client’s Clutter Image Rating ( points or
more) and clutter scores on other measures. However, even with mod-
erate scores on these scales, you may encounter unhealthy and even dan-
gerous problems in the home. If your client has children or elders living
at home, you must engage in a frank discussion about the level of risk to
them and about your professional responsibilities for reporting danger-
ous conditions if they exist. Such a discussion should occur in the office
before the home visit and should cover information about the reporting

33
 process and how you can help them with it. It is important that your
clients understand that the health and safety of their loved ones may ne-
cessitate more drastic action than they may have anticipated.

Also necessary before the home visit is a discussion of steps you antici-
pate may be needed to protect your own health and safety. These could
include wearing gloves, protective clothing, and/or a breathing mask.
Take these with you just in case, but use them only if you feel it is nec-
essary. Also, be prepared to have no place to sit down and little room to
move around during the home visit. Anticipating these issues will make
it easier for you to accomplish what is needed for this visit.

Homework

Homework assignments for these early assessment sessions are likely to

vary substantially, depending on the degree of motivation and skills of
clients. You can assign self-education tasks, as well as tasks to help clients
gather information and to encourage self-observational skills that will be
useful during treatment. In general, be thinking in the back of your
mind during all therapy sessions whether some aspect of the topic being
discussed might lend itself to a homework assignment to help move the
therapy along. The following are some recommended homework assign-
ments for assessment sessions, but you may wish to design your own that
follow logically from the discussion during sessions:

✎ Instruct the client to read “What Is Hoarding?” from the workbook to

learn more about hoarding behavior.

✎ Have the client complete questionnaires (Saving Inventory–Revised,

Saving Cognitions Inventory, ADL-H, Clutter Image Rating, and
measures of suspected comorbid conditions).

✎ Ask the client to assemble a box or bag of items to bring to office ap-
pointments for sorting.

34
Chapter 3 Case Formulation

(Corresponds to chapter 3 of the workbook)

Materials Needed

■ Reading: “Reasons for Saving”

■ Brief Thought Record (optional)

■ Acquiring Form

Outline

■ Work with the client to develop a model of hoarding.

This chapter describes how clinicians develop a model collaboratively

with the client to understand how the hoarding problem developed and
why it continues. The process usually takes one to two sessions, with
some homework assigned between sessions to collect additional infor-
mation to complete the model. However, model building is an ongoing
process throughout treatment. At this early stage we frequently do not
search for the client’s core beliefs, because they are more difficult to iden-
tify and gradually become more apparent during the work on clutter and
acquiring problems. Thus, core beliefs are discussed in later chapters.

Why Develop a Model of Hoarding?

Recall from chapter  that hoarding behavior is complex, deriving from

a combination of vulnerabilities, core beliefs, information processing
problems, beliefs about and meanings of possessions, emotional responses,
and learned behaviors. The first two assessment sessions served to iden-

35
 tify the features of the client’s hoarding problem. Now it is time to draw
them together into a conceptual model that explains how and why the
hoarding occurs. Table . lists the most common factors to look for dur-
ing the model-building process.

We advocate developing two types of models. The first is a general con-

ceptual model that incorporates all aspects of the problem. This is in-
tended for general reference during treatment to help clients understand
their behavior in the broad context of their life experience. The second
is a more specific functional analysis to describe individual episodes of
acquiring or difficulty removing clutter. This analysis of action in real
time helps clients grasp why they have just behaved as they did. Both
models lead directly to intervention strategies that target the problems
identified in the models. We begin with the general conceptual model.

General Conceptual Model

Separate conceptual models may be needed for problems with organiz-

ing, acquiring, and discarding, but often the elements leading to these
three symptoms are similar enough that one model can adequately de-
scribe these features. As noted in chapter , the models should include
special vulnerabilities, information processing deficits, the meaning of
possessions, and the emotional reactions clients experience during ac-
quiring, organizing, and clutter removal efforts. The models should also
include information about how these are connected, reinforced, and
maintained. We suggest drawing the contributing factors in pictorial form,
with arrows leading from the various components to resulting emotions
and behaviors.

Developing a model collaboratively helps clients learn to observe and ex-

amine their thoughts and emotions critically to understand them better.
Thus, model building enables clients to take the first step toward dis-
tancing themselves from the problem, and adopting a more rational
rather than purely emotional stance. Model building also establishes the
client’s role as detective and collaborator, working with the clinician to
understand and resolve the hoarding problems. To facilitate this, clini-
cians use open-ended curiosity questions like, “That’s interesting; where
do you think that thought comes from?” and “How do you think these

36
Table 3.1 Elements Useful in Developing the Conceptual Model

Personal and family vulnerabilities

Family history of hoarding (possible hereditary traits/biological underpinnings)
Comorbid problems (e.g., depression, social anxiety, obsessive-compulsive symptoms)
Parental values and behavior (e.g., acquiring, difficulty discarding, clutter in the home, control
over decisions, values about waste, sentimentality)
Physical constraints (health, time, space)
Traumatic events (e.g., loss of parent, assault, deprivation, moving)

Information processing problems

Attention—Difficulty sustaining attention on a difficult task
Categorization—Problems with grouping and organizing objects into categories
Memory—Poor verbal or visual memory leading to reliance on visual cues
Perception—Failure to notice clutter or a strong visual attraction to objects
Association—Tendency to generate lots of ideas about or uses for objects, creativity
Complex thinking—Focus on nonessential details, inability to separate important from unim-
portant details
Decision-making problems—Considering too many facets of a problem, ambivalence; often
related to fear of making mistakes

Meaning of possessions/thoughts, beliefs, and attachments to possessions

Beauty/aesthetics—Finding beauty in unusual objects
Memory—Belief/fear that memories will be lost without objects or that objects contain memories
Utility/opportunity—Seeing the usefulness of virtually anything.
Opportunity/uniqueness—Seeing opportunities presented by objects that others don’t
Sentimental—Attaching emotional significance to objects
Comfort—Perceiving objects (and related behaviors like shopping) as providing emotional comfort
Safety—Seeing objects as sources of safety (safety signals)
Identity/potential identity—Belief that objects are part of the person or represent who the per-
son can become
Control—Concern that others will control one’s possessions or behavior
Mistakes—Perfectionistic concern about making mistakes or about the condition or use of
possessions
Responsibility/waste—Strong beliefs about not wasting possessions, about polluting the envi-
ronment, or about using possessions responsibly
Completeness—Postponing action until the person feels “right” or complete
Validation of worth—Objects help validate the persons’ self worth
Socializing—Buying or collecting items provides social contact not available in other ways

Emotional reactions
Positive—Joy, pleasure, comfort, satisfaction
Negative—Anxiety, guilt, grief, sadness, anger
continued

37
Table 3.1 continued

Learning processes
Positive reinforcement (saving and acquiring produce positive emotions)
Negative reinforcement (saving permits escape or avoidance of negative emotions)
Hoarding behaviors prevent the opportunity to test current beliefs
Hoarding behaviors prevent the opportunity to develop alternate beliefs

two components are connected?” When developed, the conceptual

model can be used throughout treatment to determine goals and meth-
ods for achieving them, and to demonstrate progress when change oc-
curs. Of course, the model should be revised whenever new information
comes to light.

We suggest starting the model by writing the problem behavior (e.g.,

“Clutter/Difficulty Discarding” or “Acquiring” or “Organizing”) near
the bottom of a piece of paper. Then place above these symptoms the
vulnerabilities, information processing problems, meanings of posses-
sions, and emotional reactions that seem connected to the hoarding be-
havior. Draw arrows from these problems to the emotions they engen-
der and then to the behaviors that follow. The consequences and their
role in reinforcing the behaviors should be specified as well. The first
“working model” is usually revised several times before it accurately cap-
tures the complete picture for a given hoarding symptom.

Developing the model also enables the client and clinician to identify
goals and points for intervention, such as reducing anxiety about losing
valuable information, reevaluating beliefs about responsibility for pos-
sessions, and reducing shopping patterns that add to the clutter.

Beginning to Build the General Conceptual Model

A reading from the workbook titled “What Is Hoarding?” (assigned in

chapter ) can help remind clients of factors that contribute to and main-
tain hoarding. Begin working on the model by asking a series of ques-
tions and commenting about what you have already learned during the

38
 Hoarding Interview or observed during the home visit. Here is an ex-
ample of a beginning dialogue.

Case Vignette

Clinician: To understand how your problem with clutter has developed and what
keeps it going, we find it helpful to work out a model on paper. It
seems pretty clear to me that you are most unhappy about the clutter
at home and you also have a problem with acquiring, especially at tag
sales. Would you agree?

Client: Yeah, I really need to get rid of some of this stuff.

Clinician: Right. So let’s start by understanding how the clutter happens and why
you have trouble getting rid of it. So first, I’ll put the words “Difficulty
Discarding and Clutter” here at the bottom of the page. Above it, we’ll
figure out what contributes to this. Does this make sense to you?

Client: Yeah, I usually like to see things visually, so that’s okay.

Clinician: Lots of things can contribute to clutter. In your case, we’ve talked
about your family history and you’ve also mentioned some personal
events in your past that seem related to the clutter. Let’s put a box up
here on the left that we’ll call “Vulnerability Factors” and list the things
we think have contributed. What would you include in there?

Client: Well, when my mother threw out my old toys when we moved, that
really upset me, so that might be one.

Clinician: Agreed. I can write that as “Mother threw out toys.” What else?

Client: Um, I think I react against my mother’s housecleaning. You know, she
was so particular and everything had to be so neat. I hated it. I don’t
like a neat house. I like a little clutter.

Clinician: Okay, can I put that down as “Family rules about neatness?”

Client: Yeah, geez, she never would let me make my own decisions about my
room. I honestly think that’s part of why I have trouble deciding about
my stuff.

Clinician: Okay, so we can add, “Not allowed to make decisions.”

39
 Client: Yes, that’s part of it for sure. And also, my grandparents’ home, my
Dad’s parents, you know, was pretty much a mess, but we had a lot fun
there, my cousins and I. So maybe that’s part of it too. I think I liked
their house better than my own.

Clinician: That sounds important. I’ll add, “Grandparents’ clutter was fun.”
Would that capture it?

Client: Yeah.

Clinician: [summarizing to consolidate the points] So far, what we have are sev-
eral past experiences that contribute to making you vulnerable to hav-
ing clutter. These are your mother’s strict standards for tidiness and not
allowing you to make decisions about your own things and having fun
at your grandparents’ cluttered home. It sounds like you associated
neatness with unhappy emotions and clutter with happy ones. Does
that sound right?

Client: Yes, that’s certainly right. But now I hate the clutter here. It’s over
the top.

Clinician: That’s why you’re here. It’s interesting to see some of the reasons why
some clutter appeals to you and these might have something to do
with avoiding cleaning up. Now, let’s talk about other things that
might make you vulnerable to clutter. What else occurs to you?

This dialogue illustrates the collaborative style with which the clinician
reminds clients of events they have reported during the assessment that
seem like relevant causal factors. Open-ended questions are used to elicit
other possibilities.

Vulnerability Factors

The previous example begins with childhood history as a vulnerability

factor. Table . offers a variety of other vulnerability factors to explore.
Ask about each of these in turn, focusing especially on factors identified
during the assessment and on the features that can be modified during
the intervention time frame. Sometimes clients describe a contributing
family history that cannot be altered, although exploring this history
may help clients understand how their early experiences contributed to

40
 their hoarding problems. During treatment, clients can use cognitive
and behavioral strategies to help process emotional baggage left from
parental restrictions or past traumas in light of current adult knowledge,
interests, and personal goals. After the model is clear, you and your
client can decide what problems to work on and in what order.

Picking up from the previous exchange, the dialogue about vulnerabil-

ity factors might go as follows.

Case Vignette

Client: I’m not sure, maybe the break-in I had in my s might have con-
tributed. I felt so violated that the burglars took my stuff. I was really
upset.

Clinician: How do you think that contributes to clutter now?

Client: Well, I started getting seconds and thirds of things, in case something
got stolen, and I put the duplicates in other places burglars might not
look.

Clinician: Okay, so the burglary led you to try to make sure you had backups in
case things were stolen. Does that belief that you need extras in case
things are stolen still operate now?

Client: Yes, I think it does. I always think, “Just in case,” you know. And also,
I think I use the clutter to stop somebody from coming in. Nothing
happened during the burglary because I wasn’t home, but I started
thinking I could have gotten hurt in a break-in and I started piling
some heavier items up so it would stop someone from getting in. I
think that’s why I keep it so the door is hard to open.

Clinician: That’s really important, so we’ll need to work on thoughts about safety
before you can clear that clutter. I’ll add “Burglary” to the section on
vulnerability factors. Also, soon we’ll get to a section on “Thoughts
and Beliefs,” where we should add the part about “Keeping items just
in case” and the idea that “Clutter prevents people from hurting me.”
We can talk about these in a bit.

Client: Yeah, I think that part is important. It’s why I keep a lot of stuff.

41
 Clinician: Good. Now, any other vulnerability items? I’m going to name a few
and you tell me if you think they are related to the clutter problem at
all. What about depression? You told me there was a family history of
this and you have had some periods of depression. Are they connected
to hoarding in any way?

Client: I suppose that when I’ve been depressed about something, you know,
like my Dad dying last year, I really don’t do much at all on the clutter.
Now that I think about it, sometimes my low mood makes it hard to
do any work. Like, I really don’t even want to bother.

Clinician: Okay, so we’ll add “Depressed mood” here on the vulnerability factors
list. What about your physical health? Anything there that contributes?

Client: No, not really. I don’t have any real health problems. If I’m really sick I
go to bed, but it isn’t that often.

Clinician: What about social anxiety? We’ve talked about that a bit and I know
you avoid some social gatherings. Has the clutter got anything to do
with this?

Client: I’m not sure. I’d have to think about that.

Clinician: Okay, good idea. I’ll put it here on the model with a question mark
after it and would you be able to think about that more for homework?

Client: Yeah, sure. I can do that.

Clinician: Great. Let’s both of us add that to the homework section of our ses-
sion forms.

Information Processing Components

Information processing problems are often linked to negative emotions

and to problematic beliefs. Table . lists the most common information
processing problems. Help clients determine whether they have any of
these problems by noting that many people have one or more of these
symptoms, and ask whether they have difficulties in any of these areas.
For example, ask about attentional problems as children—learning dif-
ficulties in school and the nature of these. Ask clients to compare them-
selves with others they know well to determine whether there are probable

42
 deficits or merely beliefs about such things as poor memory. To avoid
prolonging this phase of model development, at this point identify only
obvious deficits for which clients have clear evidence and include these
in the model. If other problems emerge later during treatment (e.g.,
while working on organizing possessions), revise the model at that time.
The following dialogue illustrates the method of questioning.

Case Vignette

Clinician: As you read in the “What Is Hoarding?” reading in your workbook,

most people with a lot of clutter have some difficulty processing infor-
mation. For example, lots of people can’t pay attention to a task long
enough to get the work done. They get distracted and move on to
something else before they are finished with the first task. Is this a
problem for you?

Client: Yeah, actually. My mother used to complain about this, and I had
some special classes as a kid. I’m not sure what it was called, but now I
think I had ADD or something like that.

Clinician: Has this problem got anything to do with your clutter?

Client: Oh, yeah, in spades. I can never seem to finish stuff. You know, I start
sorting a pile of papers on my desk and pretty soon I’ve found a photo
and that gets me thinking about when it was from and pretty soon I’m
looking at old photos instead of sorting. It happens all the time.

Clinician: We’ll put “Attention” here under the heading “Information Processing
Deficits.” What about the sorting itself ? When you work to organize
your papers, do you have any problems deciding what to put with what?

Client: Yup, that too. I can’t figure out what filing method to use. I start to
label folders and then I get confused about what to put where. Like the
other day, I was trying to file some papers and I just couldn’t do it. I
picked up a travel brochure from a Vermont resort, but I couldn’t de-
cide whether to write travel or brochure or Vermont. So many times I
get so caught up in questions like that that I give up.

Clinician: So these kinds of decisions are difficult. What about decisions about
other things?

43
 Client: Absolutely. People hate to go to dinner with me because I can’t make
up my mind about what to get.

Clinician: So let’s put “Decision-making problems” in our model and we’ll ex-
plore it as we go along. Also, it sounds like categorizing or organizing
is a problem as well.

Be sure to review all relevant information processing deficits. Together

with the vulnerabilities noted earlier, the information processing deficits
help to define what possessions mean and the role they play in your client’s
life. These meanings are outlined next.

Meaning of Possessions: Thoughts and Beliefs

As noted in chapter , the beliefs about and attachments to possessions

drive compulsive hoarding. These features define the meaning objects
hold. The types of thoughts, beliefs, and attachments we frequently see
in hoarding are shown in table .. Clinicians can use any of the follow-
ing methods to help clients identify these thoughts and beliefs during
sessions.

. Examine the Saving Cognitions Inventory collected during the

assessment (see chapter ) to see which individual items and sub-
scale scores are high.

. Ask clients to review the Reasons for Saving list from the work-
book to select thoughts and beliefs they recognize in their own
reasons for saving. Included are beliefs about emotional comfort,
loss and mistakes, value of possessions, identity, responsibility,
memory, control, and perfectionism.

. Ask clients to notice and report what they are thinking while they
are sorting in the office.

. If it seems helpful, use the Brief Thought Record (figure .) to

record triggering events, identify thoughts and beliefs, and the
emotions and behaviors these provoke. Blank copies are provided
in the corresponding client workbook and can be downloaded
from the TreatmentsThatWork™ website at www.oup.com/us/ttw.

44
 Brief Thought Record
Initials: PK
Trigger situation
Sorting stuff on kitchen table,
found some old financial forms
Found some old magazines
Figure 3.1
Example of a completed Brief Thought Record.
45
Date: 11/16/06
Thought or belief Emotions Actions/behaviors
I don’t know if we need these Anxious I put them in another pile on the
for taxes or something else. I’m kitchen counter
afraid to throw them out.
I should read these. There might Anxious, guilty that I haven’t I put some of them into a bag to
be something important in them. read them. give them away later.
Somebody could use them. I
could give them to my neighbor,
she likes this kind of magazine.
 . Use the downward arrow method (see chapter ) when clients ex-
perience very strong feelings about possessions during sorting in
the office.

. Use probes or behavioral experiments (see chapter ) to test for

beliefs and attachments.

The questioning dialogue to identify clients’ thoughts and beliefs during

sorting in the office might go as follows.

Case Vignette

Clinician: Let’s sort through the group of items we collected from your kitchen
table at our last visit to understand how you think about these things.
Can you pick up the top one and tell me your thoughts as you do so?

Client: Okay, this is a magazine from last summer that I’d like to read.

Clinician: Say a little more about why you’d like to read it.

Client: Well, it’s a news magazine and it might have something in it I should
know about.

Clinician: So, in our model, the thought goes something like, “I might need to
know information from this.” Is that right?

Client: Yup, I don’t want to miss out on information that might be important.

Clinician: We could phrase this as “Might need to know.” Is that a pretty com-
mon reason for you to save things?

Client: Yes, I think so.

Clinician: Let’s try another item that’s different.

Client: Okay, this is a box of note cards I haven’t used yet. So I’d like to keep
them to use.

Clinician: For the cards, then, the thought is something like “These are useful,” yes?

Client: Yes. I don’t want to waste something that’s useful.

Clinician: Okay, we can add the thought “Avoid wasting useful things.” Any
other reason to save this?

46
 Client: Nope. I don’t really like them so it’s not that they are pretty, just useful.
That’s probably my dad talking—he always kept a lot of stuff that
might be useful.

Clinician: So we might add “Keeping useful things.” I’m also going to put up
under “Vulnerability Factors” what you just mentioned about your dad
teaching you not to be wasteful. Okay, so far we have several beliefs or
reasons for saving—needing to know information, concerns about
waste, and thoughts about the usefulness of objects. Also, earlier you
identified thoughts about keeping items just in case, as well as the
thought that the clutter might somehow keep you safe. Let’s try a few
more to see if any other thinking emerges that’s different from these.

Emotional Responses

Most of the thoughts identified in the previous dialogue are followed

by immediate emotional reactions that make discarding difficult. Emo-
tional responses can be identified before, after, or at the same time
clients are reporting their thoughts. For some clients, it may be easier to
identify their emotions before the beliefs about and attachments to pos-
sessions. Typically, these emotions are negative and include feelings of
fear and anxiety, grief and loss, sadness, guilt, and anger. These feelings
occur when clients contemplate or attempt discarding, and occasionally
when they simply handle their possessions. Also, clients often identify
positive feelings like pleasure, comfort, or satisfaction (e.g., in finding
lost objects, in passing items along to someone who might use it, and so
forth). These positive feelings, even if fleeting, help reinforce hoarding
behavior. Your goal is to help clients become accustomed to identifying
their feelings about clutter and saving. Ask about recent sorting experi-
ences that are fresh in their mind to determine the emotions and con-
nect them to the triggering thoughts and subsequent behaviors. The se-
quence is thoughts–emotions–behaviors. For example, fear and anxiety
probably follow from thoughts about losing items, about vulnerability,
and about safety. Grief may stem from clients’ beliefs about their iden-
tity being defined by possessions, and anger could result from perceived
threats to free choice and personal control.

47
Case Vignette

Clinician: So far we have several reasons for saving—needing to know informa-

tion, concerns about waste, ideas about the usefulness of objects, clut-
ter providing safety, and so forth. Let me make sure I understand the
emotions that follow from these types of thoughts. If you think, “I
need to know what’s in this,” but then threw it out anyway, how would
you feel?

Client: Oh, I would feel pretty anxious about not knowing what’s in there. I’d
feel afraid I would miss out on something I should know.

Clinician: When you use the word afraid, do you mean you actually feel fearful?

Client: Yes, it’s very intense fear.

Clinician: So the thought that you might need to know this leads to an emotion
of fear about missing out on something important. In the model, let’s
connect the thought about needing to know to the emotion of fear.
What about the idea of wasting something; what emotion does that
provoke?

Client: I don’t know, uncomfortable.

Clinician: Guilty?

Client: Yeah, a little I think.

Clinician: Okay, guilt. So we can add guilt to our model, right after the belief
about being wasteful. [The clinician continues to ask about other
negative emotions tied to beliefs.] Do you have any positive emotional
reactions when you are going through your stuff?

Client: Sure. Once I get going, I often enjoy going through my stuff. I start
out trying to sort it, but then I find some little treasure I haven’t seen
for a while. I wouldn’t want to miss that by throwing everything away.

Clinician: Okay, I hear a belief that removing clutter will cause you to miss some-
thing important and also that you feel happy when you find some
items. Let’s add that belief and also that emotion of pleasure to the
model. Now, let’s go on to see what actually happens when you’ve had
these thoughts and feelings.

48
Learning Processes

When the meanings and emotional responses are clear, it is time to fig-
ure out how these features result in clutter. As evidenced in table .,
there are four avenues to hoarding symptoms. Positive reinforcement of
saving or acquiring comes from the short-term benefits of acquiring or
saving; the excitement, joy, or other positive emotions make it more likely
that the client will continue to collect and keep things. This is most evi-
dent when clients experience pleasure at finding a treasured item that has
been buried in the pile for a long time. Avoidance behaviors are nega-
tively reinforced by removing the distress associated with discarding. For
instance, putting the newspaper back on the pile rather than recycling it
allows the client to avoid the distress associated with the idea of missing
out on important information or opportunities. Each of these actions
(acquiring, putting something in sight) or inactions (avoiding discard-
ing, not putting an item away) contributes to the clutter. At the same
time, the actions also help clients feel better by reducing their negative
emotions (less anxiety, less guilt). Negative reinforcement is a powerful
mechanism for maintaining clutter. The clinician might proceed as follows.

Case Vignette

Clinician: Let’s add in the behaviors that follow after you have one of these
thoughts about an item you picked up from the clutter. So you picked
up the magazine, thought about needing information from it, felt anx-
ious about getting rid of it, and then what?

Client: Oh, I put it down. [laughs] You know, back on the pile.

Clinician: Okay, so feeling anxious about needing information doesn’t lead you to
pick up the magazine and read it?

Client: Well, maybe eventually, but not right away.

Clinician: Why not?

Client: I don’t have time right now.

Clinician: Got it. So in your mind it goes something like, “This might have im-
portant information, I need the information, I better not get rid of

49
 this.” Then you feel anxious and think, “I don’t have time to read it
now, I better put it back on the pile.” And then you set it down.

Client: Yes, that about captures it.

Clinician: And for the note cards, what do you do with them?

Client: I just set them down on the back of the counter because they don’t be-
long in the kitchen, but I can’t really put them away anywhere.

Clinician: Why not?

Client: Well, I don’t really know where they go yet. And I can’t get into my
study, for example, to put them away, it’s too cluttered right now.

Clinician: So the sequence is that you find the note cards in a pile, you think,
“These are useful; I better not waste them.” You feel a bit guilty if you
don’t keep them, and then you set them down in a different place.
Then how do you feel at the moment when you’ve set them down?

Client: Well, I suppose I feel a little relieved, but it doesn’t last long. Because,
really, I’m just moving stuff around, but not much goes out.

Clinician: That’s what it sounds like, but that brief period of feeling relieved is an
important reinforcer of the whole process. Let’s go over the whole se-
quence for these types of items. You see an object in your home, you
have a thought or belief about it, for example about needing informa-
tion or wasting things, and this triggers an emotional reaction like
anxiety or guilt, to which you respond by keeping the item and mov-
ing it to a different place. This helps you avoid the negative emotions
of fear and guilt that would happen if you got rid of the item, but
from what you’ve told me, it doesn’t actually help you make much
progress to clear the clutter.

Client: Yeah, I think I understand and you’re right, I don’t clear the clutter
very fast, but I wouldn’t want to just throw stuff out that might be
important.

Clinician: I agree. Right now we are learning how the process works for you, and
then we can decide what to do about it. We have figured out a few vul-
nerability factors, and we’ve just been looking at how your thoughts
and beliefs produce certain emotions that lead to your behavior in rela-
tion to clutter. We want to make sure our model captures the problem

50
 well. I wonder if you’d be willing to observe yourself at home while
trying to sort a little pile of your things—maybe the items on the
kitchen table, because that’s a place you wanted to work on first.
There’s a form in your workbook called a Brief Thought Record that
you can use while you are sorting at home to put down your thoughts
at times when you have a strong emotional reaction. So, when you
start feeling quite anxious or unhappy or guilty or angry, and also
when you have strong positive feelings of pleasure or enjoyment, that
would be a time to stop what you are doing and ask yourself what you
were thinking. This gives us a way to see if there are other ideas or be-
liefs besides those we have here that contribute to clutter. What do you
think?

Client: I can do that. You mean not for every thought, but just the ones I react
to strongly.

Clinician: Exactly. You can just fill out three or four Brief Thought Records and
we’ll review them the next time we meet to see if we need to add any-
thing to the model.

Client: Will do.

Figure . is a graphic representation of the model as it has been devel-

oped so far with this client. The model connects the overall categories,
but it is also possible to connect individual components of each category
to saving and clutter.

Special Considerations for Models for Acquiring

Clients’ acquiring behaviors are usually based on elements similar to

those that drive saving and clutter, but models for acquiring usually have
more positive feelings and fewer negative ones. Acquiring problems may
be evident in several types of behaviors, including

■ Collecting free items or accepting items from others

■ Picking up things others have thrown away

■ Compulsive buying in stores, yard sales, flea markets, and the like

51
 Personal/family vulnerability factors: Information processing problems:
Mother threw out toys Attention
Mother too neat Decision-making
Not allowed to make decisions Categorizing/organizing
Grandparents’ clutter was fun
Burglary

Thoughts and beliefs:

“I might need to know this.”
“It’s bad to waste useful things.”
“Keep items just in case.”
“Clutter keeps me safe.”

Emotional responses:
Fear of missing out
Fears about safety
Guilt over being wasteful

Positive reinforcement: Negative reinforcement:

Excitement at finding a lost Escape or avoidance of
treasure unpleasant emotions

Difficulty Discarding
and Clutter

Figure 3.2
Example of a hoarding model.

■ Buying multiple items “just in case” something happens to the

original

■ Kleptomania or stealing

■ Ordering subscriptions, mail order items, home shopping network

products, and so forth

52
 You can ask clients to complete the Acquiring Form in the workbook as
a homework assignment to determine what they accumulated during a
specified period (e.g., two weeks). Figure . is an example of a com-
pleted Acquiring Form.

Then work out the model for acquiring by asking clients to recall a re-
cent experience and report what they were thinking and feeling, and

Acquiring Form

Make a list of the types of items you typically bring into your home and how you acquired
them. Think about items you acquired during the past week and record what items you acquire
during the coming week. Do not include groceries or other perishable goods. Rate how uncom-
fortable you would feel if you didn’t acquire this item when you saw it by using a scale of  to
, where  equals no discomfort and  is the most uncomfortable you ever felt.

Discomfort if not
Item and where you typically find it acquired (0–100)

Shoes for me or the kids, consignment shop 90

Clothes for me—dresses, skirts, blouses, pants

consignment shop 80

on sale at department store 60

Kids clothes

consignment shop 95

on sale at department store 70

Kitchen items like nice knives, utensils 60

Decorative itmes for the house, figurines, pictures mainly at 5 & 10 store 75

Mystery books at my favorite used book store 80

Magazines at corner store, esp, house decorating 70

Figure 3.3
Example of completed Acquiring Form.

53
 their behavior during and after the episode. Also ask clients about their
attempts to resist or control acquiring and what items or contexts pro-
voke the greatest difficulty with resisting urges to acquire.

Functional Analysis of Hoarding Behavior

The model described earlier is a general conceptual model that outlines

the factors contributing to the hoarding problem. You can also generate
more specific models to demonstrate the functional relationships be-
tween specific elements in the general model. This has considerable util-
ity during treatment because it helps clients understand what just hap-
pened, and it can be used to develop treatment strategies. Because this is
especially helpful for acquiring problems, we describe and illustrate this
functional analysis model using acquiring as the target behavior. Start
with information from the general conceptual model and tie it to a re-
cent situation the client recalls readily.

Case Vignette

Clinician: Can you tell me what happened over the weekend?

Client: Well, I went out to run some errands and I drove by that clothing store
I like. Before I knew it, I turned into the parking lot and was in the
store. I bought $ worth of clothes I really don’t need. My husband
was furious when I got home. We’ve been trying to pay off our huge
credit card bills and this won’t help.

Clinician: Do you mean you had not planned to go to this store or to buy clothes?

Client: No, but I had to drive by it to get to the grocery store.

Clinician: So the sight of the store was a sort of trigger for going in and buying?

Client: Yeah, I just can’t seem to pass by that store without stopping.

Clinician: So this has happened before?

Client: Yeah, way too often.

54
 The immediate triggers for buying episodes for most clients are varied.
Often they involve the sight of a “sale” sign in a favorite store window, a
newspaper or TV ad, a picture of a product, or seeing other people buy-
ing something. The list is endless. After the trigger is identified, you can
begin to identify the antecedent conditions:

Clinician: The sight of the store seems to be a powerful cue or trigger for your
shopping. What happened just before you went to the store?

Client: Well, I just had a fight with my husband. It was over money and how
much I spend. He blames me for our money problems and for the
clutter and mess at home. Granted most of the stuff is mine, but no
one in the family helps me with it. He is always trying to tell me what
I should do and buy, and it makes me mad. He doesn’t appreciate what
I do around the house.

Clinician: So you were upset when you left the house, and then you went by the
store and couldn’t resist stopping. Do you ever stop at a store like that
without intending to or do you buy excessively when you aren’t angry
or upset?

Client: Yeah. Sometimes I buy when I am in a good mood, like after the last
session when I thought I was making great progress. I was on my way
home and drove by the same store. Traffic was heavy, and I just veered
off into the store parking lot and bought a bunch of stuff. That’s what
prompted the argument last weekend.

Now a pattern begins to emerge that clarifies when acquiring happens.

Clients frequently acquire when they are in a highly emotional state.
Other background or vulnerability factors are similar to those identified
in the general conceptual model. From here we move on to the thoughts
and beliefs about the buying itself and the immediate consequences:

Clinician: What happened when you went into the store?

Client: I just walked around and looked at the dresses. I was still pretty upset.

Clinician: Do you remember what thoughts you were having at that moment?

Client: Yes, I was thinking about being told not to buy anything, and I
thought to myself, “I deserve to have nice things. Why should some-

55
 one else tell me what to do?” That’s when I decided I was going to buy
something.

Clinician: What happened then?

Client: After a few minutes I wasn’t upset anymore. In fact, I was enjoying
myself. I like clothes; they make me feel good. I just kept piling things
onto the counter, and at that moment I really liked the things I was
buying.

Clinician: So this whole process and the decision to buy led you to feel better?

Client: Yes.

These thoughts and beliefs are outlined in a general way in table .. For
this client, the thoughts had to do with control and validation. Other
common beliefs associated with acquiring include opportunity, unique-
ness, availability, low cost, and so forth. People who hoard often work
hard to control their acquiring, but these types of thoughts remove their
inhibitions about acquiring and allow the impulse to acquire free reign.
When the acquiring occurs, the immediate consequences are usually a
positive mood and even a sense of euphoria. After identifying these im-
mediate positive consequences, continue to the long-term negative ones:

Clinician: You liked what you bought at the time. Did your feelings about them
change later?

Client: Yeah. I was really feeling good as I left the store, but as soon as I turned
out of the parking lot, I started to regret buying all this stuff. I knew
we’d have another argument and I wished I had gone the other way to
the supermarket so I wouldn’t have seen the store.

Clinician: What other thoughts did you have?

Client: Well, later I really got down on myself. I’m such a weak person for
buying all this unnecessary stuff. Our house is crammed full, and here
I am out spending money we don’t have for more stuff I will probably
never wear! I just felt totally worthless.

At this point, summarize what you and the client have learned about the
episode and review all the sequences:

56
Clinician: Let’s see if we can put all this together into a model that helps us
understand how this episode happened. You left the house angry with
your husband and upset. Then you passed your favorite store and
stopped. You thought to yourself, “I deserve to have nice things” and
“No one has the right to tell me what I can and can’t have.” Then you
made the decision to buy something and began feeling better. Pretty
soon you were in a good mood and enjoying yourself. I’m not sure, but
I think this led you to buy even more things. However, later you re-
gretted your purchases and began to feel pretty bad, not only about
buying things, but also about yourself as a person. Does that about
sum it up?

Client: Yeah, that about does it.

Clinician: It sounds like you are most vulnerable for buying episodes when you
are experiencing either strong positive or strong negative emotions.
Have you bought excessively when you weren’t in one of these moods?

Client: Not usually. Normally I stop myself when I think about all our bills
and what else we could use the money for.

Clinician: Okay. Now as you described this episode, it sounds like your shopping
helped you cope with and get rid of your bad mood. Is that right?

Client: Yes.

Clinician: So shopping works in the short run to make you feel better, but soon
you feel worse because you have spent too much money and it will just
make the clutter at home worse. So the short-term benefits of feeling
better are quickly followed by the longer term costs of feeling worse. Is
that right?

Client: Yeah.

Clinician: So if we diagram this episode, we can start with a box at the top that
says “angry and upset” followed by a trigger, which was the sight of the
dress shop. Then we have the thoughts you were telling yourself in the
car and then in store—that you deserve to have nice things and that
no one has the right to tell you what to do. These overwhelm your re-
luctance to buy things. In a sense they give you permission to buy and
to ignore your more rational thinking when you resist the urge to buy.
Does this make sense so far?

57
 Client: Yes, it does.

Clinician: The actual buying of the clothes and the immediate aftermath is plea-
surable, a sort of a high, but soon it is followed by frustration with
your own behavior, conflict with your husband, more clutter at home,
and some pretty bad feelings about yourself. Right?

Client: Right.

Clinician: Do you think the negative moods and conflict this creates increase the
chances that you will be in a bad mood and engage in other buying
episodes?

Client: Probably.

Clinician: So this is a vicious cycle that perpetuates itself to some extent.

Client: Yes, I see that it probably does.

Figure . is a graphic display of this functional analysis model sketched

out during the therapy session. You can point out places in the model
where the behavior is positively reinforced (e.g., immediate enjoyment)
and negatively reinforced (e.g., relief from anger and upset). It is also
important to highlight how this process actually increases the likelihood
of the episode happening again. Equally important is commenting that
engaging in this behavior may prevent the client from finding more
adaptable ways of coping with negative emotions. After this functional
analysis is laid out, you can begin to work on portions of the process,
such as thoughts that lead to the decision to buy or alternative ways of
coping with anger and emotional upset. Sometimes clients handle this
process by trying to avoid the triggering stimuli. Although this might
work to some extent, it is not likely to be very effective in the long run
because cues for acquiring are so plentiful.

After you and the client have a working knowledge of how the saving
and acquiring behaviors are maintained by vulnerability factors, situa-
tional triggers, thoughts, and emotions, the next step is to plan the treat-
ment as described in the next chapter.

58
 Negative feelings:
Angry, upset

Negative thoughts about self: Shopping trigger:

“I am totally worthless.” Driving by the store

Feelings: regret, worry

Disinhibiting thoughts:
“I deserve nice things.”
“No on has the right to tell
me what to do.”
Thoughts:
“My husband will be mad.”
“I spent too much money.”

Feelings: Decision to buy

Pleasure
Enjoyment

Figure 3.4
Functional analysis of a compulsive buying episode.

Homework

Homework assignments that may be useful between sessions for devel-

oping the model include the following:

✎ Ask the client to think about and write down vulnerability factors
(family history, experiences, strongly held beliefs) that contribute to
saving and/or acquiring between sessions.

✎ Instruct the client to review the Reasons for Saving list from the work-
book and to select thoughts and beliefs that contribute to acquiring
and saving.

59
 ✎ Have the client complete the Acquiring Form between sessions to ob-
tain a full list of the types of items accumulated in recent weeks and
months.

✎ Instruct the client to work on the model for hoarding or acquiring (fig.
.) at home to identify components that contribute.

✎ Ask the client to monitor her thoughts and feelings using the Brief
Thought Record in the workbook to record triggering events, thoughts
or beliefs, emotions, and behaviors while sorting at home or when
acquiring.

✎ Ask the client to try out behavioral experiments to discard an item or

not to acquire something to identify the beliefs that prompt saving and
acquiring.

✎ Instruct the client to work on a functional analysis (fig. .) at home

to capture the sequence of triggering events, thoughts, feelings, and
actions that contribute to difficulty discarding or acquiring.

60
Chapter 4 Treatment Planning

(Corresponds to chapter 4 of the workbook)

Materials Needed

■ Photos from home visit

■ Client’s model of hoarding from chapter 

■ Treatment Goals List

■ Clutter Visualization Form

■ Unclutter Visualization Form

■ Acquiring Visualization Form

■ Practice Form

■ Personal Goals Form

Outline

■ Work with the client to establish treatment goals and set rules for
treatment.

■ Complete visualization exercises.

■ Use problem-solving methods to troubleshoot barriers to progress.

This chapter outlines the steps for planning treatment. Now that much
of the assessment is completed and you and your client have worked out
a model to understand the client’s hoarding problem, it is time to estab-
lish your client’s treatment goals and to describe the rules you’ll follow dur-
ing the therapy. We suggest several visualization exercises to help your

61
 client clarify his or her thoughts and feelings about organizing, reducing
clutter, and limiting acquiring. After this, clinicians should connect the
therapy methods to the client’s hoarding model so it is clear how you’ll
address the problems and in approximately what order. Sorting will form
the basis for most of the components of treatment. These include () skills
training, () cognitive therapy methods, and () behavioral methods.
Homework is assigned between all sessions and usually pertains to the
work done during sessions. Because insight and motivation can wax and
wane for most people who hoard, this planning session is intended to
decrease clients’ fears about treatment and increase motivation and con-
fidence in the therapy.

If a client plans to work with a coach who will need training in doing
the therapy, this might be a good time to have the coach present for part
or all of the session, depending on the client’s wishes and the extent of
the coach’s involvement in the intervention process. During this session,
the coach can begin to understand possible motivational problems and
how the work should proceed. Clinicians can model appropriate behav-
ior for coaches. The role of coaches is to help clients remain focused on
their task, provide emotional support, facilitate decision making by ask-
ing open-ended questions and expressing curiosity, help with hauling to
remove unwanted items, and accompany clients on nonacquiring trips
as needed. Rules for coaches are similar to those for clinicians: Avoid ar-
guments, don’t take over decision making, don’t touch or move items
without permission, don’t tell the person how they should feel, and don’t
work beyond the coach’s own tolerance level.

Treatment Goals

The following are common goals arranged in order of most clients’

interests.

. Increase understanding of compulsive hoarding. You and your client

have already begun to understand compulsive hoarding behaviors
and the thoughts and feelings about possessions that influence
these behaviors. Being able to identify and understand hoarding
symptoms helps develop confidence in tolerating the discomfort
that inevitably occurs while curbing acquiring and saving, and

62
 sorting clutter. Treatment should also promote optimism about
improvement and feelings of empowerment, while decreasing
stigma, shame, and isolation. You can also suggest that at the end
of therapy, better understanding will enhance the client’s awareness
of early warning signs for setbacks and the ability to manage them.

. Create living space. Most clients and their family members feel
cramped by the clutter that prevents them from using their living
spaces the way they want. Creating living space is a goal with al-
most universal appeal for clients. To achieve this goal, early efforts
in treatment should be devoted to clearing the most desired living
spaces.

. Increase appropriate use of space. After living spaces have been

cleared, they should be used for their intended purpose, consistent
with clients’ living style and needs. For example, clients will want
to use kitchen counters for preparing meals, kitchen tables for eat-
ing meals, living rooms for relaxing personal and family activities
and entertaining friends, playrooms for children’s play activities,
bedrooms for restful sleeping, and so forth. Focus immediately on
the potential value of these spaces, after they are uncluttered, to
emphasize the importance of keeping them clean after they are
cleared.

. Organize possessions to make them more accessible. Many people

have difficulty following through to develop an overall organiza-
tional plan for storing wanted items. Especially for clients who
have difficulty with spatial organization, acquiring these skills
often provides an added sense of competency and self-esteem that
further encourages compliance with treatment. The clinician and
client work together to develop a filing system and appropriate
locations for storing saved items.

. Improve decision-making skills. Clients who are slow to make deci-

sions about sorting their things usually benefit from learning to
limit the options or categories for items commonly found among
the clutter. For example, books might be sorted into books to sell,
books to store, and books to display. (Of course, once sorted,
books must be moved immediately to their planned location.) The
clinician provides initial assistance to establish a small number of

63
 categories to render decision making easier. This procedure can be
used for many types of possessions.

. Reduce compulsive buying or acquiring and replace these behaviors

with other pleasurable activities. For clients who have this problem,
treatment helps them master strong urges to acquire new things
they cannot afford or do not have the space or time to use effec-
tively. Because acquiring is usually associated with strong positive
emotions like comfort and joy, developing alternative pleasurable
activities is also an important goal of the intervention.

. Evaluate beliefs about possessions. Treatment helps people with

hoarding recognize their beliefs about saving and acquiring, and
uses cognitive techniques to change beliefs they decide are not
reasonable. At the same time, clients learn skills to manage their
emotional attachment to possessions and reduce associated avoid-
ance behaviors.

. Reduce clutter. Parting with unneeded possessions is what many

clients fear most about treatment, but it is often not the central
problem. As the goals of creating living space by organizing and
reducing acquiring are accomplished, the volume of possessions
will gradually diminish, but additional removal of clutter is neces-
sary through recycling, giving away, selling, or discarding items.
For many, removing items becomes much less anxiety provoking
after establishing personal rules for keeping and storing desired
items.

. Learn problem-solving skills. Problems arise as clients pursue the

previously listed goals. Problem-solving skills are applicable to a
variety of hoarding problems, such as family squabbles about
hoarding, how to make space for sorting, managing money to
avoid overspending, and so forth.

. Prevent future hoarding. An important goal of the intervention is

to enable clients to acquire skills to prevent the accumulation of
clutter in the future. These relapse prevention skills include notic-
ing early warning signs (thoughts, feelings, and behaviors) that
signal noticeable increases in hoarding symptoms, and indicate the
need to apply previously learned skills and/or consult with the cli-

64
 nician. In addition, because work on hoarding will occupy less
time, alternative pleasurable or productive activities should replace
time spent on hoarding.

There is also a list of treatment goals in the workbook that your client
can review and follow along with. After reviewing these goals, clinicians
should ask clients to complete the Personal Goals section of the form to
help them identify their own goals for the coming weeks and months.
This can be completed during the office session or given as a homework
assignment.

Treatment Rules

The following rules contained in the Treatment Rules list from the work-
book are intended to ensure that treatment progresses in a manner and
pace manageable for clients. These rules are specifically intended to in-
crease clients’ self-efficacy about managing their own hoarding symptoms.

. Clinicians may not touch or remove any item without explicit permis-
sion. Most people with severe hoarding problems are extremely
concerned about others discarding possessions without consulting
them. This may have been exacerbated by the misguided efforts of
friends and family to help by doing exactly that. Thus, an impor-
tant aim of treatment is for clients to develop trust that their rela-
tionship with the clinician is truly collaborative. The rule that cli-
nicians never touch possessions without permission is not an easy
one to follow, because the impulse to pick things up is powerful in
clinicians who want to help. However, if acceptable to both par-
ties, clinicians can remove items at clients’ request, especially when
these are designated for trash or recycling. Later during treatment,
your client may even empower you to make decisions about sort-
ing items, after the rules for doing so are very clear to both of you.
This rule may need modification if exposure treatment is needed
to overcome clients’ obsessive contamination or checking con-
cerns. In this case, negotiate touching specifically for exposure
purposes with the client. Clients’ initial fears often ease consider-
ably as the therapy progresses.

65
 . Clients make all decisions about possessions. Treatment is designed to
teach clients to make appropriate decisions about saving and or-
ganizing their possessions. To accomplish this, clients must learn
organizing and decision making. You can help your client work
through the decision-making process, and you can occasionally
offer advice when this seems truly helpful, but you cannot make
decisions for clients without interfering with an important goal of
therapy. It is likely that past attempts to help by friends and family
members have violated this rule and have caused clients to be
overly sensitive to other people’s involvement.

. Treatment proceeds systematically. If not already completed during

the assessment process, now is the time to determine the plan for
where, when, and how to sort cluttered areas. Most clients work
room by room, because this makes progress highly visible and im-
proves motivation. However, some clients may prefer to blend
this plan with sorting by category, selecting particular piles from
different rooms for sorting because these contain similar types of
objects that can readily be sorted, discarded, and stored appropri-
ately. Generally, practice in organizing, sorting, removing posses-
sions, and reducing acquiring progresses from easier to harder
situations. Choose a method according to your client’s preference
and tolerance, the likelihood of immediately observable progress,
and rapid learning of organizational skills. If clients insist on
methods clinicians consider problematic, try an experiment to de-
termine whether their preferred method works and, if not, con-
sider alternatives.

. Establish an organizing plan before sorting possessions. Clinicians

must assist clients in developing a clearly defined organizational
plan for deciding where to store kept items. Many clients tend to
generate too many categories, becoming confused by the process.
Establishing a limited number of categories at the outset of sort-
ing will reduce this problem. For this reason we suggest sorting
objects before paper, which requires many categories. Chapter 
focuses on this topic.

66
 . Clients must think aloud while sorting possessions. This rule helps cli-
nicians and clients understand the beliefs and emotions that deter-
mine behavior around acquiring, organizing, saving, and remov-
ing possessions. Speaking aloud helps clients become consciously
aware of their rationale for saving and will be useful in learning
how to alter problematic beliefs.

. Only handle it once (OHIO)—or at most twice. The goal here is to

prevent the churning of possessions that are merely recycled from
one disorganized pile to another. Clients learn to make decisions
quickly and firmly by handling objects minimally, although “once”
may not be possible as items often must go to interim locations
before space is cleared for final destinations. Allow some flexibility
when clients are unable to make a final decision but are making
clear progress.

. Treatment proceeds in a flexible manner. Flexibility and creativity

from both clinician and client are needed to solve the logistical
problems associated with organizing a house too full of things.
When clients become stalled because organizing one area depends
on having another space ready for storage, problem solving from
the clinician may be needed.

Visualization and Practice Exercises

The exercises described in the following pages are intended to help

understand the client’s motivation for treatment. These tasks can be used
any time during the assessment and model development phase, and they
may be especially useful in developing goals and preparing for treatment.
We recommend doing the clutter visualization task first, followed by
unclutter visualization and imagining the ideal home. Examples of com-
pleted visualization forms, as well as blank copies are included in the fol-
lowing pages. Additional blank copies can also be found in the corre-
sponding client workbook. You may photocopy the forms from the book
or download multiple copies from the TreatmentsThatWork™ website
at www.oup.com/us/ttw.

67
Clutter Visualization

For this task clients visualize the current cluttered state of a target room
in their homes to determine how much discomfort they experience as a
result of the clutter and the nature of their thoughts. Use the Clutter
Visualization Form on page  for this purpose. Clients should select an
important room such as the kitchen, dining room, living room, or bed-
room (but for some this may be a storage area) and record the room on
the form. Then ask clients to close their eyes and imagine standing in the
middle of the room, slowly turning around to see everything in it. Ask
for a description of this view and, after about a minute, ask about how
much discomfort they experienced in visualizing this room, on a scale
from  (no discomfort) to  (the most discomfort you can imagine).
This scale from  to  will prove useful later in treatment for self-
ratings of emotions and strength of beliefs. If clients have difficulty
visualizing, consider using the photographs of this room taken during
the home visit to cue their reactions.

Next, ask clients how they felt (emotion) and what they thought (be-
liefs) during their visualizing. Feelings might be negative (anxious, fearful,
embarrassed, ashamed, guilty, disgusted, confused, overwhelmed, pres-
sured, disoriented, hopeless, depressed, frustrated, discouraged) and also
positive (happy, pleased, relieved, comforted, hopeful, proud). Record
these on the form. Next ask about thoughts, helping clients formulate these
in a short sentence and distinguish them from feelings. Record these
thoughts on the form. Examples are as follows: “This is ugly.” “I’ll never
find anything in this mess.” “There must be buried treasures here.” “It’ll
only take me a little while to clean this up.” If clients have trouble iden-
tifying their thoughts, suggest ones that seem likely for this client, as well
as others that are quite unlikely (“Were you thinking that this is a really
pleasant room?”). These contrary ideas offer a springboard to clarify
thinking. As in the model development phase, recording these feelings
and thoughts while visualizing provides a model for self-observation and
self-reporting needed for upcoming homework.

Finally, summarize information from the visualization exercise about the

link between clients’ thoughts and feelings, and the important motiva-
tors for change. For example,

68
Clutter Visualization Form

Room:

A. Visualize this room with all of its present clutter. Imagine standing in the middle of the
room slowly turning to see all of the clutter.

B. How uncomfortable did you feel while imagining this room with all the clutter? Use a scale
from  to , where  ⫽ no discomfort and  ⫽ the most discomfort you have ever felt.

Initial Discomfort Rating:

C. What feelings were you having while visualizing this room?

.

.

.

D. What thoughts (beliefs, attitudes) were you having while visualizing this room?

.

.

.

69
 When you imagined the living room with its clutter, you thought that
other people who saw it would think you were inadequate and you
wondered why you can’t clean it up. Those thoughts left you feeling
embarrassed and ashamed. You also felt overwhelmed at the idea of
cleaning up. It seems like learning to clear the clutter would probably
enable you to feel much better about yourself, but also that you are
likely to feel overwhelmed and perhaps wanting to avoid dealing with
the clutter. Does that sound right to you?

This might lead to further discussion of aspects of the client’s model for
hoarding behavior and of how to resolve potential barriers to working
on clutter during treatment as well.

If clients report little or no discomfort and have strong positive feelings

during the visualizing, explore their interest in treatment using motiva-
tional interviewing techniques from the next chapter (e.g., “Having
these things around pleases you. Why would you want to change this?”
or “I hear that you can see the benefits of keeping your home like this.
Are there any costs?”). Note that some clients do prefer cluttered living
spaces and these preferences must be kept in mind while helping clients
generate realistic goals for treatment. Figure . shows an example of a
completed Clutter Visualization Form.

Unclutter Visualization

This task is designed to help clients examine their feelings about posses-
sions and the likely impact of removing clutter during treatment. Ask
clients to use the Unclutter Visualization Form on page  and ask them
to visualize the same room used for the previous task, but this time with-
out any clutter. To assuage fears about what might have happened to their
things (e.g., “Where did it all go?”), ask them to imagine that everything
they wanted to keep is still there, but organized and put in its place. To
make this image vivid, ask clients to describe the appearance of the room
in some detail, including uncluttered furniture tops and a floor clear of
any clutter. It may be difficult for clients to imagine at first, but give them
some time to develop the image and ask them to narrate as they do. If
necessary, the photographs of the cluttered room could be used to help

70
Clutter Visualization Form

Room: Kitchen

A. Visualize this room with all of its present clutter. Imagine standing in the middle of the
room slowly turning to see all of the clutter.

B. How uncomfortable did you feel while imagining this room with all the clutter? Use a scale
from  to , where  ⫽ no discomfort and  ⫽ the most discomfort you have ever felt.

Initial Discomfort Rating: 90

C. What feelings were you having while visualizing this room?

. Overwhelmed - Oh my God!

. Anxious

. Depressed

D. What thoughts (beliefs, attitudes) were you having while visualizing this room?

. How am I going to clean this mess up? I don’t know if I can deal with all of this stuff.

I have no place to put it.

. I don’t know what to do. My husband is so upset with me. He’s going to leave me if I

can’t do this. My kids just make it worse. If I clean it up, they’ll just mess it up. How

can I stop that?

. I’ll never get it all done. I shouldn’t have let this happen.

Figure 4.1
Example of a completed Clutter Visualization Form.

clients imagine what is underneath the clutter. As they visualize the un-
cluttered space, ask them to consider what they can do with this room,
including activities they could engage in, ways to decorate the room, and
so forth. Allow approximately one to two minutes for visualization
(more if this seems helpful), and then ask for a rating of discomfort
(–).

71
Unclutter Visualization Form

Room:

A. Visualize this room with the clutter gone. Imagine cleared surfaces and floors, tabletops
without piles, and uncluttered floors with only rugs and furniture. Don’t think about where
the things have gone; just imagine the room without clutter.

B. How uncomfortable did you feel while imagining this room without all the clutter? Use a scale
from  to , where  ⫽ no discomfort and  ⫽ the most discomfort you have ever felt.

Initial Discomfort Rating:

C. What thoughts and feelings you were having while visualizing this room?

.

.

.

D. Imagine what you can do in this room now that it is not cluttered. Picture how pleasant this
room will feel when you have arranged it the way you want it. Describe your thoughts and
feelings.

.

.

.

E. How uncomfortable did you feel while imagining the room this way? ( ⫽ no discomfort
and  ⫽ the most discomfort you have ever felt)

Final Discomfort Rating:

72
Unclutter Visualization Form

Room: Kitchen

A. Visualize this room with the clutter gone. Imagine cleared surfaces and floors, tabletops
without piles, and uncluttered floors with only rugs and furniture. Don’t think about where
the things have gone; just imagine the room without clutter.

B. How uncomfortable did you feel while imagining this room without all the clutter? Use a scale
from  to , where  ⫽ no discomfort and  ⫽ the most discomfort you have ever felt.

Initial Discomfort Rating: 50

C. What thoughts and feelings you were having while visualizing this room?

. It looks empty—hard not to worry about where things went.

. My kids will probably just mess it up again.

. My husband will like it.

D. Imagine what you can do in this room now that it is not cluttered. Picture how pleasant this
room will feel when you have arranged it the way you want it. Describe your thoughts and
feelings.

. I have always hated the color in here. We could paint it yellow like I always wanted.

Now it needs curtains. I bought some a long time ago and they are probably still around

somewhere.

. The whole family could eat breakfast at the table in the morning without a huge

mound of clutter in the way!

. I could cook again and use my cookbooks.

E. How uncomfortable did you feel while imagining the room this way? ( ⫽ no discomfort
and  ⫽ the most discomfort you have ever felt)

Final Discomfort Rating: 25 I sort of got excited!

Figure 4.2
Example of a completed Unclutter Visualization Form.

73
 Ask clients to describe their emotions, both negative and positive, and
identify thoughts during the experience. Record these on the form. A
Socratic questioning style (“That’s interesting, I wonder . . .”) and re-
flective listening strategies (“It sounds like . . .”) are useful to clarify pos-
sible underlying beliefs. Help clients connect their beliefs (e.g., about
being wasteful) to their emotions (e.g., guilt, satisfaction). It is impor-
tant not to challenge beliefs at this stage, although you can ask about the
connection of thoughts and feelings to ones previously reported during
assessment and model building. Be careful that you ask genuine curios-
ity questions so the client does not become defensive (e.g., “Previously
you mentioned . . . . Is that what you mean here?”). To enhance moti-
vation, ask, “Are there ways your life would improve if this room were
uncluttered?” If needed, prompt with open questions such as, “How
would it help you if your kitchen counter were cleared of stuff ?” Figure
. shows an example of a completed Unclutter Visualization Form.

Ideal Home Visualization

Clients can also clarify their goals for therapy by imagining their ideal
(but not perfect) home, room by room. This should be the home they
currently live in, with rooms decorated in the manner they would find
most satisfying. This is especially useful if the unclutter visualization ex-
ercise was somewhat disturbing. This task can be done in the office or
during the home visit. In visualizing the ideal home, ask clients to pro-
vide details such as where furniture would go, what items would be
visible, where things are stored for easy access, and so forth. Some clients
might benefit from a homework assignment to draw a floor plan for each
room that illustrates the placement of furniture and other items. Many
clients have not considered how they would like to decorate their rooms
because the clutter has prevented this option. Later in treatment when
significant clutter has been cleared, the ideal home exercise can be ex-
panded to actual decorating of spaces.

74
Visualizing Acquiring

Ask clients to imagine a typical situation in which acquiring contributes

to their hoarding problem. Select one they will encounter soon and ex-
pect to have trouble resisting, such as a yard sale, a store bargain, an item
that looks pretty, or a free offer. In the image, ask the client just to look
at the item, but not pick it up. Allow about a minute of silence and then
ask “How strong is your urge to get this?” (have them rate the urge using
a scale from  [no urge] to  [irresistible]) and “What thoughts do you
have as you look at the item?” Record these on the Acquiring Visualiza-
tion Form on page , along with a brief description of the scene they
imagined. Now ask clients to imagine leaving without acquiring the item
they will be unable to get again (lost opportunity). Allow about a minute
of silence for visualizing and again ask for a rating of distress to this new
image and what thoughts they have about leaving the scene. You can use
examples to prompt the thoughts, such as, “Were you thinking that
you’d miss a really good buy?” Other examples might be, “I’ll miss out on
important opportunities” or “I won’t feel complete if I don’t get this.”
Comment on any aspects that seem especially important motivators for
acquiring or that seem to be important links to components of hoard-
ing in the client’s model. If clients have trouble generating a distressing
image, you can add components that might prompt a more realistic
image, like seeing another shopper considering the item they’ve iden-
tified. Figure . show an example of a completed Acquiring Visualiza-
tion Form.

Photo Exercise

Many people who hoard have grown so accustomed to living in a clut-

tered home that they no longer notice the clutter. This may be a form of
avoidance or possibly just habituation. Some clients react with shock to
the photographs of their home, suggesting that the photographs allow
them to see the clutter in a different light that being in the home does
not. For some clients, viewing the photos of their home helps them rec-
ognize the problem and stay motivated to work on the clutter. After the
first home visit, ask clients to review pictures of each room and indicate
their reactions on seeing the photos. Explore these reactions as appro-

75
Acquiring Visualization Form

Visualize a typical situation in which you have a strong urge to acquire something. In your
image, don’t actually pick up the item, just look at it. Please describe the location and item you
imagined.

Rate how strong was your urge to acquire the item ( ⫽ no urge to acquire,  ⫽ irresistible urge).

Acquiring urge

What thoughts did you have while you imagined this scene?

.

.

.

Visualize this scene again, but this time, imagine leaving without the item. How much discom-
fort did you experience while imagining ( to ).

Discomfort Rating

Please list any thoughts you think would help you to not acquire an object.

.

.

.

Now rate how uncomfortable you feel about leaving without the item(s) from  to .

Discomfort Rating

76
Acquiring Visualization Form

Visualize a typical situation in which you have a strong urge to acquire something. In your
image, don’t actually pick up the item, just look at it. Please describe the location and item you
imagined.

Inside my favorite consignment shop. Seeing a nice pair of high-heeled shoes that would fit me.

Rate how strong was your urge to acquire the item ( ⫽ no urge to acquire,  ⫽ irresistible urge).

Acquiring urge 100

What thoughts did you have while you imagined this scene?

. These are really pretty and they fit and they are a great bargain. I need to get these.

. I shouldn’t be spending money on me, but I should get these now or they’ll be gone the

next time I come in.

. I could wear these to church with my black and white suit.

Visualize this scene again, but this time, imagine leaving without the item. How much discom-
fort did you experience while imagining ( to ).

Discomfort Rating 90

Please list any thoughts you think would help you to not acquire an object.

. I don’t have any money right now.

. I already have a lot of shoes and I have ones that are this color.

. I should leave these for someone else who needs them more than I do.

Now rate how uncomfortable you feel about leaving without the item(s) from  to .

Discomfort Rating 70

Figure 4.3
Example of a completed Acquiring Visualization Form.

77
 priate to enhance recognition of the severity of the problem and to en-
hance motivation for change.

Experiments

At the beginning of treatment, clients often want to get started with

treatment before the assessment has been completed. It is important to
have specific tasks for them to do that get them started and help them
understand the difficulties they will face as well. Experiments help clients
determine how much discomfort they can tolerate. Assignments should
be designed collaboratively with the client to provide a valid test of their
beliefs and assessment of their need for help with the problem. Be sure
to frame this as an experiment, with no expectations regarding the
client’s ability to let go of items (or resist the impulse to acquire). The
most important feature is the information provided, not the client’s ac-
tual behavior.

Clients who believe they can sort and get rid of unwanted items but just
haven’t had time to do so can see whether this is true. Ask them to get
rid of (discard, recycle) something that provokes moderate discomfort
and record how they feel for the next few hours and days using the Prac-
tice Form in the workbook. First, ask clients how distressed they feel
(, totally relaxed and comfortable; , most uncomfortable they have
ever felt) at the outset and then again after they get rid of the selected
item (or don’t acquire it, if client is doing an experiment to stop acquir-
ing). Continue to get ratings every  minutes or so as your conversation
during the session moves on to other topics. If discomfort declines, call
this to the client’s attention and, at the end (either during the current
session or the next), ask what he or she can conclude about the experi-
ence. If discomfort declines slowly or not at all, extend the experiment
into a second or third day to help clients draw conclusions about habit-
uation of their discomfort. Figure . shows an example of a completed
Practice Form.

This brief exposure will provide some indication of how clients are likely
to react to direct exposures later during sorting (see chapter ). Some
will habituate quickly to the loss of the item, whereas others may require

78
Practice Form

A. What was the item (to remove or not to acquire)? get rid of 2 old news magazines

Initial discomfort ( ⫽ no discomfort to  ⫽ maximal discomfort) 50

B. What did you do (not acquire, trash, recycle, give away, other)

put both magazines in the recycle bin

Discomfort rating ( to ) after  min 45

after  min 30

after  min 20

after  min 5

after  min 0

after  hour 0

the next day 0

C. Conclusion regarding experiment: That wasn’t so bad. At first I was afraid I might need

something from the magazines, but after a while, I decided the news was old anyway

and it probably wouldn’t make a difference to me now. Then I felt o.k. about getting rid

of something.

Figure 4.4
Example of a completed Practice Form.

more time and more direct cognitive interventions to reduce discomfort.

These probes also provide a context for later behavioral experiments that
test clients’ specific hypotheses. Even if clients are unable to get rid of
anything, the experience helps the clinician assess interventions that may
be needed. After the practice during the session, ask clients to do a simi-
lar behavior experiment on their own at home using the Practice Form.

79
Connecting Methods to the Model

After engaging in the visualization exercises that seem useful, it is im-

portant to work on linking treatment strategies to the client’s model of
hoarding behavior. Throughout treatment, sorting clutter in the office
and at home serves as the basis for most treatment methods. These
methods include () learning skills for attention focusing, organizing,
decision making, and problem solving; () cognitive therapy to examine
and correct faulty thinking and beliefs; and () exposure to induce ha-
bituation of emotions and reduce avoidance behavior. Clinicians usually
begin with skills training for organizing and applying these strategies
during the sorting process. After this, clinicians generally apply cogni-
tive therapy methods, often in the context of exposure strategies. Other
skills training methods are applied depending on the client’s need and
progress in treatment. Figure . illustrates the methods used to address
the vulnerabilities, information processing problems, thoughts and be-
liefs, emotions, and behaviors for the client described in chapter . All
these methods rely on homework between sessions and presume that cli-
nicians will spend some time in clients’ homes or at acquiring sites to fa-
cilitate exposures until clients can undertake these tasks on their own as
homework assignments. Dialogue illustrating how to connect clients’
problems to therapy methods follows.

Case Vignette

Clinician: Let’s talk about our treatment plan for you and what this will involve.

Client: I’ve been wondering how we were going to fix all this stuff. It seems
like I’ve got a lot of problems, sort of overwhelming.

Clinician: I realize it may seem that way to you, but actually, your situation is
very typical of most people we see with hoarding problems, and we
have several treatment methods that work very well for these problems.
Let’s look at your model so I can show you what we will probably do
for each of the things that contribute to hoarding.

Client: Okay. I’m glad to hear there’s a plan at least.

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 Vulnerability factors: Information processing problems:
Review early beliefs about Skills training for problem
mother and burglary reactions solving, organizing, attention
focusing, and decision-making
Cognitive therapy and activity
scheduling to address depressed
mood

Thoughts and beliefs:

Cognitive therapy to examine and
challenge beliefs that support
hoarding and acquiring

Emotional responses:
Exposure to sorting and
removing clutter
Exposure to acquiring cues
without acquiring

Positive reinforcement: Negative reinforcement:

Review costs of acquiring Exposure inhibits this process
and clutter
Find other sources of pleasure

Increase organizing and

discarding

Reduce clutter and acquiring

Figure 4.5
Hoarding model with treatment strategies.

Clinician: Let’s start with the information processing problems we’ve talked
about—focusing attention, making decisions, and organizing. These
are probably interconnected, and I usually find it easiest to work on
skills for organizing first and then on methods to keep you focused on
the task at hand when you are sorting your things. So we’ll develop a
pretty comprehensive organizing plan and get fairly detailed about
where things should go and what goes with what.

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 Client: Yeah, I sure do need to do that, but how can we do it with no space to
put stuff ?

Clinician: I agree, that’s a challenge—a problem, in fact—and for this we’ll first
do some straightforward problem solving together to come up with
ideas for how to get things to where they go, once we know where they
belong. I’ll teach you some problem-solving skills, because we’ll proba-
bly need these periodically during treatment. [Reinforcing client for
participating actively in posing this challenge,] You’re absolutely right.
That will be a first priority to figure that out before we can do much
sorting of clutter.

Client: So then, what next?

Clinician: Then we begin to sort things to fit your organizing plan and as we do

this, we might want to modify the plan a bit and also work on your
problems staying on task. We can see what seems to get in the way of
keeping at the sorting process. I have some ideas for what you might
try and I’ll suggest those when we get to that point.

Client: How long will that be?

Clinician: Probably within the next couple of sessions, depending on how long it
takes us to figure out the organizing plan.

Client: Okay; that seems reasonable.

Clinician: Once that’s in place, you’ll be doing a lot of sorting, and in fact that is
the main activity of treatment. When you are sorting in the office and
at home, I’ll work closely with you to examine what you are thinking
and decide whether your thinking makes sense to you. So if we look at
the vulnerabilities you listed on your model, we already know these are
linked to the beliefs that maintain clutter and acquiring. You and I will
work on these, using cognitive therapy.

Client: What’s that?

Clinician: Cognitive therapy is a method we’ve already started to use by having

you identify your thoughts that affect your feelings when you are try-
ing to sort and when you acquire something. Our next steps will be for
me to ask you questions to help you decide when your beliefs make
sense to you and when they don’t. We’ll look for alternative beliefs and

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 see if these make more sense to you under some circumstances. For ex-
ample, we’ll talk about your ideas about needing to know and about
waste when these come up as you are sorting. We can also use cogni-
tive therapy to help with your depression that sometimes gets in the
way of sorting.

Client: What about my emotions? It makes me anxious to sort stuff, and

guilty too.

Clinician: Right. When you start to think differently about things, you will also
start to feel differently about them as well. Remember that most of
your feelings follow directly after you have a thought about your pos-
sessions or about buying something. We can help reduce your fears by
testing them out in experiments, a little like the one we did today to
see how you felt after you got rid of something. You started out feeling
uncomfortable and half an hour later, you were less anxious. That’s
what usually happens when people practice something difficult over
and over again. [Clinicians should avoid discussing exposure therapy at
this stage because it will make little sense to clients who don’t yet see
why they might need exposure to discarding.]

Client: I’m not sure I’m ready for a lot of that right now.

Clinician: I understand, and that’s why we start with organizing skills and cogni-
tive therapy, and then do more and more sorting and removing clutter
as we go. It takes a while to build up to this, but you’ll find it gets eas-
ier and easier and, in fact, you’ll sort more quickly as your decision
making gets quicker, because you are less worried about what you are
doing.

Client: Okay, I think I get it. We start with organizing and work on my
thoughts and other things as we go along.

Clinician: Exactly. It’s hard to say exactly how long this will take, but you do have
quite a bit of clutter, so my guess is that we’ll need about six months
and maybe more.

Client: Well, it’s not like I haven’t had the problem for years now. It’s at least
 years, so a few months is no big deal I suppose.

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Troubleshooting Barriers to Progress

Even the most highly motivated person may experience barriers to making
progress. A number of factors can make dealing with hoarding especially
difficult. Some of these barriers are personal, such as depression, atten-
tion focusing problems, other OCD symptoms, health problems, and
feelings of being overwhelmed. Others are more external, such as lack of
social support, external pressure to fix the problem, and lack of time to
sort because of a very busy lifestyle. Explore these problems with clients
using problem-solving methods taught in chapter . In our experience,
solutions are often possible.

Depression

As we have noted, up to one third of people with serious hoarding prob-

lems also experience major depression. Sometimes depression can be quite
severe, involving poor appetite, sleeping problems, and low motivation
to do almost anything. This is especially likely for someone who has
suffered recent losses. If clients exhibit depression (e.g., poor appetite,
sleeping problems, low energy), and especially if they report significant
suicidal ideation (this is rare in our clinical experience so far), clinicians
may wish to request an additional psychiatric evaluation.

In most cases, moderate depression will resolve as the clutter and hoard-
ing behaviors improve. Clients may also benefit from antidepressant
medications or from cognitive behavioral therapy for depression. You
can advise clients that one way of coping with depression is to increase
activity such as exercise and social activities. Getting started with this is
difficult, but is often very effective in improving mood, although this
may take some time. Note that the activities required during this treat-
ment program may also have a beneficial effect on mood, but initially
clients may need to force themselves to do things until their mood im-
proves as they make progress. Soft-pedal praise for tasks accomplished
early in treatment, because depression may interfere with clients’ ability
to accept overly positive comments. When this is not a problem, strong
encouragement for activity scheduling may helpful.

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OCD Symptoms

Obsessive and compulsive symptoms accompany hoarding problems for

some clients. Most common are fears of making mistakes in discarding,
and excessive checking of papers and objects intended for discarding.
Some of our clients had contamination fears (e.g., dirt, germs, and chemi-
cals) and washed and/or cleaned after handling items they considered.
Symmetry concerns and ordering behaviors to arrange items “just so” can
interfere with organizing activities. If clients do exhibit OCD symptoms,
plan to add specific interventions focused on exposure to feared situa-
tions or items; blocking of cleaning, checking, and ordering/arranging
rituals; and altering beliefs about the rationale for these fears. These
methods can be used before hoarding treatment for those with severe
OCD symptoms, or during hoarding treatment for those with less inter-
fering symptoms. For details regarding how to implement CBT for
OCD symptoms, see Kozak and Foa’s () guide, Mastery of Obsessive–
Compulsive Disorder.

Distractibility

Another problem associated with hoarding is distractibility or difficulty

staying focused on any task, not just hoarding, and time management.
Some clients recognize this in themselves and may have received a diag-
nosis of ADD with or without hyperactivity. Such problems with attention
might be partly responsible for their hoarding problem. Review infor-
mation collected during the assessment and refer to strategies suggested
in Chapter  to work on this during treatment. You may also refer to
Mastering of Your Adult ADHD (Safren, Perlman, Sprich, & Otto, ).

Kleptomania

Although rare, a few of our clients have disclosed that they sometimes
stole items from stores. One client felt slighted when store clerks did not
connect with her socially, because they were her only source of social
contact on most days. Her resulting anger led her to steal small items

85
 from the store. Recognizing the cause of her stealing helped her reevalu-
ate her interpretation of the clerk’s behavior and relieve her need to steal.
Of course, stealing is dangerous behavior, but criticizing clients who
know this behavior is illegal, and urging them to stop is unlikely to re-
solve the problem and may ruin your relationship with them. Instead,
help clients analyze the sequence of events that led to this behavior to
develop a strategy for eliminating it.

Sensitivity to Criticism

Many hoarding clients have a lifelong history of criticism from others

for their behavior and have become highly sensitive to any kind of im-
plied criticism. This may be especially evident in clients with social anxi-
ety and depression who too easily jump to conclusions about clinicians’
(and others) views of them. Be especially alert to clients’ perceptions of
your comments. If you suspect an unstated problem, ask for feedback,
suggesting that “sometimes people get angry or hurt by things I say. It is
very important to tell me whenever this happens so I can fix the prob-
lem.” The ensuing discussion can provide an opportunity to examine er-
roneous thinking styles and the actual evidence for perceived criticism,
and to correct misimpressions.

Hoarding clients can be particularly sensitive to criticism during the first

home visit, especially when the clinician is the first person in years to
cross their threshold. Delays in getting into the homes of these clients
probably reflect their intense fear of criticism, even from someone they
have asked to help them with the problem. During this first visit, avoid
any kind of negative statement about the condition of the home, treat-
ing the situation matter-of-factly, regardless of severity.

Anger

Anticipate that at some point during treatment, some clients will be-
come angry with you because you have become associated with repug-
nant tasks they have avoided for years. This may happen during sorting
sessions or when clients are working alone and are feeling very uncom-

86
fortable. Anger is especially common in clients who are easily offended
by criticism or tend toward suspicion and paranoia. The following list
includes potential steps for dealing with anger, regardless of whether it
seems justified:

. Ask questions to clarify exactly how clients feel and whether they
think the perceived attack was intentional or mean-spirited.

“I can hear that you are upset. Say more about what led you to feel
this way.”

“Did this bother you a lot this week?”

“Are you angry with me for putting you in this position?”

“Did you feel I was purposefully being mean?”

. Reflect and summarize clients’ statements and ask if your percep-

tion is accurate:

“Okay, if I understand you correctly, you are angry because you

felt attacked and criticized by me at the end of the last session.
Is that right?”

. Admit mistakes and apologize briefly. Do not blame clients, inter-

pret their feelings, or imply they are inappropriate, because this
is invalidating and creates more distance between you and your
clients.

“I’m sorry that what I did led you to feel upset. I think I made a
mistake when I challenged your thinking. I should have asked you
more questions to understand it better. This was my mistake.”

. Explore the source of the anger or frustration when clients are

ready, including cognitive biases. For example, one woman en-
gaged in several cognitive errors (see chapter ), including all-or-
nothing thinking and overgeneralization to conclude that a hint of
criticism or her own mistake meant she was not only inadequate,
but a total failure. She discounted statements about her good qual-
ities and jumped to conclusions that the clinician disapproved of
her. The clinician used Socratic questioning (see chapter ):

87
 “You thought I was criticizing you. I also said some nice things
about you. Did you hear those?”

“That’s interesting; why do you think you discounted them? How

do positive comments make you feel?”

“Do you do this with other good things too? Such as when you are
successful at something?”

“It sounds like your standard for what is ‘acceptable’ is very high.
How often are you able to meet it?”

. Formulate hypotheses and test them (see behavioral experiments

in chapter ). For example, clients with perfectionistic standards
who perceive negative evaluations from others, might be asked:

“The next time you think I or someone else close to you is being
critical of you and you start to feel angry, would you be willing
to try an experiment? Would you be able to ask whether the
person meant to criticize you? This will tell us how often you
are being hard on yourself, and will help you figure out whether
someone is actually being critical or whether you are assuming
they are. When you do this, you need to ask people who will be
honest with you.”

“You could try an experiment to test whether one mistake means

you are a failure. Is there something you can schedule for your-
self this week where you can make small mistakes and see if you
can still feel good about the parts you did well?”

Feeling Overwhelmed

Clients facing extremely extensive clutter piled to the ceiling in many

rooms are likely to feel overwhelmed at the prospect of working on it.
The problem seems so huge that it is difficult to know how or where to
start, or whether progress is even possible. This can lead to procrastina-
tion and avoidance of homework assignments. Help clients by discuss-
ing their powerful feelings, and structure tasks in a simple, stepwise
manner. Ask clients to help by telling you when an assignment seems too
hard and reporting negative feelings as soon as they arise.

88
Need for Social Support

A potential barrier to making progress for some clients is the lack of so-
cial support from others for their efforts. In our experience, many people
with hoarding problems have great difficulty making progress on their
own. The presence of another person in the room (even if interaction is
minimal) may provide emotional support that reduces uncomfortable
feelings. The presence of others can also help distractible clients stay fo-
cused. Others can also provide positive reinforcement, and just knowing
that someone will visit can be a powerful motivator. Help clients deter-
mine who might provide a calming presence while they work without
interfering with their efforts. If supportive family members or friends
can assist, provide them with information about the components of
hoarding and specific guidelines for what to do and not to do, as dis-
cussed in chapter . These are best conveyed by having the person pres-
ent during one or two home sessions to observe the clinician working
with the client.

A word of caution is in order here. We have found it difficult to use fam-

ily members as coaches or helpers. Long-standing patterns of criticism
and “taking control” are difficult for family members to break and can
interfere with treatment. Even with explicit instructions and modeling
from therapists, some family members just can’t refrain from clandestine
discarding of the client’s possessions. Unfortunately, this can also be true
of friends and other helpers. Be sure to anticipate such problems if fam-
ily members or others are involved in treatment.

Avoidance of Feelings

Some clients may try to avoid their emotional experience and prema-
turely abstract the meaning without actually experiencing their feelings.
This creates a problem because they are not reporting their immediate
reaction to the questions (beliefs and emotions), and therefore the mean-
ing they abstract may reflect a rationalization rather than actual under-
lying core beliefs. One way around this problem is to ask them to report
the first thing that pops into their head when they are asked a question
and encourage them to notice feelings, even unpleasant ones.

89
Unusual Beliefs

We have occasionally encountered unusual beliefs associated with hoard-

ing problems. Some of our clients have shown fears of death. One el-
derly woman stated, “God would not allow me to die in a place that was
so cluttered and dirty.” She concluded that if she cleaned and removed
the clutter, it would be time for her to die. Another elderly client re-
ported feeling that cleaning up her home meant it was time for her to
move to a nursing home. In a related vein, some clients who began re-
moving clutter after having not done so for years reported a fear that
they would lose interest in everything, including life. These fears were
reflected in sudden refusal to work on decluttering after a period of rela-
tive success.

In such situations, clinicians can investigate the source of the problem

and use cognitive strategies to work on faulty beliefs. However, it is im-
portant not to challenge such beliefs directly until clients are ready to
examine them. For instance, a belief that it is wasteful to discard some-
thing of potential use may reflect part of the client’s identity as a re-
sponsible and good person. Challenging these ideas is likely to provoke
distrust in a clinician who does not appear to respect their views. Ask
clients to clarify what they believe and how they came to this conclusion,
but focus this line of questioning on how to incorporate their belief into
a lifestyle that is functional.

Special Issues

Sometimes clients face imminent deadlines to remove most or all of the

clutter because of deadlines or ultimatums delivered by law enforcement
or community agencies, or by family members who threaten to leave or
are planning drastic measures to remove clutter. In these cases, intensive
methods may be needed that require figuring out how to engage others
in the sorting sessions. In such cases, clinicians can consider extending
their own hours to work with clients at home. Clients might wish to hire
a professional organizer to help sort. Another option is for clinicians to
train friends, family members, paraprofessionals, or student assistants to

90
 assist clients with sorting and hauling. Consider using a professional
cleaning agency if clients agree and will be able to exercise decision mak-
ing about removing items. A cleaning agency may be essential if clutter
includes significant amounts of human or animal waste, which poses a
health risk to in-home workers.

We caution that working on hoarding problems often creates consider-

able frustration for clinicians. Progress on clutter is likely to be slow at
first, and clinicians must remain patient and optimistic about change.
Keep in mind that much of the work early during treatment is to change
beliefs about and attachments to possessions, not merely to reduce clut-
ter. The clutter is a manifestation of these beliefs and emotional reactions.
Focusing too much on clutter and not enough on changing attitudes
and behaviors about possessions can stall therapy.

Homework

Homework assignments for this segment can be self-education tasks as

well as those that help clients gather information to encourage self-
observational skills useful during treatment. Emphasize the importance
of homework as follows:

Another thing I want to mention is that I’ll ask you to do homework

every week. You and I will agree together on things that make sense
for you to do. But once you agree to it, I’ll expect you to do it or tell me
what happened if you don’t do it. This is very important because we
are only meeting once a week and we can’t possibly work effectively on
the hoarding without a lot of work between sessions. This is not going
to be easy for you. Are you sure you want to do this?

This final question reflects motivational interviewing discussed in the

next chapter. It is intended to help address the common problem of early
enthusiasm for treatment followed by waning of motivation and effort.

The following are recommended homework assignments for this phase

of goal setting and treatment planning:

✎ Ask clients to think about goals and put them on the Personal Goals
Form in the workbook.

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 ✎ Instruct clients to monitor their thoughts and feelings during sorting,
discarding, and acquiring to help develop the hoarding model further.

✎ Have clients complete a behavioral experiment to test their beliefs

using the Practice Form from the workbook.

92
Chapter 5 Enhancing Motivation

Outline

■ Use motivation-enhancing strategies with clients who exhibit ambiva-

lence about treatment.

Two major impediments to successful intervention for compulsive hoard-

ing are the lack of insight into the severity of the problem and low moti-
vation to resolve it. In chapter , which talked about treatment planning,
we described four visualization exercises that are useful for identifying
low insight and ambivalence about reducing clutter. Here we provide
ways to recognize motivational problems and outline a variety of strate-
gies for resolving them. Some of these intervention techniques are based on
well-researched motivational interviewing methods developed by William
Miller and Stephen Rollnick () described by them in their book titled
Motivational Interviewing: Preparing People for Change. We strongly urge
clinicians to read this volume and view the accompanying training video-
tapes. In this chapter we describe other motivation-enhancing strategies
we have found useful, such as problem-solving skills, visits to the home
by other people, and behavioral experiments.

The methods described here should be used whenever clients exhibit

ambivalence about the work that interferes with progress. Clinicians may
elect to spend entire sessions using motivational methods or may simply
apply one or more strategies briefly until the client expresses an interest
in change and is willing to proceed with planned interventions. If clients
do not express a clear wish to resolve their hoarding problem after two
or three sessions using motivational methods, seek alternative strategies
to address the hoarding problem (e.g., recommend that family members
consult with agencies that may be able to help motivate clients by en-

93
 forcing regulations regarding public health, housing, elder abuse, neg-
lect, and so on).

Recognizing Levels of Insight and Motivation

Just as clients have differing levels of severity of hoarding symptoms,

they also enter treatment at varying levels of insight and motivation to
work on the problems. The following subsections describe three general
categories and present suggestions for the intensity of the motivational
work needed.

Noninsightful Clients

Clinicians occasionally encounter clients who disagree that their hoard-

ing behavior is inappropriate and fail to recognize the impairment that
is evident to others. Family members, social service agencies, and legal
authorities usually refer these individuals, especially if a threat to public
health or neglect or abuse of children, elders, or animals is involved. Oc-
casionally, clients are legally mandated to clean out their homes within
a limited time frame or face fines and court-ordered cleaning services.
Because these interventions are usually very traumatic for the client, cli-
nicians who accept such referrals can first negotiate a longer time frame
(at least three months and preferably six months) for the decluttering
and cleaning process, unless health and safety problems are so severe that
immediate cleaning is essential. Begin immediately with motivational
methods, while indicating that your goal is to help clients meet the
health and safety requirements (however “unfair”). In fact, these require-
ments may be the only current impetus for change for these noninsight-
ful clients. Expect to spend two to three sessions on motivational work
before clients are prepared to begin organizing, sorting, and removing
items, and assume that motivational interviewing will be needed through-
out the intervention.

94
Insightful but Reluctant Clients

Many people who hoard recognize their difficulty, but are ambivalent
about treatment. Sometimes this is because well-meaning family mem-
bers have intervened in the past and have thrown out their things with-
out their permission, and sometimes it is because they are simply over-
whelmed by the magnitude of the task. Goaded into treatment by family
members, these clients can be difficult to engage and may only give lip
service to the goal of decluttering. For them, motivational methods are
especially helpful to enable them to feel in control of the therapy pro-
cess. Remember that most people with serious hoarding problems have
lived this way so long they have difficulty imagining any other lifestyle,
and in some cases they no longer even notice the clutter around them.
Consider asking these clients what they cannot do because of clutter or
acquiring problems (e.g., cook a meal, take a bath, buy basic items) to
provide the most relevant goals for treatment. Suggesting the need to
discard clutter at this early stage can disrupt already limited motivation.
After motivational strategies help develop a trusting relationship, and
early efforts to sort items have met with some success, clients are more
likely to take the next step of removing clutter to achieve their goals.

Insightful and Motivated but Noncompliant Clients

Many, if not most, hoarding treatment seekers find their motivation wanes
when faced with decisions to dispose of possessions. Clients’ thoughts
turn away from the advantages of creating living space to the loss of the
object and its meaning. Often, the most significant difficulty for clients
is deciding to let go of (discard, recycle, sell, donate) things when they
are by themselves. Doing homework is a critical component for endur-
ing success in controlling clutter. Although such clients may not rou-
tinely need motivational strategies, periodic emphasis on personal goals
and values may help them remain committed to completing homework
tasks between sessions.

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Addressing External and Internal Impediments to Motivation

Among the several variables that influence clients’ motivation to engage

in therapy are lack of appropriate pressure and support from others who
care (especially among those who live alone), the absence of visitors to
the home, toxic levels of criticism from family members, and significant
depression. As evident from this list, family and friends can be both a
help and a hindrance. As we noted in chapter , people with compulsive
hoarding tend to live alone, and their attachment to others may be ten-
uous; some suffer from social phobia and have dependent interpersonal
styles. Although these characteristics are not in and of themselves prob-
lematic for treatment, the lack of contact with others who would disap-
prove of the hoarding may reduce their insight into the problem and
motivation to fix it. Related to this is the missing “visitor effect”—the
tendency to tidy up one’s home when visitors are coming. Because this
is such a strong motivating factor for many people, we recommend ar-
ranging regular home visits, initially by the clinician, and as soon as pos-
sible by supportive family members and friends. We have also had good
success conducting treatment in a group format, with group sessions
routinely scheduled in people’s homes.

We have already alluded to motivational problems among clients who

enter treatment at the behest of a partner or family member frustrated
by the hoarding. In some cases, spouses have threatened to leave, and
clutter and compulsive buying have become weapons in an interpersonal
conflict. These issues must be fully explored using motivational strate-
gies to verify that clients can articulate personal (not merely family) goals
before active treatment begins.

For many hoarding clients, being at home is an unpleasant experience,

and as a result they have structured their lives to spend as little time there
as possible. In these cases it may be important to develop strategies to
get them to spend more time at home, especially doing things that are
enjoyable.

Hoarding clients frequently complain about fatigue and health-related

problems as impediments to completing homework. The aversiveness

96
 and enormity of the decluttering task contributes to these experiences.
When they happen, we incorporate them into the case formulation inas-
much as they reflect conditioned avoidance. We treat them in much the
same way we would approach a physical fitness problem. For example,
one of our clients could work for only  minutes before he became ex-
hausted at the beginning of treatment (Frost, Steketee, & Greene, ),
but after two months of gradually increased practice, he was able to work
for more than an hour without a break.

Clients with serious depression may find themselves without energy for
homework or tolerance for the discomfort of making decisions about
clutter. If mood appears to be the impediment to motivation, clinicians
can consider immediate and direct treatment for the depression (e.g.,
medications, cognitive therapy) while assessing the hoarding problem
and establishing a treatment plan, waiting until mood is improved be-
fore assigning significant homework or working on sorting and remov-
ing clutter.

Understanding Their Experience

Most hoarding clients feel ambivalent about changing their hoarding be-
havior. On the one hand, they recognize the problems hoarding has cre-
ated for them, but on the other, they have clear and powerful reasons not
to get rid of their collection of newspapers, for example. More than
likely, your client will have negative experiences from other’s attempts to
help them. These will have taken the form of arguing for getting rid of
stuff—“just throw it out.” But this view does not take into account
clients’ ambivalence, and an argument will ensue in which helpers pres-
ent reasons for getting rid of things and clients dig in their heels and
present reasons for keeping them. Progress stalls quickly in this scenario.
It is crucial that clinicians approach the problem very differently. The
motivational interviewing strategies outlined here are designed to dis-
arm defensiveness by helping clients first articulate and then resolve their
ambivalence.

97
Identifying Ambivalence

Clinicians must first register the presence of ambivalence before they can
apply motivational techniques. Be alert for the following verbal and motor
behaviors that signal ambivalence: relentless complaining and diverting
discussion to other topics; arguing; nonverbal signals of ambivalence; ar-
riving late, canceling, and “forgetting” appointments; not doing home-
work; and discouragement despite progress.

Relentless Complaining and Diverting Discussion to Other Topics

Clients complain repeatedly about others or about rules or regulations.

For example, “I don’t see why I can’t just live like this; I’m really not
bothering anybody” or “The city has no right to do this.” One woman
digressed regularly, using treatment sessions mainly to complain about
the people in her life (her landlord, her daughter, her coworkers). When
questioned about her interest in working on the hoarding problem, she
agreed that she was more interested in solving other problems, necessi-
tating a change in the goals of the therapy.

A variant of this problem is evident in clients who try to engage clini-

cians in understanding, rather than working on the problem. Although
it is important to help clients understand why their hoarding developed,
spending a lot of time on this issue will impede progress on treatable as-
pects of the symptoms. An analogy to a broken leg is useful: Repairing
the leg is the first priority and then clients can determine why it hap-
pened to prevent a recurrence. After giving this explanation, treat re-
peated “why” questions as diversions from the central goal of improving
hoarding symptoms.

Arguing

Clients challenge clinicians’ statements or homework recommendations.

For example, “That doesn’t really make sense. How am I going to re-
member what I want to get if I don’t get it when I’m there?” Occasion-

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 ally, such behaviors emerge in clients with perfectionistic, controlling, or
narcissistic traits who are not yet convinced that decluttering or reduc-
ing acquiring is their goal. Arguing signals an absence of collaborative
work and is certainly grounds for examining motivation.

Nonverbal Signals of Ambivalence

Sighing, not paying attention, and turning sideways are examples of non-
verbal behaviors that may also signal that clients are ambivalent about
the treatment or uncomfortable with what the clinician has said. When one
man sighed audibly when his clinician suggested strategies for handling
some problems he was describing, it was clear that he had dismissed her
recommendations and would not follow through. In such instances,
stop the action and inquire what the sigh meant, or offer the hypothesis
that the client was unhappy with the exchange.

Arriving Late, Canceling, and “Forgetting” Appointments

These therapy-interfering behaviors often, but not always, reflect moti-

vational problems that signal the need to help clients articulate their am-
bivalence before strengthening their commitment and confidence in
their ability to change. In probing why the pattern is occurring, be aware
of other possible explanations. Sometimes clients miss appointments
because of other problems such as OCD rituals or ineffective planning.
This would be evident in their missing not only therapy appointments,
but other meetings as well (e.g., medical appointments, work-related meet-
ings, and so forth). In this case, a problem-solving strategy (see chapter
) may be helpful. Sometimes the timing of treatment is problematic,
because other, more pressing problems interfere with clients’ energy and
time to devote to work on hoarding. If so, reschedule therapy for a later
date to avoid irregular sessions, wasted efforts, and unsteady progress.
Occasionally, clients are uncomfortable with the therapy or the clini-
cian. Helping clients to express their concerns at the end of each session
with the routine request for feedback should bring such issues to light.
Of course, accept these criticisms and work to resolve them.

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Not Doing Homework

One of the most common problems is insufficient homework comple-

tion for adequate progress during treatment. “I haven’t had time to go to
any stores to practice.” “I have a hard time finding time to sort. I have
things I want to do to socialize and get ready for the next day.” “I don’t
want to get depressed or anxious, so I keep busy with friends. I really
don’t have time to sort.” (See the previous section on impediments to
motivation.) We recommend resolving this therapy-interfering behavior
using motivational methods and problem-solving strategies before mov-
ing on in this guide.

Discouragement Despite Progress

Some clients discount progress, especially if they are depressed, hold

perfectionistic standards, or have such extensive clutter that small im-
provements are difficult to see. In addition to the motivational methods
described here, we recommend clinicians use updated photographs to
compare with baseline photos to enable clients to recognize even small
changes.

Assumptions Behind Motivation Enhancement Methods

Miller and Rollnick () consider motivational interviewing to be more

of an orientation than a set of techniques. The approach requires col-
laboration, “a partnership that honors the client’s experience and per-
spectives” (p. ) to evoke motivation. It draws on client strengths and
assumes the autonomy of the client who has the right and capacity to
make informed choices. The explicit assumptions of this method are as
follows:

■ Motivation to change must be elicited; it cannot be imposed by

others. Clients who enter treatment because they are pressured by
friends and family to do so are unlikely to change their behavior
unless they first decide they would be better off if they did so.

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■ If ambivalence about change is not identified and discussed,
noncompliance and a lack of common goals will undermine the
activities, exercises, and discussions during treatment.

■ The client’s job is to articulate the ambivalence, whereas the clini-

cian helps the client express and explore all sides of their ambiva-
lence. Many hoarding clients recognize the problems hoarding cre-
ates for them and express a desire to change. However, when faced
with the task of actually discarding a cherished possession, their
motivation evaporates. Helping them discuss their ambivalence
sets the stage for using their goals and values to overcome fears
about losing possessions. It also helps clarify the specific beliefs
that are interfering with recovery.

■ Direct persuasion is counterproductive and should be avoided.

Thus, directive or authoritative styles do not work well. Instead,
the clinician’s style should be thoughtful and curious to elicit am-
bivalence, consistent with the Socratic style of cognitive therapy
(see chapter ).

■ Readiness to change develops from the interpersonal interaction of

the clinician and the ambivalent client. Clients whose family and
friends have trampled on their freedom of choice will be suspi-
cious of the intentions of helpers. Developing a trusting relation-
ship may take longer, but is absolutely essential.

■ Therapy is a partnership, not a relationship between expert and

recipient. Clinicians cannot make decisions for their clients nor
take responsibility for them. Rather, clinicians and clients must
work side by side to understand the impediments and to help
clients learn to make wise decisions.

The four basic principles of enhancing motivation (Miller & Rollnick,

) are consistent with these assumptions:

■ Expressing empathy. Conveying respect, understanding, and devel-

oping a shared purpose requires reflective listening that assumes
that ambivalence is entirely normal.

■ Developing discrepancy. Motivation to change arises from clients’

perception that their current circumstance is discrepant from their

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 personal goals and values. Clinicians try to heighten this awareness
so clients recognize their problem, and present their own argu-
ments for change.

■ Rolling with resistance. Instead of arguing and confronting resist-

ance, clinicians view resistance as clients’ best attempts to cope
with their circumstances, which reflect their personal beliefs. Clini-
cians invite new perspectives and consider clients the primary re-
source in identifying solutions. Client resistance becomes a signal
to respond differently.

■ Supporting self-efficacy. Clients must not only recognize that they

have a problem, but also believe they can do something about it.
Clinicians’ beliefs in clients’ capabilities become self-fulfilling
prophecies as clients choose and carry out change behaviors.

Strategies to Enhance Motivation

In a previous chapter we recommended a few strategies to enhance mo-

tivation such as the imagery exercises and establishing goals and values.
The practical strategies described next for building motivation are in-
tended mainly for noninsightful clients, but are also useful for insightful
clients whose motivation wanes periodically. These methods are adapted
from Miller, Andrews, Wilbourne, and Bennett () and from Miller
and Rollnick (). The goals of these methods are to enable clients to
make statements that indicate:

. Recognition of the problem

. Concern about their behavior

. Intention to do something about their behavior

. Optimism about the possibilities for change

These goals are pursued using a variety of strategies described briefly

here. Keep in mind the need to emphasize clients’ personal choice and
control over all aspects of the interchange.

Open-ended questions (using the terms what, why, and how) encourage
clients to provide information about themselves. Examples are, “What

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 led you to decide to come for treatment?” “Why do you think the clut-
ter got out of hand?”

Reflective listening statements (not questions) indicate the clinician heard

the client or noticed his or her reactions. They help clients feel under-
stood. Reflections include repeating, rephrasing, and paraphrasing, es-
pecially feelings (“you didn’t like that,” “these things are important to
you”) and thoughts (“you don’t want your daughter to interfere”). They
can be followed with open-ended questions and in the following sequence:

Client: [avoiding accepting responsibility] I clear it and stuff just ends up

there. I don’t understand how it got this way.

Clinician: You put things on the table and didn’t realize you were doing this.
When does that happen?

Complex reflections, as Miller and Rollnick () note, amplify what

clients have said with educated guesses about their thoughts and feel-
ings, and double-sided reflections that comment directly on ambiva-
lence: “On the one hand you feel . . . , but on the other hand you . . . .”
They recommend that clinicians make direct statements that reflect the
client’s thoughts, feelings and behaviors without adding unnecessary
phrases like it seems. This takes a bit of practice, but produces a more
powerful comment that helps clients clearly evaluate their experience.

Summarizing what clients have said during the past few minutes helps
them hear themselves talking with a little more perspective. A clinician’s
summaries can reinforce some points more than others. They should be
brief and without qualifications or unnecessary modifiers as well. Here’s
an example: “You are very angry with your landlord for making the com-
plaint and think he exaggerates your problem. You have worked hard to
clean up the hallway and living room, but this has taken more time than
you expected or he allowed. You’d like him and your family to get off
your back, and you are sure you can solve the clutter problem by your-
self.” The clinician can follow this with an open-ended question, “What
do you think of all this?”

Affirming self-efficacy with supportive and appreciative statements based

on a clinician’s actual feelings conveys respect for clients’ feelings, struggles,
and accomplishments. Examples are: “You understand peoples’ needs and
are very thoughtful” and “You are pretty organized and a pretty good

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 problem solver at work, so it seems likely you will learn to do this at
home too.”

Evocative questions are designed to provoke self-statements in which

clients indicate recognition of their problem, express concern, and de-
scribe an intention to change and optimism about their capacity to do
so. These questions go beyond open-ended ones by directing clients to
discuss the effects of their hoarding. Examples are: “How has this affected
your husband?” “How does the clutter fit with the things you value in
life?” “What are the successes you’ve had that make you think you could
do this?” When clients have made tentative motivational statements, the
clinician can help strengthen them by asking almost paradoxically,
“Why would you want to change this, especially when it would feel like
giving up part of yourself ?”

Exploring the pros and cons of hoarding is typically done by asking

questions that elucidate both the positive and negative elements of the
problem. Consider the following series of questions: “What do you like
about tag sales? What about the other side? What are some reasons to
stop shopping so much? What are the not-so-good parts of owning all
these things?” Encourage clients to generate these pros and cons them-
selves. However, sometimes it may work better to inquire about some that
clients have already alluded to: “You mentioned that you spent more
money than you liked. Is that a disadvantage? Maybe you don’t really
overspend.” Another sequence might be: “I got the idea from your com-
ments that your self-esteem has suffered. Is that true? How big a deal is
that for you?”

Asking for elaboration is intended to encourage clients to expand on the

negative consequences of problematic behaviors. For example, “You
mentioned that sometimes you waste time looking for things. Can you
give me an example of how the clutter takes more of your time?” When
clients are reporting complaints by others, clinicians might ask: “Was
that their main concern?” Requests for elaboration of talk about chang-
ing hoarding behavior are especially useful to enhance commitment to
change.

In using extreme contrasts, clinicians try to amplify possible reluctance

to work on hoarding behavior, as well as the benefits of working on the
problem. “What is the worst thing that can happen if you go along as

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you have been?” “If you were to decide to work on this problem seri-
ously with me, what do you think would happen?” “What are the best
things that could come out of change?”

Looking forward and looking back are strategies that help amplify con-
cerns by asking clients to project themselves into the future or into the
past. “If you think ahead five years, what would you like your life to be
like?” “Suppose you were planning to commit time to working on this
problem, what would that mean for your marriage?” This method can
be especially useful for clients who tend to blame others for their prob-
lem. Looking back will only be useful for clients whose history contains
a period in which hoarding was not a significant problem: “Contrast
now with how you felt before these problems began. What was your life
like then?”

Reframing statements are intended to change clients’ interpretation of

events by emphasizing the positive aspects of the situation. They clarify
the ambivalence clients feel. For example, “You think that behind your
wife’s nagging about your collecting things is a real concern for you, al-
though you still find it annoying.”

“Change talk” refers to clients’ statements about the desire, ability, rea-
sons, need, and commitment to change. As Miller and Rollnick ()
suggest, readiness to change is often evident when clients stop arguing,
quiet down, appear calmer, and perhaps express sadness. They may ask
questions about what to expect during treatment. Clinicians can strengthen
clients’ commitment to changing and confidence in their ability to do so
by asking simple questions when the client has made tentative state-
ments about making changes. “What would you like to do next?” “What
might be your first goal?”

Emphasizing personal choice is a critical component of motivational en-

hancement. Be clear with clients that all choices and decisions about orga-
nizing, acquiring, and getting rid of things are made by them. The clinician
serves as a sounding board, but makes no decisions about possessions.

Taking the negative side of an argument helps disarm someone who is

accustomed to defending their hoarding behavior: “Why would you want
to change this? You really enjoy having [buying ] all these things.”

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 Cautious interest is expressed via questions such as “How important is
this to you?” “How confident are you that you can do this?”

Rating the importance of change and clients’ confidence in change is an-

other strategy for enhancing change talk. Ask clients to indicate how im-
portant it is to change their hoarding problem on a scale from  to ,
where  equals not at all and  is extremely important. To encourage
more change talk, ask why they chose that number. If it is a high num-
ber, simply ask why it is important. If it is a moderately low score (a 
or ) ask why the person didn’t pick a lower number. Alternatively, ask
what would need to happen for the client to move from a  to an  on
the scale. A similar procedure can be followed in asking how confident
clients are about being able to change. Then summarize their statements.
And ask about next steps: “Where does that leave you now?” “What are
you thinking about your hoarding at this point?” “What’s the next step?”
“Where does hoarding fit into your future?” Throughout these conver-
sations, comment positively on clients’ willingness to talk with you about
their situation. Clinicians can also express confidence that clients will be
able to make changes after they put their mind to it.

To encourage decision making about treatment, clinicians can use clients’

own wisdom to help them determine what they want to do (e.g., “Tell
me what you think will happen based on your own experience”). Offer-
ing a small menu of options facilitates feelings of control and capability
(“You need to decide what is most important. You can decide to work
on reducing what comes into your home, on organizing and sorting
your things, or on making decisions about what to get rid of.”). Clini-
cians who are concerned about clients’ expressed preferences can ask per-
mission to offer an opinion before doing so.

Methods to Avoid in Motivating Clients to Change

Clinicians should avoid a premature focus by not presuming that hoard-

ing symptoms are the main reason clients have agreed to see them. Begin
with a broad focus and narrow it later. Avoid arguing. Arguments that
champion change only make patients more defensive. Avoid labeling the
problem; clients do not need to admit or declare that they have a prob-

106
 lem, only that they are interested in change. Using the term hoarding is
not required for motivation or success, although some may find it help-
ful to have a formal diagnosis if it enables them to realize that others
suffer similarly. Use labels only when the patient indicates it is helpful.
Avoid blame. No one is at fault for the development of this problem,
and many factors have certainly contributed. Clinicians should not side
with clients against someone (parent, sibling, others), because this can
cause clients to have to defend the person. It is best simply to listen
closely and use the strategies described earlier in this chapter.

An important rule of motivational interviewing is to avoid asking too

many questions. A general rule of thumb is never to ask three questions
in a row; after two have been asked and answered, summarize or com-
ment. Finally, clinicians should take care not to set themselves apart
from patients by adopting the role of expert and lecturing, even though
they will need to use their expertise to enhance clients’ understanding of
themselves. The relationship should feel like a partnership in which
clients are experts about themselves and clinicians are expert about em-
pirical information about the problem and others who have it.

Other Motivation Enhancing Methods

Problem Solving

We have already noted that many clients feel overwhelmed; have limited
time to work on hoarding; experience medical problems, depression, fa-
tigue, distractibility, or other personal mental and physical conditions;
or lack the help to manage clutter removal. These are all concrete prob-
lems that may lend themselves to a problem-solving strategy. Because
this method is described in the next chapter, we will not detail it here,
except to note the basic components: defining the problem, generating
solutions, selecting a solution, implementing it, and evaluating the out-
come. We recommend that whenever a concrete personal, interpersonal,
or practical barrier presents itself, clinicians should engage clients in de-
liberate problem-solving efforts and work out a homework assignment
consistent with the efforts to solve the problem.

107
Behavioral Experiments

When clients express reluctance to proceed because they fear intense

anxiety will overwhelm them or they are concerned they will be unable
to perform some task, clinicians can recommend a behavioral experi-
ment to test their concern by framing it as a hypothesis. This emphasizes
the scientist role outlined in the description of cognitive techniques (see
chapter ) and helps clients step back a little to evaluate the situation
more objectively.

Using Metaphors

A metaphor may be useful for some clients who are reluctant to engage
actively in change behavior. Describe therapy as like using a life preserver
when a person is afraid of drowning—clients must let go of the sinking
boat to try a better option, but there is no way to know whether the life
preserver will really work until clients try it. This metaphor acknowl-
edges the emotional strain of letting go of usual methods of coping in
favor of trying new methods.

Speaking to Successful Clients

A good method for helping reluctant clients become more confident

about change is to have current clients speak to a former client who has
completed treatment successfully. Ideally, this person would be as simi-
lar as possible to the current client. The clinician can broker this contact
by asking the current client if speaking to someone who has completed
the hoarding program would be helpful. If the client is interested, the
clinician contacts the former client to verify willingness to communicate
and then provides each person with first names and phone numbers to
make contact. Having a model who has successfully completed the in-
tervention can be a strong motivating factor to continue.

108
 Table 5.1 Ways to Enhance Homework Compliance
Schedule particular times for work.
Ask if someone can be present at home or at acquiring settings during
practice.
Suggest client listen to pleasant music during homework sessions.
Design methods to interrupt self-defeating thoughts.
Monitor the homework that is done, including when, where, number of
hours, and so forth.
Call clients to check on whether they are doing their homework.
Ask clients to phone in homework progress reports.
Request weekly pictures of progress at home.
Plan very brief phone contacts before and after homework.

Enhancing Homework Compliance

Lack of homework compliance is the source of much client ambivalence

and clinician frustration. It is probably the single most common prob-
lem for clinicians. Table . lists some possible solutions.

Homework

Working on motivation may not always lend itself to homework assign-

ments, especially when clients have not yet committed to treatment. As
motivation increases, however, homework assignments may be appro-
priate. Possible assignments include the following:

✎ Have the client make a list of the pros and cons of hoarding (e.g., the
good and bad parts of acquiring or of having clutter in the home).

✎ Ask the client to list, in order of importance, the things he or she val-
ues most in life.

✎ Ask the client to consider how hoarding fits with his or her personal
values (i.e., the personal goal or value that would be gained if the
home were uncluttered).

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Chapter 6 Skills Training for Organizing
and Problem Solving

(Corresponds to chapter 5 of the workbook)

Materials Needed

■ Photos from home visit if available

■ Task list

■ Organizing plan

■ Personal Organizing Plan

■ Preparing for Organizing Form

■ How long to save paper

■ Filing Paper Form

■ Questions about Possessions Form

Outline

■ Train the client in effective problem-solving skills.

■ Work with the client to develop organizing skills.

■ Work with the client to develop and implement a Personal Organizing

Plan.

■ Teach the client strategies for organizing paper and how to create a
filing system.

Our observations of hoarding clients have taught us that many of them

lack skills to organize effectively and to solve the problems that inevitably
arise during the course of working on hoarding. Their past organizing

111
 efforts took a great deal of time but accomplished little more than churn-
ing piles. As we noted in chapter , several problems may be at work,
such as attention focusing deficits, reliance on keeping items in sight, and
trouble categorizing objects. Because many hoarding clients are unable
to sustain attention on repetitive chores like organizing and sorting
(Hartl et al., ), clinicians must use strategies that help focus atten-
tion and limit the scope and duration of tasks. Many clients rely heavily
on keeping objects in view to remember them, resulting in piles of
things covering the furniture and floors. The short-term relief provided
by setting items within sight is outweighed by the long-term conse-
quence of losing many more items in the clutter. In addition, hoarding
clients tend to create too many categories while sorting their own things
(Wincze, Steketee, & Frost, in press), and have trouble conceptualizing
how and where to store items. Learning to problem solve and to catego-
rize, file, and store items out of sight is essential for successful resolution
of hoarding.

The strategies described here will guide clinicians to train clients in effec-
tive problem-solving skills and stepwise organizing methods. These meth-
ods can be applied in any order, depending on how you conceptualize
the client’s problems. Not everyone will need all skills. Eventually these
skills can be interwoven with other cognitive and behavioral methods, but
we recommend spending at least two sequential sessions on this module
to consolidate basic skills before combining them with other methods.
Clinicians may also wish to consult publications by professional orga-
nizers for additional organizing strategies, as well as manuals for ad-
dressing attention deficit problems (see the Recommended Reading list
at the end of this book).

Educating Clients and Developing Goals

Clinicians can introduce the topic of skills training by noting which skill
problems seem to contribute to clients’ hoarding problems. The follow-
ing introduction is an example.

I think there may be some skills that might help with this hoarding
problem. A lot of people who develop problems with hoarding have
trouble solving problems effectively. You and I have already talked

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 about some of the problems that need solutions. For example, you were
just wondering how to manage your time to get more done on the
hoarding problem, so this time problem is something we might start
on. Today, I’d like to go over some steps for problem solving that
would help us with this and with other problems that will certainly
crop up as we work.

Another skills issue is that most people with hoarding problems need
some help learning to sort and organize their possessions. I think this
might also be true for you from what we’ve discussed. I know you like
to keep things in sight so you won’t forget them, but I think this might
tax your memory too much. Although I know it’s not your intention,
keeping too many things in sight can actually make them harder, not
easier, to find. You’ve told me that you put a travel brochure on top
of a pile in your living room because you were afraid you’d forget it
if you put it in the file cabinet. But now that it’s covered by other
things, I have the impression that it’s harder to remember where it is
and you’d have trouble actually finding it if you wanted it in a few
months. What do you think? [waits for reply]

I’d like to propose that we consider developing some filing systems that
will work for you. This can be a challenge for people who have some
problems staying focused, so we’ll want to find strategies that can help
with this. How does this sound to you?

At this point, clinicians and clients should decide on the goals for this
part of the work on hoarding. These might be to:

■ Learn a systematic strategy for solving problems

■ Define categories for items to be kept

■ Decide on an overall organizing plan with locations for each cate-

gory of saved items

■ Develop a plan for sorting and moving items to interim and final
destinations

■ Decide on categories for unwanted items (e.g., give to people, give

to charities, recycle, throw out)

■ Plan how to dispose of unwanted items

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 ■ Develop a plan to put newly acquired or recently used items rou-
tinely where they belong

■ Decide how to build reinforcers into the organizing/decluttering

process

Systematic Problem Solving

This section briefly describes simple steps for problem solving that clients
will learn best by applying them to a current problem (see table .).

One of the most common problems clients have in working on hoard-

ing is managing time to accomplish tasks between sessions. This might
reflect a motivational problem that requires strategies from chapter ,
but it might also occur even when clients feel very committed to the
work and confident they can do the homework. In the latter case, we use
problem-solving steps.

Begin by helping the client label the failure to complete the homework
as “a problem to be solved” to short-circuit self-blame and guilt, and to
free clients to focus on new ideas. This defines the problem. Then, help
clients identify the factors they think could be responsible for not get-
ting work done between sessions. In one case, the client was able to work
well when the clinician was present, both in the clinic and at home, but
not when she was alone. Problems finding time, feeling fatigued, and
feeling lonely while working seemed to be contributing to her not get-
ting the work done. At this point, the clinician encouraged her to come
up with many potential solutions that addressed each element of the
homework problem and added a few silly ones to get the creative process

Table 6.1 Problem-Solving Steps

. Define the problem and contributing factors.
. Generate as many solutions as possible.
. Evaluate the solutions and select one or two that seem feasible.
. Break the solution into manageable steps.
. Implement the steps.
. Evaluate the outcome.
. If necessary, repeat the process until a good solution is found.

114
going. Often the silly ideas help generate more feasible ones the client
might not otherwise think of. The clinician also added ideas the client
hadn’t mentioned and listed all of them on a sheet of paper. The list of
potential solutions eventually included both global and specific ones, as
well as ridiculous and reasonable ones that addressed the sources of the
problem (e.g., time, fatigue, loneliness):

. Hire a cleaning crew to clean the place up.

. Burn the house down.

. Schedule the homework in her calendar in bright-red ink.

. Skip meals and work on the homework instead.

. Work in the early morning when she is not tired.

. Work for shorter time periods.

. Work while watching TV.

. Dress up in silly clothes while working to lighten the mood.

. Work while listening to music.

. Sing while she works.

. Invite her sister-in-law to sit with her and do other things while
she works.

. Pay someone to talk to her while she works.

. Call the clinician before she starts and after she finishes her
homework.

This process provoked some laughter and proved to be fun for the client,
so moving on to selecting the top choices was not difficult. The clinician
initiated a discussion of the advantages and disadvantages of these ideas.
After rejecting the options of burning the house down and skipping
meals, she came up with a plan that included scheduling homework into
her calendar in the morning for half-hour periods while watching a talk
show program she liked. She got up earlier than usual to do this, but
didn’t mind because she liked the show and she compensated for her
early rising by going to bed a little earlier at night. She also decided to
invite her sister-in-law who lived nearby and knew about her hoarding

115
 problem to come for coffee on the weekend while she sorted. After the
first week, her new plan increased her homework time to about an hour
a day, enough for her to begin to see progress, which proved very moti-
vating to keep up her new schedule. Had the plan not worked, the cli-
nician would have needed to help her reevaluate the original ideas and
consider others that might better solve the problem.

This problem-solving approach can be used to deal with a variety of

stressful life problems that come up during treatment, including the com-
mon problem of feeling so overwhelmed by the clutter that clients find
it difficult to begin their work.

Managing Attention and Distraction

A variety of strategies are helpful in controlling attentional focus. Some

of these are especially pertinent to working on organizing and problem
solving. For a comprehensive overview of how to treat ADHD, see Mas-
tering Your Adult ADHD (Safren et al., ).

The first step in managing attention and distraction problems is to mea-

sure clients’ attention span. This is probably most easily done by timing
how long clients can sort possessions at home (or in the office if neces-
sary) until they become distracted or confused. Timing the sorting of sev-
eral different kinds of materials may be necessary because distractibility
can vary with the difficulty of the sorting task.

If you find a high level of distractibility, consider training clients to delay

their distractibility. To do this, set a timer for the length of their mea-
sured attention span and then ask them to practice working with their
attention on the task until the timer goes off. When clients can do this
successfully several times in a row, increase the time setting. Continue in
this vein until they can work without distraction for a reasonable length
of time (e.g., half an hour or more if the original time to distraction was
 minutes). Note that this procedure is also an exposure to the discom-
fort clients feel when they try to make difficult decisions about saving,
discarding, and organizing. Assign this as homework so the task-focused
attention generalizes to their home setting when they are working alone
or with their coach (if they have one).

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Creating a high level of structure in clients’ lives will minimize attention
deficits. For example, use a calendar to establish a routine that will im-
prove clients’ functioning and help them feel more in control of their
lives. The calendar should list all planned activities, including home-
work. It must be updated frequently (often several times a day) as time
commitments develop. This may be a challenge for some hoarding clients
who have trouble keeping track of things. Appointments for organizing/
sorting sessions should correspond to times clients are most likely to
complete the task. For instance, some people work better in the morn-
ing rather than the afternoon.

Setting priorities and keeping track of them in the accompanying work-

book to maintain focus are keys to managing distractibility for hoarding
clients whose priorities often shift depending on their mood and other
life events. The workbook contains a Task List with columns for task de-
scription, priority ranking, the date it was put on the list, and the date
it was completed. Safren and colleagues () recommend three prior-
ity rankings. Priority A is for tasks of highest priority that must be done
within a day or two, B is for tasks that must be done over a longer term,
and C is for tasks of lesser importance that might be more attractive and
fun, but less important than A and B tasks.

During scheduled work times (several times a week or even daily if time
permits), clients should follow a consistent routine, beginning with re-
ducing the distractions by turning off the TV, radio, telephone, com-
puter, and so forth. Sometimes, however, clients find that background
music can be helpful in calming an anxious mood or improving a de-
pressed one. Next, clients should review their priority list and select an
appropriate goal for the session. The project should be broken down
into small and manageable steps, the first one being very clearly defined
and easily implemented. Clients might need to self-monitor what dis-
tracts them to improve their attentional focus. Common distractions for
people who hoard are telling stories about possessions or having to find
something else before deciding about the possession at hand. Setting up
categories and locations for possessions, as described in other sections of
this chapter, may speed the process along.

It is critical that clinicians devote time throughout treatment to estab-

lishing and checking on the use of a calendar, notebook, and work rou-

117
 tine so that clients learn to rely on them to structure their lives and guide
their behavior. The problem-solving strategies described in this chapter
will be useful for dealing with difficulties that arise in trying to manage
attention and distraction. Clients who find their eyes wandering to other
items in the room might generate ideas for how to limit this source of
distraction—for example, by covering areas adjacent to the one they are
working on. Clients who find that their thinking jumps forward in time
to upcoming tasks might solve this problem by breaking the current task
into brief segments they can execute quickly, so they have the feeling of
moving forward in their work. They might also write down distracting
thoughts for later consideration to help them continue with the task. In
addition to these strategies, the cognitive restructuring exercises described
in chapter  will help clients develop more adaptive ways of thinking
about tasks and, in turn, will minimize distractions caused by the aver-
siveness of the task.

Developing Organizing Skills for Objects

We find it helpful to begin the organizing skills section by training

clients to organize objects and subsequently working on the more com-
plex task of organizing paper. The first step is to define the categories for
items that will be removed from the home and then work on categoriz-
ing items that will be saved. This sequence helps clients feel more com-
fortable that their strong wish to avoid waste by recycling objects or giv-
ing them to a worthy cause will be respected. During the actual sorting
itself, clinicians can use strategies from the next chapters to help reduce
unreasonable urges to keep, give away, or try to sell worn out or useless
objects that few others would want and are better put in the trash.

Categorize Unwanted Items

The following categories are likely to be the main choices for how to dis-
pose of items clients would like to remove from their homes:

■ Trash

■ Recycle

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 ■ Donate (e.g., charities, library, friends, family)

■ Sell (e.g., yard sale, bookstore, consignment shop, Internet sales)

■ Undecided

Discuss these categories and develop a short list of options for giving items
away that are relatively easy to execute and cover the range of items likely
to end up in this category (e.g., books, clothing). This helps plant the idea
that many items will be removed but may be usefully recycled, sold, or
given away. For those especially concerned about being wasteful, this dis-
cussion may increase clients’ willingness to remove items. There is no need
to suggest what proportion of possessions should be placed in these cate-
gories, but the process of determining them helps clients think differently.

Develop an action plan for how and when to remove items in each of
these categories. This is an important issue because it is very common
for clients to set items aside for removal but have difficulty actually get-
ting them out of the home. Determine when weekly trash pickup or re-
cycling occurs or, if none is available, decide how clients will dispose of
trash bags and recycled items. Ask clients to learn about local charities
that could benefit from their unwanted items and to find out how to
give them away. We strongly recommend that clients who do not need
the money earned from selling their things give them away instead. This
is often much easier to accomplish, especially if local charities will come
to pick up unwanted items. Clients who want to sell items will need to
identify appropriate outlets. Because extra steps make it more likely that
items will not be removed, make sure these plans are realistic, feasible,
and require limited effort. Homework assignments can include calling
charities and sales outlets to make plans to remove unwanted possessions.

Select Categories for Saved Objects

The goal here is to define a limited number of categories for each type
of possession to make it easier to decide where the item belongs. The or-
ganizing plan in the workbook includes a long list of categories of saved
items (e.g., mail, photos, clothing, newspapers, office supplies) and typi-
cal locations where most people keep them. A plan for organizing paper
items requires a finer grained approach that is described a little later in

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 this chapter. Review this organizing plan with clients, noting that each
household may have different types of items and may choose different
locations for keeping them. The clinician’s goal is to convey that clients
need to keep similar items together in one main place.

Next, introduce the numbered but otherwise blank Personal Organizing

Plan from the workbook. Help clients determine what kinds of items
clutter their homes and need to be categorized and organized. Review-
ing the photos taken during the initial assessment may be helpful for this
purpose. Ask clients to list each category in the left-hand column and
write down the final location (room, piece of furniture, etc.) where these
items belong. Some clients have difficulty naming the categories for pos-
sessions but are more effective at deciding where they go. In this case
begin by asking about rooms (e.g., living room, dining room, bedroom,
basement) and storage locations within these rooms (e.g., desk drawers,
closet shelves, bookcase) to find out what items belong in these places
(discussed later). Try to keep the task manageable (nonfrustrating) by
finding a method that works best for clients. Completing this form can
be assigned for homework if the client is confident of using it. Figure .
shows an example of a completed Personal Organizing Plan.

Pick Locations for Categorized Items

Clients must eventually have an appropriate storage/filing location for

all their things. Filing cabinets, bookshelves, and other storage furnish-
ings will be needed, and some clients may decide to make structural
changes to the home (e.g., built-in bookcase, closet) to help them get or-
ganized. During home sessions, ask clients to select a pile of disorga-
nized possessions and help them determine the category and location for
each until they can do this independently. During office visits, use the
same procedure for a box or bag of items brought from home. Use the
Personal Organizing Plan to record these details.

To help clients make these decisions, use a questioning style (e.g., “What
category does this belong to? Where should that go?”) and comment posi-
tively on their ideas whenever these seem reasonable. If some ideas seem
unfeasible, ask how they arrived at this choice and whether they can think
of alternatives. Offer suggestions if necessary, but encourage clients to

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Personal Organizing Plan

Target area: Kitchen

Item category Final location

. Dishes cupboards above counter

. Pots and pans cupboard underneath counter

. Spices small cupboard above counter

. Food—boxes, cans, etc. pantry closet

. Dish towels, aprons drawer

. Bowls and baking pans corner lazy susan

. Silverware large top drawer

. Cooking utensils 2 drawers—large and small

. Household cleaning products cupboard under sink

. Paper supplies pantry closet

. Odds and ends, hardware bottom drawer

. Glasses, stemware cupboard above counter

. Recycle bins pantry floor

. Recent magazines shelf near table, move to recycle when 6 mos. old

. Recent newspapers recycle bin if more than 2 days old

. Current financial papers & bills upright file on top of small desk

. Older financial papers, tax papers file in desk drawer

. New mail desktop, recycle bin for all junk mail

. Flyers, advertisements desktop bin, recycle old ones

. Dog food pantry bin

Figure 6.1
Example of a completed Personal Organizing Plan.

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 develop and try out their own ideas. If clients are at a loss to categorize,
some education may be helpful. When one of our clients seemed not to
understand the category of office supplies, her clinician used the website
of a large office supply company to see the categories this company used
for organizing their supplies. The client then went home to organize her
things into desk drawers as displayed on the website.

Develop a Plan for Sorting and Moving Saved Items

Use the Preparing for Organizing Form from the workbook to help clients
determine what preparations are needed before undertaking major sort-
ing tasks. These are likely to include choosing and obtaining

■ Storage furniture such as a filing cabinet, bookcase, desk

■ Containers such as clear plastic bins, cartons, large and small

boxes, kitchen containers

■ Supplies such as colored labels, markers, tape

If necessary, help clients think through where to find these things, how
to transport them home, and other practical concerns. Clients who ago-
nize over purchasing decisions may require assistance to address fears
about making the wrong choices (see chapter ).

Because many final destinations are already full of clutter when treat-
ment starts, you’ll need to establish interim locations or “way stations” to
store things until the final location is available. This process usually re-
quires () clearing a space that serves as a staging area for sorting, () clear-
ing temporary storage areas (e.g., porch, spare room), and () several
large boxes labeled with the appropriate destination and contents. You
might want to warn clients and family members that some sections of
their home will look worse temporarily while they sort.

Implementing the Organizing Plan

When the organizing plan, necessary equipment, and storage locations

are in place, clients can begin sorting their things using the following de-
cision tree (figure .).

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 Decide whether to
keep or remove item

Not wanted: Wanted:

Determine category Determine category
Trash, recycle, donate, sell Sort into nearby box

Move categorized
items to interim
Move to final location location
Trash container
Recycle bin
Box for charity
Box for family/friends Move to final
Box for sales items location

Figure 6.2
Decision tree.

The actual process of deciding whether to keep or remove items is likely

to be fraught with difficulty as clients struggle with problematic beliefs
and strong emotions. Cognitive and behavioral strategies for working on
these are given in chapters  and . For now our focus is on helping clients
select useful categories, plan the organizing process at home, and prac-
tice sorting into categories in the office using items brought from home.

Skills for Organizing Paper

Creating a Filing System for Documents

People who hoard often mix important and unimportant things, such as
checks and bills mixed with grocery store flyers and newspapers. We sus-
pect this is because everything seems important and therefore is put in
the same pile. To help with the chaos in their lives, it is crucial to set up
a filing system for bills and documents, as well as places to store other

123
 papers such as informational materials, upcoming events, travel infor-
mation, pictures, and so on. Establishing a filing system early on helps
with the sorting of items in each room. A commonsense approach to
creating this system is best, and clients can be encouraged to consult
with friends or family members if they feel stuck deciding how and
where to file papers. Many decisions are straightforward, but some diffi-
cult ones require extra thought. Examples include what to do with old
bills and how long to keep financial and tax documents. We provide
some suggestions here:

How Long to Save Paper

Keep for One Month

■ Credit card receipts

■ Sales receipts for minor purchases

■ Withdrawal and deposit slips. Toss after you’ve checked them

against your monthly bank statement.

Keep for One Year

■ Paycheck stubs/direct deposit receipts

■ Monthly bank, credit card, brokerage, mutual fund, and retire-

ment account statements

Keep for Six Years

■ W- forms, s, and other “guts” of your tax returns

■ Year-end credit card statements, and brokerage and mutual fund

summaries

Keep Indefinitely

■ Tax returns

■ Receipts for major purchases

■ Real estate and residence records

■ Wills and trusts

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 Keep in a Safety Deposit Box

■ Birth and death certificates

■ Marriage licenses

■ Insurance policies

If clients balk at developing a filing system and putting papers out of

sight, remind them of their goals to create usable living space and to be
able to find things easily. To accomplish this, they will need to create and
use a paper filing system. You can expect that fearful beliefs and emo-
tional attachments will intrude as you develop the filing system with
clients. You may consider a behavioral experiment to examine clients’ fears
regarding a filing system. Refer to chapter  for other cognitive strategies
to use here.

Planning the Filing Process

After agreeing on the need for a filing system, the following questions are
useful in the planning process:

When is the best time to work on filing? Select a time when clients will
be alert and less likely to be distracted by other tasks.

Where will you start? Start with the area that makes the most difference
to clients.

How frequently should you file and for how long? Organizing on a very
regular basis, preferably every day or every other day, helps clients become
comfortable with their new filing system. New mail should be sorted
daily.

Where will files be stored? Do you have enough storage space? If storage
space is not yet readily available, consider storing files temporarily in
cardboard or plastic file boxes that can be stacked in an interim location
and moved later to the appropriate place.

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 What materials do you need to file effectively now and in the future? Pos-
sibilities include file cabinets, file folders, labels (especially color-coded
ones), pens, Rolodex or equivalent for address/phone information, and
boxes for temporary sorting. Consider adding shelves or bookcases. For
categories with many items, consider using large file folders or clear plas-
tic storage bins available cheaply at discount stores.

File Categories

Ask clients to review the Filing Paper Form in the workbook to deter-
mine which of the categories listed there are relevant for their own filing
systems. Each category will need its own file folder and some categories
may need to be subdivided. A list of several common categories can be
found in table ..

Table 6.2 Common Filing Categories for Paper

Addresses and phone numbers Humor
Archives: wills, insurance policies, other Instruction manuals/warranties
important papers Medical
Articles (e.g., garden, cooking, etc.) People: One file for each household member
Automobile Personal/sentimental
Calendar items (reminders for that specific Photographs
month) Product information
Catalogs Restaurants
Checking account(s) Savings account(s)
Computer School papers
Correspondence Services
Coupons Stamps
Diskettes Stationary
Entertainment Taxes
Financial Things to do, lists
Credit cards Things to file (things that have to be reviewed)
Bank statements Trips/vacation information
Retirement
Savings account(s)
Stocks

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Common Items for Filing

Paper items often require continual sorting and filing, and time is needed
during sessions to discuss strategies for this. Dealing with the daily mail
is a very common problem. Discuss how clients currently handle mail
and ask clients to bring two or more days’ worth of mail to the office for
sorting practice. While sorting it, ask clients to decide first which items
they want to keep and which ones they can get rid of. The Questions
about Possessions Form from chapter  can be used to facilitate deci-
sions. Help clients identify thoughts and feelings about mail they are un-
certain about, being careful not to appear judgmental. At this stage, do
not point out faulty logic or correct cognitive errors—simply ask for a
decision. For unwanted mail, ask whether it should go into the trash, re-
cycle bin, or an “out” box to be delivered elsewhere. If clients want to
save an item, ask to what category it belongs and help clients decide
where to put it. Most people have a box or small pile of items that are of
current interest (e.g., upcoming events clients might wish to attend,
travel plans being considered for the near future, household purchase
options not yet decided). Even these should be sorted into type, but they
can be kept in view rather than filed because of their short-term nature.
This group of papers should be examined weekly or monthly and un-
wanted or out-of-date papers discarded.

Another common problem concerns the accumulation of magazines and

newspapers. A similar decision process can be used here with the news-
papers or magazines from the past couple of weeks. Ask clients to decide
whether to keep or remove the newspapers or magazines from the house.
If kept, does the client want the whole thing or just a part (e.g., an ar-
ticle)? Determine where to put each item and how long to keep it. Help
clients develop their own rules for these decisions. Typical rules are one
week or until recycling for newspapers, and a few months for magazines.
Some magazines can be kept as resource material if clients truly use these
for this purpose. Consider canceling subscriptions to magazines and
newspapers that clients rarely read.

Remember that the initial focus of these exercises is developing the

organizing and filing systems without too much concern about clients’

127
 decisions to keep too many items. You can work on these shortly (see
chapter ).

Maintaining the System

The sheet in the workbook titled “How Long to Save Papers” may help
address clients’ questions about this issue. It is also important to help
clients establish new daily routines to replace old habits and prevent dis-
organized clutter from accumulating. The following alternative behav-
iors may be useful:

■ Pick a time to sort new mail and papers every day.

■ Incorporate some recreational time into each day after sorting to

boost spirits and reinforce the sorting work.

■ Empty trash twice weekly (more often if required).

■ Take trash out for pickup (or deliver to sanitation facilities) at the
same time every week.

■ Do dishes daily; wake up to a clean sink and counter.

■ Do laundry every week (more often if required).

■ Establish times and a system for paying bills to meet due dates.

■ Put all new purchases away upon arrival or within the same day.

■ Put away any used items as soon as the task is done.

A few succinct general organizing rules such as the following can be posted
on clients’ refrigerator doors (Anne Goodwin, personal communication):

■ If you take it out, put it back.

■ If you open it, close it.

■ If you throw it down, pick it up.

■ If you take it off, hang it up.

■ If you use it, clean it up.

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Homework

The following homework examples are recommended for developing

skills in problem solving and organizing:

✎ Have the client practice the problem-solving steps for a problem iden-
tified during the session.

✎ Ask the client to call charities and sales outlets to make plans to re-
move unwanted possessions.

✎ If items are sorted in the office, have the client take home the items he
or she intends to save and put them where they belong. If the final desti-
nation is inaccessible, the client should develop an interim location.

✎ Have the client write down the preparations that need to be made on
the Preparing for Organizing Form and complete selected tasks before
the next session.

✎ Have the client complete the Personal Organizing Plan for items re-
maining in the current target work area and assign a sorting task to put
the items into their intended location.

✎ Have the client complete an additional Personal Organizing Plan for

paper items.

✎ Ask the client to identify the appropriate filing space for paper and
nonpaper items, assemble the necessary materials, generate file cate-
gories, label file folders, and put papers in an interim or final location
for filing.

✎ Ask the client to bring in a few days’ worth of mail for use during the
organizing paper session.

✎ Ask the client to bring in items for discussion that he or she could not
decide on or categorize at home.

✎ Have the client continue at home any other tasks begun in the office.
✎ Have the client develop a plan for using cleared spaces and keeping
them clear of new clutter.

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Chapter 7 Exposure Methods

(Corresponds to chapter 6 of the workbook)

Materials Needed

■ Habituation graph

■ Questions about Possessions Form

■ Behavioral Experiment Form

Outline

■ Work with the client to develop an exposure hierarchy.

■ Begin graduated exposure exercises.

In this chapter we describe how to use graduated exposures in conjunc-

tion with cognitive therapy techniques to enable clients to reduce their
clutter. This chapter and the following one will guide treatment for the
bulk of the intervention. Exposures are aimed at reducing avoidance be-
haviors, whereas the cognitive therapy methods described in chapter 
alter thinking and beliefs that contribute to avoidance and clutter, espe-
cially when clients find that removing clutter is much harder emotion-
ally than they expected. Remember to use motivational interviewing
techniques from chapter  when clients hit emotional roadblocks that
impair their resolve. We begin with exposure strategies, including be-
havioral experiments. Remind clients to use their Personal Session Forms
to keep track of what they learn and of their homework assignments.

131
Setting the Stage for Exposures

Identifying Avoidance

Sorting possessions entails exposure to several components of hoarding

that clients usually avoid. Review the hoarding model to remind clients
to identify what they are trying to avoid and to show how avoidance
maintains their fears and their clutter. For example, keeping items in a
disorganized way helps them avoid distress about making decisions that
might be wrong (mistakes), worries about memory and about losing an
opportunity or information, feelings of loss and vulnerability, and em-
barrassment about clutter and inviting people home. (Of course, some
forms of avoidance are actually adaptive. For example, not allowing any-
one into the home protects clients from ridicule, scrutiny from authori-
ties, or eviction.) Indicate that clients’ strong negative reactions to get-
ting rid of possessions trigger strong urges to avoid these feelings, fitting
the pattern of most anxiety problems. Unfortunately, the more people
avoid facing their fears, the more entrenched their discomfort becomes
so that soon emotions, rather than rational thinking, control what they
keep and discard.

Habituation

Exposure to avoided situations is the most effective way to overcome fear

and discomfort. Label this process habituation and describe it as follows:

When we are uncomfortable in a situation in which there is no actual

danger (for example, encountering a friendly dog), our discomfort de-
clines over time as a natural process; we habituate. This is what hap-
pens to people who live near a train track or a subway line. When
they first move in they hear the noise whenever it occurs, and it keeps
them awake at night. But soon, they barely notice it and sleep through
it easily. The same process of habituation happens when we are ex-
posed to situations that make us anxious. Initially, we are very un-
comfortable, but with time we become used to it and it no longer dis-
turbs us. For example, children with dog phobias can overcome their

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 Discomfort during exposure

Anxiety

Time

Figure 7.1
Habituation graph.

fears through gradual exposure to dogs of increasing “scariness,” start-

ing with puppies, then little dogs, and eventually larger dogs. Fearful
children are initially uncomfortable, but this discomfort gradually de-
creases over time until eventually they can pet and play with the dog
without discomfort. Let me illustrate what happens on a graph.

Use the habituation graph (figure .) or a similar hand drawing to illus-
trate the gradual drop in discomfort, but indicate that not everyone follows
exactly the same pattern. Some people habituate slowly, others quickly,
and others have up-and-down reactions that gradually reduce over time.
Remind clients that discomfort is not something they can control or talk
themselves out of. It is a physiological process that requires repeated ex-
posure practice to reduce discomfort. Emphasize that the experience of
some discomfort is necessary for habituation to occur, and that this is
part of the process of learning how to control their hoarding problem.

Developing an Informal Hierarchy

Exposure is easiest to accomplish by helping clients develop a hierarchy

of increasingly difficult sorting situations. For example, discarding pa-
pers with unidentified phone numbers may be easier for a client, whereas

133
 getting rid of newspapers is harder. Help clients create their own list of
types of items and locations in the home, ranked from easy to hard. This
need not be a formal list, but serves as a general plan for sorting, mov-
ing, and removing clutter. Remind clients that they will undoubtedly ex-
perience some discomfort while they sort their things, and the intent is
to increase their tolerance gradually for making decisions and getting rid
of items. To make progress on the clutter, clients must learn to tolerate
some discomfort, because removing things that cause no discomfort will
not help them reduce anxiety and learn new skills to prevent future
hoarding. In addition, clinicians will introduce various cognitive therapy
techniques to help them deal with beliefs that have been reinforcing
hoarding problems.

Direct Exposure to Sorting

Sorting at home should begin in areas and with objects that are relatively
low on the discomfort hierarchy. Proceed with the following general steps:

■ Select the target area.

■ Determine the types of possessions in the target area and eventual

storage locations.

■ Assemble the necessary organizing materials to facilitate moving

the items.

■ Determine which items will be easiest and hardest.

■ Select a type of possession to begin with (e.g., clothing, newspapers).

■ Use the categories and filing systems created earlier to select in-
terim and final locations.

■ Permit a temporary “undecided” category when clients are unable

to decide.

■ Identify hoarding beliefs when clients have difficulty deciding or

letting go.

■ Apply cognitive strategies as appropriate (discussed later).

■ Continue until the target area is clear.

134
■ Plan the appropriate use of the cleared target area immediately.

■ Plan how to prevent new clutter to this area.

Sorting in the office should mimic the work at home by having clients
bring in boxes or bags of things from the areas they are working on, es-
pecially papers they think will be hard to sort on their own as homework
until they have practiced with the therapist. Typical examples are stacks
of papers collected from one area like the surface of a table or desk, or a
stack of things on the floor. Mail is often an excellent thing to bring to
office sessions if clients have problems opening and sorting mail every
day. Likewise, newspapers, magazines, or other saved paperwork that is
not filed can be the focus of decisions about sorting and discarding.

By now it should be clear that exposure to fears about making the wrong
decision, losing an opportunity, and forgetting important things happens
naturally during the course of sorting at home and in the office. Dis-
comfort arises when clients decide to put away items (out-of-sight fears)
they choose to keep, as well as when they decide to get rid of them.
When easy and hard items are mixed together throughout the home, set
aside more difficult items for later discarding and work first on easier
items, even if this means that initially only a few items are discarded.
When clients have difficulty deciding to get rid of items they must even-
tually learn to discard, ask them to discuss their thoughts and feelings
about this, including how uncomfortable they feel (using a scale of  to
, where  equals no discomfort and  is the most uncomfortable they
have ever felt). Ask them to review the list of Questions about Posses-
sions from the workbook to identify questions that seem especially perti-
nent to their decision-making process. When they are able, ask clients to
put the item in a discard (or recycle) box and again rate their discomfort,
pointing out habituation whenever this occurs. Emphasize the need to
tolerate some discomfort, which will decline, and the importance of per-
sistence in the face of discomfort.

Sometimes clients need to begin removal with very low discomfort

items. One way to accomplish this is to give clients an insignificant item
(e.g., yesterday’s newspaper, unopened junk mail, a receipt, a pencil
stub) or one that does not belong to them and is likely to provoke lim-
ited discomfort when discarded. Ask clients to give up the item and in-
dicate how much discomfort they feel in doing so. Invite discussion of

135
 their feelings and the attitudes and beliefs that seem to underlie them.
Look for classes of objects that may be appropriate for exposure treat-
ment in the coming sessions. To help clients habituate to feelings of guilt
over being wasteful, they will need to discard things others might con-
sider useful. For this situation, you can ask clients to buy a newspaper or
other minor but useful item and recycle it before reading or using it.

As skill in sorting and decision making improves, discomfort gradually

habituates and progress increases. But progress on sorting is rarely en-
tirely smooth, and many clients, especially those with traumatic histo-
ries connected to their hoarding, move forward in fits and starts. Be pa-
tient and look for incremental progress you can highlight when clients
become discouraged by the slow pace. Emphasize the goal of categorizing/
sorting and removing as much material as possible, and the necessity for
experiencing some discomfort to notice that it declines with time.

Establishing Rules

Sorting can be facilitated by creating a set of general rules that remove

the necessity of making decisions about each separate object. Ask clients
to generate rules they will find useful in determining when to discard ob-
jects, and record these rules on paper for reference during sorting expo-
sures. For example, items not used in the past year and those with more
than one copy could be discarded. Another example is to get rid of all
items of clothing and jewelry that are not flattering.

Because recycling, selling, and giving away items is easier for many clients
than discarding, it is wise to have rules for these categories as well, espe-
cially when clients overestimate what can be sold or recycled. Clinicians
can help clients obtain their community’s recycling specifications and
review them with their clients to encourage compliance. Some clients
want to sell or give away items that are not acceptable for this purpose
or would require tremendous time and effort to clean or repair. General
definitions or rules will be helpful in such cases. Socratic questioning
and taking another perspective are methods that may help clients rec-
ognize what items would or would not qualify for recycling, selling, or
giving away.

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Extended Exposure: Clean-outs

Clean-outs are usually day-long affairs in which the client’s family and
friends or the clinician’s staff or students are enlisted to help clear away
clutter. These extended sessions expose clients to a variety of situations
that are typically avoided, such as allowing others into the home, letting
others touch and even make decisions about some items (after basic rules
are established), making decisions quickly, and, of course, discarding.
The timing and planning of clean-outs are crucial. Holding a clean-out
before the client is ready can create frustration for both the client and
the therapist, and can set back the course of treatment. Clients must first
have practiced discarding so they can make decisions quickly and with
limited discomfort. In our experience, clean-outs work best when a sig-
nificant amount of the material is destined for the trash (instead of do-
nation or sale) and the volume of clutter is simply too large for clients
to manage easily. A well-timed and planned clean-out can result in rapid
improvement that is followed by renewed effort and sustained reduction
in clutter.

Clean-out sessions require advance planning to set ground rules for how
volunteers will move objects from the house to the dumpster and to pre-
pare clients to make rapid decisions about objects. Arrangements must
be made to coordinate dumpster delivery and pickup or other trash-
hauling plans to ensure that discarded items are removed from the prop-
erty on the same day to prevent clients from retrieving or searching
through items again.

Rituals: Washing, Checking, and Reassurance Seeking

A number of clients with compulsive hoarding also have other OCD

symptoms, including contamination fears and washing or cleaning ritu-
als, fears of making mistakes, and concomitant checking and reassur-
ance rituals. In the case of contamination fears, decide whether addi-
tional work on this problem is needed before, during, or after work on
hoarding. Contamination fears that interfere with progress on hoarding
symptoms will require attention at the outset of therapy. Several manu-

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 als (see the list of suggested reading at the end of the book) are available
to help clinicians work on this problem.

When OCD rituals are mild enough to address during hoarding treat-
ment, clinicians can ask clients to minimize and eventually eliminate them.
For example, one client agreed to reduce her washing of items for her
cupboards, so she simply wiped them briefly and put them away. She
agreed that after her sorting was completed, she would decide how much
general cleaning was needed in her kitchen and that this would be much
easier when all items were put away.

Checking rituals are often inherently tied to hoarding fears as clients

check papers, envelopes, and other things to make sure they have not
missed something. After discussing the problem and determining what
“normal checking” would look like among friends or relatives, encour-
age clients to reduce gradually the time they take for this. Several sessions
of sorting will probably be needed to practice this and to increase effi-
ciency and speed. The Questions about Possessions Form, other cogni-
tive strategies, and behavioral experiments to determine whether refrain-
ing from checking is tolerable can be useful here. Eventually, clients should
establish formal rules to limit their checking behavior.

Many clients avoid decision making and assuage their fears of making
mistakes by seeking reassurance from the clinician, family members,
friends, coworkers, and others. It may be difficult to distinguish clients’
requests to clarify a treatment assignment or to decide about discarding
an item from repetitive reassurance seeking that reduces discomfort.
Problematic requests can usually be identified by their persistence. Clients
repeat their question, often in several different forms, seeking to allay
their anxiety rather than obtain new information. If in doubt, ask clients
directly whether they already know the answer, but feel anxious and
obliged to verify by asking again. Inquire about their thoughts just be-
fore they asked to determine automatic thoughts and interpretations.
Cognitive strategies may prove useful here, or simply arrive at an agree-
ment about minimizing or eliminating requests for reassurance. Be sure
to ask family and friends to follow the same rule.

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Imagined Exposure

We have previously described visualization techniques that are useful in

planning treatment (see chapter ). Some additional imagery exposures
can be effective aids to direct exposure when clients are too fearful to
begin sorting and discarding, and when they have fears of catastrophic
outcomes (e.g., house destroyed) or believe in unrealistic possibilities.
The methods given in the following pages require that your client be
able to form clear images and to feel the emotions associated with the
images. Imagined exposures should be followed with actual exposures as
soon as feasible.

Using Imagery Before Direct Exposure

As for other anxiety disorders, prolonged imagined exposures can help

hoarding clients prepare for direct exposures they fear and avoid. Clini-
cians can use this strategy when clients are reluctant to engage in dis-
carding tasks or have been unable to complete homework, usually because
they fear some catastrophic outcome from sorting and discarding. Begin
by asking clients to close their eyes and imagine the feared situation. Ask
them to describe the situation using the first person (e.g., “I am sitting
in my living room in front of a pile of newspapers”). Ask them to pro-
vide sensory and especially visual details to help make the image as clear
as possible. Inquire about the client’s thoughts and emotions in reaction
to the context and then gradually move the action forward so the client
imagines the most unpleasant aspects of the scenario and dwells on them.
Guide the imagery, asking clients to describe the details and report regu-
larly on their thoughts, feelings, and actions. Include feared outcomes,
such as finding that a discarded item is desperately needed. Ask clients
to rate their discomfort every  to  minutes and continue the scene until
discomfort has declined noticeably, preferably by half its peak amount.
This may take as long as  minutes or more for the initial scene.

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Imagined Loss of Possessions

Imagery exposures may be useful when clients have strong fears of los-
ing their things through a catastrophe (to fire, flood, and so forth). They
also help clients decide the relative value of objects they own. Ask clients
to imagine that their home will be destroyed soon by a forest fire, an
earthquake, or a flood and that they have a short window of time in
which emergency personnel will allow them to remove a few personal
belongings before they leave. Keep the time period long enough to allow
them access to several important items, but short enough that they can-
not save unimportant items. What would they save if they had one
minute? What would they save if they had  minutes? Paint this picture
with sensory details, thoughts, emotions, and actions. Clients can do this
exercise in the office or as a homework assignment. Ask them how they
would cope if they actually lost everything they owned (an analogy to a
recent disaster in the news may be useful, so clients imagine themselves
in the place of people who lost their homes). What would they mourn
most? What would be okay to lose? Ask what is lost and also what they
retain (e.g., memories, capacities, family, and friends). Use the exercise
to help clients establish priorities regarding the value and importance of
items. This imagined exercise can be used in conjunction with the defin-
ing importance and value cognitive strategy described in the next chapter.

Imagined Exposure to Lost Information

A consistent theme in trying to remove newspapers and magazines is the

belief that they contain interesting or useful information that should not
be discarded. In this case, ask clients to imagine all the newspapers and
magazines in the world, and all the information and potential opportu-
nities they contain. Have them try to picture all the newspapers in the
United States they have not yet read. Of course, even for a single day, this
would mean many thousands of newspapers produced in cities and
towns across the United States, which would fill a large space. Related
imagined exposure can focus on the number of lectures they have missed
or other informational venues they have not accessed (e.g., Internet in-

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 formation). After discomfort habituates to the relevant scene, plan to do
actual visits to newsstands or magazine shops as homework.

Behavioral Experiments

Behavioral experiments provide a brief version of gradual exposure with the

added feature of testing a hypothesis or belief. As noted earlier, the test-
ing of beliefs is often about the severity of clients’ discomfort while try-
ing to get rid of or not acquire an item. Here we use experiments to test a
variety of clients’ beliefs that support their hoarding. We suggest using
the Behavioral Experiment Form from the workbook for each experiment.
Clients first state the context and record in writing their hypothesis
about what will happen, and then rate the strength of belief and initial
discomfort. Clients record what actually happened after the experiment
and their actual discomfort. Then, they state whether their prediction
came true, how they explain what happened, and their conclusion about
whether their original belief was correct. Obviously, this experiment is
intended for situations in which clinicians believe there is a high likeli-
hood that clients will learn that dire predictions do not come to pass and
that their beliefs are mistaken. Behavioral experiments can be used through-
out the therapy to test and modify clients’ thinking. Figure . shows an
example of a completed Behavioral Experiment Form.

Needing Objects in Sight

When the sight of a possession evokes strong emotions and memories

that increase its perceived value, ask clients to distance themselves physi-
cally and temporally from the item and then get rid of it. Suggest that
clients give the item to a friend or to the clinician to hold for one week
or more if needed. At the end of the time period, clients decide whether
to keep or dispose of the item without the client seeing it again. The ini-
tial hypothesis is that clients will be unable to part with the object without
careful scrutiny, and the final conclusion is hopefully they find it easier
to get rid of things that are not in sight, suggesting that they attach im-
portance to objects they see that is disproportionate to their actual value.

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Behavioral Experiment Form

Initials: MS Date: 12/05/06

. Behavioral experiment to be completed: Getting rid of piles of clutter around my bed.

. What do you predict (are afraid) will happen? I will feel more unsafe and vulnerable and I

won’t be able to tolerate it. I might be more likely to have a break in or assault.

. How strongly do you believe this will happen (–%)? 70% feeling more vulnerable; 35%

more likely to have break in/assault.

. Initial discomfort (–) 60%

. What actually happened? No one broke in and I wasn’t hurt. I did feel more vulnerable but

that only lasted 2 nights after I got rid of the piles around my bed. It was also easier to

move around my bedroom so it took less time to get ready in the morning.

. Final discomfort (–) 20%

. Did your predictions come true? No, they didn’t and I felt better than I expected.

. What conclusions do you draw from this experiment? That some of my fears aren’t really

valid. I was just too afraid to try it out. I’m safer than I think in this apartment.

Figure 7.2
Example of a completed Behavioral Experiment Form.

Influence on Your Life Experiment

Many hoarding clients express the belief that they could not live with-
out some of the things they have collected. Clinicians can suggest an ex-
periment to test whether having a newspaper influences their life. To-
gether the clinician and the client should select a paper the client believes
to be important and then gives it to the clinician, who keeps it for the
duration of the experiment. The client then keeps track of how not hav-
ing the paper affects his life during the coming week (e.g., ability to eat,

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 sleep, work, exercise). The client also notices whether any situation arises
in which the paper was needed and whether he was able to cope with
this. Feelings that occur without the paper (fearful, vulnerable, depressed,
and so on) are also recorded. The client’s stated hypothesis will likely
prove untrue as he forgets about the paper within a day, ends up not
needing it during the week, and feels calm and disinterested in it at the
next session.

Complications With Behavioral Experiments

Beliefs and behavior patterns in hoarding are notoriously rigid and re-
sistant to change. Behavioral experiments allow clients to “try on” new
behaviors or beliefs without having to give up their old ones. Because
these patterns are so persistent, clients sometimes alter behavioral experi-
ments to avoid discomfort. For instance, a client may go shopping just
before a nonshopping exposure is planned. One of our clients arranged
for a friend to rescue an object she was supposed to discard as part of an
experiment to test her beliefs about waste. Thus, as much as possible, cli-
nicians should anticipate these complications and plan accordingly. When
such events happen, they can be used as valuable learning experiences
(e.g., by examining how much the fear of wasting something controls
the client’s mood and behavior).

Homework

A variety of homework assignments involving exposures can be consid-

ered. The following are suggestions, but clinicians can devise any strat-
egy that fits well with what happened during the session. Generally it is
a good idea to assign homework that is similar to what was done during
the session to provide instruction and practice. Careful thought should
be given to how long clients can work alone. Make sure assignments are
constructed so information is generated regardless of the outcome. Clients
often fail to do their homework or do it improperly or have some un-
foreseen events occur. Be prepared to use the information provided by
these occurrences as opportunities to learn more and refine the practice
assignments. Of course, successful homework outcomes (discomfort de-

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 creased, decision making became easier) will increase clients’ willingness
to continue in this vein. Make sure clients write down the assignment on
their Personal Session Form so there is no confusion about the task.

✎ Have the client imagine getting rid of items before actually discarding/
recycling them.

✎ Have the client list items to be saved if his or her home were to be de-
molished by an imminent disaster.

✎ Have the client sort objects of increasingly greater difficulty and moni-
tor how much was removed from the home and the level of discomfort
in doing so.

✎ Instruct the client to conduct behavioral experiments to test hypothe-

ses, especially about discomfort and consequences of letting go of
possessions.

✎ Have the client take home items sorted during their session and store
them where they belong.

✎ Ask the client to bring in items (e.g., photos, mail, items from a par-
ticular area) to office appointments for sorting and decision-making
exposures.

✎ Have the client make arrangements for trash removal and, in the case
of a major clean-out, for dumpster delivery and removal.

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Chapter 8 Cognitive Strategies

(Corresponds to chapter 7 of the workbook)

Materials Needed

■ Problematic Thinking Styles list

■ Questions about Possessions Form

■ Advantages/Disadvantages Worksheet

■ Downward Arrow Form

■ Thought Record Form

■ Need versus Want Scales

■ Perfection Scale

Outline

■ Help the client identify errors in thinking.

■ Work with the client to apply cognitive therapy techniques during

behavioral exposures.

If you are not already familiar with the general application of cognitive
therapy, we recommend reading Judith Beck’s () book titled Cogni-
tive Therapy: Basics and Beyond (especially chapter ) and Adrian Wells’
() book Cognitive Therapy of Anxiety Disorders: A Practical Guide. The
cognitive therapy techniques included here are designed to help clients
step back and take a different perspective on their hoarding problems
while clients are sorting possessions in the office or at home, and while
they are making decisions about keeping or removing them. In the next

145
 chapter we apply cognitive and behavioral methods to acquiring prob-
lems in which curbing impulsive behavior is key.

Thinking Styles or Cognitive Errors

Among the easiest of cognitive strategies to apply during sorting sessions

is helping clients observe their habitual ways of thinking that reinforce
hoarding beliefs and behavior. Identifying these patterns helps clients
learn to avoid mental traps that stem from these automatic mental pat-
terns. The Problematic Thinking Styles1 list in the workbook will help
clients identify these thinking errors when they occur during the office
and homework assignments. Note that determining the category of the
thought is less important than helping clients notice their illogical thinking.

■ All-or-nothing thinking—Black-and-white thinking exemplified by

extreme words like most, everything, and nothing often accompany-
ing perfectionistic standards. Examples are “This is the most beau-
tiful teapot I have ever seen” and “I won’t remember anything
about this if I can’t bring home this reminder.”

■ Overgeneralization—Generalization from a single event to all

situations using words like always or never. Examples are “I will
never find this if I move it” and “I’ll never have another opportu-
nity if I don’t get this now.”

■ Jumping to conclusions —Predicting negative outcomes without

supporting facts, akin to catastrophizing (described next). For
example, “I’ll need something just as soon as I don’t have it
anymore.”

■ Catastrophizing—Exaggerating the severity of possible outcomes.

For example, “If I don’t buy it now, I’ll regret it forever” and “If I
throw it away, I’ll go crazy thinking about it.”

■ Discounting the positive—Positive experiences are not counted, as

in the statement “Creating a filing system isn’t really progress, be-
cause there is so much more to do.”

1
The list is adapted from Burns ().

146
 ■ Emotional reasoning—Using emotions instead of logic so feelings
substitute for facts. For example, “If I feel uncomfortable about
throwing this away, this means I should keep it.”

■ Moral reasoning—Should statements (including must, ought, have

to) accompanied by guilt and frustration, and often driven by per-
fectionistic standards, such as “I have to have this health informa-
tion in case something happens to John.”

■ Labeling—Attaching a negative label to oneself or others, such as

“I can’t find my electric bill. I’m an idiot” and “She’s just greedy
and wants all my stuff.”

■ Under- and overestimating—Underestimating the time to accom-

plish a task or one’s ability to cope or, conversely, overestimating
one’s ability to complete a task or the emotional costs of doing so.
For example, “I’ll be able to read those newspapers eventually” or
“If I get rid of this, I won’t be able to handle it.”

We recommend assigning clients the list of thinking styles for home-

work and discussing it the following week during their session. During
sorting tasks, clinicians can comment whenever they notice a thinking
error by asking clients which one it might be, using the list for easy ref-
erence. After the error is identified, discuss alternative thoughts by ask-
ing, “What’s another way of thinking about this?” If clients have trouble
coming up with a replacement, suggest one (e.g., “Even if I feel uncom-
fortable about getting rid of this, I might get used to it”) and discuss it.

Automatic Thoughts, Interpretations, Beliefs, and Core Beliefs

Recall that during the assessment and building the hoarding model, you
and your client identified relevant thinking and beliefs from the Saving
Cognitions Inventory, their list of reasons for saving, and/or completing
Brief Thought Records during visualizing or trying to discard. These cog-
nitions included automatic thoughts about getting rid of an item (e.g.,
“Oh no, I need that!”) and interpretations or beliefs (e.g., “I might never
be able to find this again” or “It’d be wasteful to get rid of this”) that jus-
tify hoarding behavior. These interpretations often contain cognitive

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 Table 8.1 Hoarding Beliefs
Value of objects
Objects representing personal identity
Objects representing safety
Need for objects
Ability to tolerate discomfort
Perfectionism
Responsibility for objects
Responsibility to people
Usefulness, avoiding waste
Confidence in memory
Need for control over objects

errors, as discussed earlier, and beliefs typically concern one or more of

the topics listed in table ..

Core beliefs have a global, overgeneralized, and absolute quality, and can
usually be very simply stated. Often they are just negative labels for the
person as a whole. When activated, core beliefs drive clients’ interpreta-
tions of events and elicit powerful negative emotions. In some cases, core
beliefs may also refer to other people. Not surprisingly, these beliefs de-
rive from early important experiences in the person’s life. For example,
“I’m bad,” “I’m a failure,” “I’m inadequate,” “I’m unlovable,” “I’m un-
worthy,” “People can’t be trusted,” and “People are mean.” In addition
to these negative core beliefs, many clients also have positive ones, such
as “I’m capable,” “I’m a good person,” and “Other people mean well.”
The clinician’s aim in using the cognitive strategies described here is to
help clients strengthen positive beliefs while examining and disputing
negatives ones.

Cognitive Strategies

The cognitive therapy methods for hoarding described here are best used
while clients are sorting, organizing, and getting rid of clutter. That is,
we recommend combining cognitive methods with behavioral exposure.
An important goal is to help clients learn how to observe their own re-
actions and become aware of their thinking in hoarding contexts as a
first step toward changing those reactions. Once you identify the im-
portant beliefs that maintain hoarding, you’ll want to help clients to
evaluate their accuracy using the strategies described later. These meth-
ods are intended to promote rational alternative viewpoints that are

148
 more plausible to clients than the original interpretation or belief. Keep
in mind the alternative belief you are aiming for, such as “I’ll be able to
find the information if I need it” or “These are just things; they don’t
represent me as a person” or “Putting things away where they belong
means I can find them when I want to.” We have had success with the
cognitive therapy methods suggested in the following subsections.

Questions About Possessions

Sometimes additional strategies are necessary to get hoarding clients to

engage in exposures. When hoarding clients consider a possession, they
think mostly about the qualities that led them to save it, but pay little or
no attention to the consequences of that decision. The Questions about
Possessions Form from chapter  helps clients pay attention to reasons for
not keeping an item. Use this form for in-session sorting exposures and
as a homework aid. Review the questions to determine which ones seem
most useful for a particular client and encourage clients to add other
questions they think might be useful.

Advantages and Disadvantages

People who hoard also tend to focus on the immediate costs associated
with discarding something, while ignoring the costs of saving all these
possessions and the benefits of getting rid of them. Examining the ad-
vantages and disadvantages of reducing working on hoarding was de-
scribed in chapter  on motivational interviewing. Here it is applied to
specific decisions about keeping or getting rid of possessions while clients
are sorting. Help them state the personal advantages of keeping an item,
followed by the disadvantages. Use the Advantages/Disadvantages Work-
sheet from the workbook. Figure . shows a completed example.

If clients overlook obvious advantages or disadvantages, suggest some

possibilities based on previous conversations. Notice that the disadvan-
tages of keeping items are very similar to the advantages of getting rid of
them and vice versa. After listing all the ideas, summarize the costs and
benefits using an alternating approach. For example, “On the one hand,

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Advantages/Disadvantages Worksheet

Specify the item(s) under consideration: Newspapers

Advantages (Benefits) Disadvantages (Costs)

Of keeping/acquiring: Of keeping/acquiring:

I’ll be well informed if I read them because They take up a lot of space
they might contain important information

I always have things to read I feel inadequate because I haven’t read

them. They are a burden I always have to
face

I can use them as packing material once I It’s hard to clean the house and the floor
read them boards are beginning to buckle

I can’t find things I know are in there

Of getting rid of item: Of getting rid of item:

I’ll have more space I might miss important information if I get

rid of them

I’ll have more freedom and won’t feel so I’ll feel guilty if I don’t read them all
obligated to them

I’ll have more time to read books or do

other things

The house will be cleaner and in better

condition

Figure 8.1
Example of completed Advantages/Disadvantages Worksheet.

150
 you like having all this information around you. It helps you feel well in-
formed. But on the other hand, you also find that having so many news-
papers is a burden and you feel guilty, you can’t find information you
want, and the house is dirtier and has less space for other things.” Avoid
overemphasizing costs and just state the findings. Then, ask clients what
conclusions they draw from this exercise. Reinforce conclusions in favor
of change with mild agreement (“That makes sense to me too” or “I tend
to agree with you”) but don’t overdo this or tentative clients may retreat
and focus on the advantages of their current behavior and the disadvan-
tages of change.

When clients agree on the need to change (e.g., remove clutter), discuss
explicit methods for doing so to cement plans for discarding. You can
also remind clients of costs and benefits when they become fearful and
ambivalent about getting rid of things. This will help them keep the
entire picture and their goals in mind when the going gets rough. The
advantages/disadvantages technique can be used for individual items
(like a receipt) and for general types of items (all receipts found in a par-
ticular place or past a certain date). Obviously, using the method for
groups of similar items is most efficient, but some clients may require
work on several individual items before they can group them together to
make a global decision. This technique also works well for fears about
putting things out of sight while organizing and for adhering to perfec-
tionistic standards. Keep in mind that asking about the costs of hoard-
ing also elicits negative emotions and even depressive feelings. This re-
quires sensitivity to clients’ needs to avoid associating negative feelings
with the therapy itself.

Downward Arrow

The downward arrow method helps identify catastrophic fears, as well as

strong or core beliefs and is often useful during visualization or exposure
tasks. Label and describe this task as a cognitive technique that helps clar-
ify thoughts and beliefs. For example, ask clients to select an item that
would provoke moderate discomfort when they think about discarding
it and list this on the Downward Arrow Form in the workbook. Ask them
to rate how distressed they feel about throwing this item away using a scale

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 of  to  where  is no distress and  is the most distressed they have ever
felt. Then continue with a series of repetitive questions after each response:

“What would that mean?”

“If that happened, what would that mean?”

“What would be the worst part about that?”

“Would anything else happen?”

If clients give unrelated thoughts ask, “Do you have any other concerns
about this?” Do not press if it seems difficult for clients to identify deeper
meanings. After reaching the client’s bottom line (no further thoughts
occur), connect the final belief or catastrophic fear to the original prem-
ise to help clients understand their own assumptions. These steps are il-
lustrated in the following dialogue for fears of putting items out of sight.

Case Vignette

Clinician: I’d like to use what we call a downward arrow method to understand
your thoughts about moving this out of the living room. It helps us
figure out your beliefs that get in the way of organizing things by put-
ting them away. Let me start by asking, What do you think would
happen if we move these papers into files in your file cabinet?

Client: I might never find them again.

Clinician: Okay, if you didn’t find them again, what would happen then?

Client: I might lose important information I would never find again.

Clinician: Why would this bother you?

Client: I’m not sure, maybe I wouldn’t know something I needed to know, you
know, about my health or something.

Clinician: Uh huh, if you did have a health problem and couldn’t find informa-
tion about it here in your home, what would that mean?

Client: I’d be unprepared for it.

Clinician: What’s the worst part about that?

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 Client: I could get really sick or die because I didn’t know what to do.

Clinician: What would that mean to you?

Client: Just that I’d be unprepared and sick. I can’t think of anything else.

Clinician: Okay. I think what you are saying is that moving these papers out of
your living room means you’d be unprepared and you’d get sick and
die. Is that how you see it?

Client: Well, that sounds a bit extreme, doesn’t it?

Clinician: Extreme? How so? [The clinician lets the client make the logical con-
nections to solidify learning.]

Client: You know, moving the papers won’t make me sick or even unprepared
because I’d have them, just not in here. And anyway, these papers
might not help with whatever sickness I get. I guess it doesn’t make a
lot of sense to keep them here.

Clinician: Okay. That makes sense. Shall we move them? [The clinician rein-
forces small changes in thinking by encouraging a corresponding be-
havior change as soon as possible.]

Client: Yeah, I guess so. It’s still hard, though.

Clinician: I understand. As you said, your behavior of keeping them here doesn’t
make much logical sense, and I have to agree with you. Let’s try mov-
ing them and see if you get used to it.

Client: Okay.

Because many clients are unaware of the presence of beliefs that drive
their hoarding, clearly stating them makes them more accessible and eas-
ier to evaluate. The downward arrow procedure can be repeated several
times until the beliefs become clear (e.g., “I’ll be stupid for not buying
this”; “As soon as I get rid of it, something terrible will happen and I’ll
need it”). Clinicians can then help clients examine the evidence for such
beliefs using other cognitive strategies suggested in the following para-
graphs, such as determining where the idea might have originated (fam-
ily teaching, personal trauma), using Socratic questioning to evaluate
the logic, and designing behavioral experiments.

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Socratic Questioning to Examine the Evidence

The Socratic questioning method involves asking clients a series of ques-

tions about their beliefs to clarify the logic they are using. The clinician’s
main aim is to point out the obvious holes in clients’ reasoning by ask-
ing questions that highlight discrepancies in their assumptions that don’t
make logical sense. This method relies on open-ended but directive ques-
tions. It is not forceful or argumentative and avoids phrases like “Yes,
but . . .” or “ . . . , right?” because these reflect efforts to convince clients
rather than ask for clarification within their own belief system and po-
tential alternative ways of appraising situations. Thus, like motivational
interviewing, the questions are exploratory to help clients review the evi-
dence they are using to draw their conclusions. Encourage clients to
think of themselves as scientists or detectives and to state their beliefs in
the form of hypotheses. For example,

You have been trying to keep everything in sight on the assumption

that this helps you know where things are. This is a hypothesis—that
keeping things in sight helps you remember them. Let’s examine the
truth of this hypothesis and see if there are any alternative viewpoints
as well. Then we can determine whether there is evidence to support
either hypothesis.

Clinicians ask curiosity questions to elucidate ideas and often rephrase

clients’ statements in slightly different words to verify that they under-
stand correctly. These questions are generally focused on the following
questions to the client:

■ “What evidence supports your hypothesis?” “What evidence

refutes it?”

■ “Is there another way of looking at that?”

■ “What is the most likely outcome?”

■ “Are you using any thinking errors?”

The following dialogue is an example that contains Socratic questions that

might be useful for a client with fears about putting things out of sight:

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 Case Vignette

Client: I like to keep things where I can see them. That way, I don’t forget
things that are important.

Clinician: Okay, your idea is that if you have things in piles you can see in front
of you, you won’t forget them and you can find them. [Client nods.]
How long do important things actually stay in sight before being cov-
ered? Let’s take this paper here, it looks like a receipt. Is it important?

Client: Yeah, I might need to return the item. Maybe it stays there a few days
or a week. I do set things on top, I know.

Clinician: So it’s visible for a few days but not much more. If you wanted to re-
turn it about three weeks from now, do you think you would find it
easily?

Client: I’m not sure. I might.

Clinician: [Rather than dispute the client’s statement, the clinician moves on.]
This pile here seems to have a mixture of things. Are you able to re-
member everything in this pile? I think that was your goal, to put it in
sight and remember it, yes?

Client: Yeah, I do know some of what is in the pile, but maybe not every-
thing.

Clinician: So, if you wanted to be sure to find something, like the phone bills
you were looking for the other day, is it best to put them in this pile
when they come? Or is there a better place to put it?

Client: I should keep them all together, probably on the desk. It’s a hassle
though, you know.

Clinician: Um, I guess so, but I think you are saying that putting the bill on the
pile isn’t really the best way to remember that you have it or where you
put it. Is that right?

Client: Yeah, not really.

Clinician: You also mentioned that you put things on the pile so you don’t forget
about them and I’m wondering what you think is the best way not to

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 forget things. Maybe we could use an example, like a bill you have to
pay or an event you want to go to. What’s the best way to remember?

Client: Oh, I put those on the fridge door, you know, then I see it.

Clinician: So the pile isn’t the best place for things you really want to remember.
What about a clipping you want to show me? Suppose you put this
clipping on that pile and I come to your home six months from now
and you want to show it to me.

Client: Oh, it’d be buried by then.

Clinician: Would you remember you had it?

Client: Maybe, but I might not be able to find it.

Clinician: So you would remember it without actually seeing it. Seems like you
don’t really need to see everything to remember it.

Client: Yeah, probably true.

Clinician: But remembering it doesn’t always help you find it after it goes on the
pile. Let me ask another thing. Are you sometimes surprised to find
things in the pile that you had forgotten about?

Client: Oh yeah, just the other day . . .

Clinician: So putting things on top of a pile so you can see them doesn’t always
help you remember you have them later on?

Client: I guess that’s true.

Clinician: I think you are telling me that your original idea that putting things on
the piles so you can see them doesn’t necessarily help you remember
them or find them after some time has passed. You like to keep them
in sight, and that makes you feel better, but it doesn’t always help you
find or remember them better. What do you think?

Notice that the clinician restates the original hypothesis and conclusion
but does not press the point too strongly to avoid triggering defensive re-
actions that entrench these beliefs. From here, the clinician can go on to
thinking about other ways the client could remember and find things.
These will take more effort so that must also be explored, perhaps using
the advantages and disadvantages method.

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Saving old newspapers is a very common hoarding trait. For this, the fol-
lowing Socratic questions and calculations may be helpful:

“How long would it take you to read one newspaper like this one?”

“How much time do you spend reading newspapers these days?”

“I bet you and I could probably figure out how many papers you have
now if we estimate from this pile here and multiply. [Showing the
calculations,] We think you’ve got about  papers. Let’s see, if
each paper takes about  minutes to read and you read for about
two hours a week, at that rate you can finish four papers a week, so
divide  by —it would take  weeks—about six years to
catch up. But you are also getting new papers, seven more every
week. So reading four papers a week, you’d always be behind and the
newspaper piles will just get bigger. If you doubled your reading
time to four hours each week, then it would take only three years to
read everything here, but you’d still have all the new papers. Let’s see
now, if you read for four hours plus the additional  1⁄2 hours every
week for new papers, that’s  1⁄2 hours per week to completely catch
up in three years time. To catch up in one year, it’d take you  to 
hours of reading every week, sort of like a part-time job. Is that how
you want to spend your time?”

“Do you like having piles of unread newspapers around you?”

“I’m wondering what your day-to-day life would be like if you never
read one of these older newspapers. Suppose you died some years from
now and never read one? How much would it matter in your life?”

“How does keeping these newspapers to read help you with the goals
you had at the beginning of treatment?”

If, in response to some of these questions, clients indicate they clearly

want to change the saving and reading of newspapers, the clinician
could ask: “What do you think you’d have to do to change this?” At this
point, problem solving will be useful. The problem has been defined as
too many newspapers to read. Options might include stopping current
newspapers and reducing time spent reading old ones. It can also be
helpful to provide some personal feedback when clients make irrational
statements during Socratic questioning. For example:

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 I actually don’t read my newspaper every day because sometimes, like
you, I just don’t have time. Some days I only scan the headlines and
some days I read just two or three stories, sometimes only parts of the
stories. I only remember a little of what I’ve read, sometimes nothing
at all after a few days have passed. Some days I don’t read it at all
and just put it in the recycle bin. It seems wasteful, but my time is ac-
tually more important to me than the newspaper. How does this com-
pare with your experience?

Look for clients’ unrealistic and perhaps perfectionistic expectations to

read everything and remember it, and to consider themselves inadequate
if they do not. These attitudes can be challenged with some of the strate-
gies outlined next.

Taking Another Perspective

Most cognitive strategies are designed to help clients step back from the
immediate situation and examine it from a different angle. Taking an-
other perspective and taking the opposite position can help them de-
velop alternative views. Using a model of a same-sex friend, family mem-
ber, or child can make the analogy more relevant. The following questions
are useful:

■ “Would this also be true for one of your friends?”

■ “Do you think your sister [brother] would agree with you?”

■ “Is this something you would want to teach your child?”

■ “Do you recommend that I do that?”

■ “What would you say to a friend or loved one who told you this?”

■ “What could you tell yourself ?”

In taking the opposite perspective, the clinician tries to convince the

client to keep an item while the client argues against this. This strategy
should be used to help clients who are making progress getting rid of
things but need to strengthen their wavering resolve. Clients select the
items they are considering discarding and the clinician provides various
arguments for keeping the item—mainly, the attitudes the client has ex-

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 pressed earlier during treatment. The following dialogue is an example
regarding a stuffed animal:

Case Vignette

Clinician: But this is so pretty and you know you like furry things.

Client: Yes, I do but I already have as many as I want. Besides, this one isn’t as
nice as the ones I already have.

Clinician: Well, you could keep this to give away to the neighborhood kids.

Client: I could, but they already have lots of toys.

Clinician: How about giving it away to the Salvation Army? Or you could wait
’til one of those phone call drives to collect things for charity.

Client: Uh, I can’t think of why I wouldn’t want to do that.

Clinician: Well, let’s look at some of the questions on your list to see if they can
help you make an argument that convinces you.

Client: Okay. . . . Here’s one. It will waste my time and take up space I want
for other things. It’ll be in my way and just be one more thing to deal
with. Besides, it really isn’t a nice toy anymore; it’s sort of ugly.

Clinician: But wouldn’t you be hurting its feelings?

Client: . . . You almost got me there. This is just a pile of stuffed fake fur that’s
old and dirty. It doesn’t have feelings. I’m getting rid of it now.

Clinician: You did a great job on these with very little help. Is there anything I
left out that would have swayed you?

Thought Records

In chapter  we suggested using the Brief Thought Record to help clients

understand the connection between triggering events, their thoughts
and beliefs, the emotion these cause, and the behavior that results. Dur-
ing exposures, it is time to change these beliefs gradually by asking
clients to identify alternative possibilities that make more sense to them

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 and to record the outcomes after doing this. These alternatives can be re-
corded on the expanded Thought Record forms in the workbook in the
additional column labeled “Alternative Beliefs.” Clients can come up
with alternative beliefs by using any of the techniques suggested here, in-
cluding Socratic questioning. We suggest assigning Thought Records at
home when clients become stuck on a particular item that provokes
strong feelings. Recording the item, their thoughts, emotions, alterna-
tive beliefs, and outcome helps clients concretize the process of deliber-
ately generating alternative ideas to counter usual thought patterns while
sorting. We suggest assigning only one or two of these per sorting ses-
sion, and only for difficult decisions.

Defining Importance: Need Versus Want

Thinking styles of magnifying, overgeneralizing, and emotional reason-

ing lead clients to magnify the importance of possessions to such a point
that it seems crucial to save them. To help clients decide the true value
of a possession based on their own goals and rational thinking requires
them to distinguish what they truly need from what they merely want.
The Defining Importance and Value Scales Form from the workbook
will be useful for this purpose. Ask clients to select a current possession
that would be moderately difficult but potentially appropriate to dis-
card. If clients select items that the clinician believes are reasonable to
keep, ask them to choose another that most people would probably dis-
card. Ask clients for an initial rating of need and want using the scale
from  to  presented in the following section. Then, review the ques-
tions on the worksheet, as well as the additional questions presented
here, to determine whether clients alter their ratings after thinking
through the true value of possessions in relation to their other important
goals in life. Ask clients to reflect on what they have learned from this
exercise and to make a decision about keeping or getting rid of the item.
Figure . shows an example of a completed Need versus Want Scales.
Additional questions to consider include

■ “Would you die without it?”

■ “Would your safety be impaired without it?”

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 ■ “Would your health be jeopardized without it?”

■ “Is this critical to your work or employment?”

■ “Is this needed to keep your financial records in order?”

Perfectionism Continuum

Especially useful for patients with dichotomous and perfectionistic

thinking is a discussion of the continuum of perfection, as represented
in the following scale:

Perfection Scale
----------------------------------------------------------------------
Defective Average Perfect
Wrong Okay Exactly Right

Review the consequences for clients of trying to do something perfectly,

using various activities, including some they must do perfectly (give ob-
ject to the right person, set up a file system) and some that don’t involve
perfectionism (watching the sunset, listening to music, eating break-
fast). Ask clients to report how much enjoyment they derive (or would
derive) from each. After clients understand the potential advantages of
being less perfectionistic, devise a homework experiment to test the hy-
pothesis that they will enjoy something and/or accomplish more if they
make a good effort rather than a perfect effort.

Metaphors and Stories

Clinicians may also find that metaphors and stories convey helpful in-
formation that is easily understood. As with other cognitive strategies,
the aim is to permit clients to step outside themselves and examine their
situation from another perspective. Metaphors or stories can be simple
or elaborate. Here is an example:

■ A man who was very concerned about mistakes found that as time
went by, he could no longer tolerate ordinary mistakes at work, so he was

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Need versus Want Scales

Item being considered: Newspaper travel section from 6 months ago.

Rate your need for the item on the following scale below:

Need to Acquire Scale

 ----------------------------------------------------------------------
No need Required
to survive

Rate how much you want or desire the item on this scale by circling a number on the Want to
Acquire Scale.

Want to Acquire Scale

 ---------------------------- ------------------------------------------
Don’t want Desperate for

Now, let’s consider the value of the item more carefully. To evaluate your true need for it, con-
sider whether you need it for survival, safety, health, work, financial affairs, and/or recreation
using the following questions:

• Would you die without it? No, of course not.

• Would your safety be impaired without it? No.

• Would your health be jeopardized without it? No, but I might feel less stressed after a

vacation.

• Is this critical to your work or employment? No, not really.

• Is it essential for your financial records (e.g., tax or insurance records)? No.

Rerate your need for the item using the following Need to Acquire Scale:

Need to Acquire Scale

 ----------------------------------------------------------------------
No need Required
to survive
Figure 8.2
Example of completed Need versus Want Scales.

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Need is different from want. To determine your want or wish for the item, think only about
your urge to have it, regardless of actual need. Consider the following questions:
• Do you keep this because you like it? How much do you actually look at it?
Yes, I like to travel.
I haven’t looked at it since I got it.
• Are you keeping it for sentimental reasons? Is this the best way to remember?
No, not this one. I’ve never been there.
I have several places I’d like to visit and these articles make me think of others.

• How much do you actually use it now? If you plan to use it soon, would you bet money
on this?
I haven’t used it.
No, not really. I probably can’t go to this place for at least a couple of years.

• Do you keep this for emotional comfort or vulnerability? Does it really protect you?
No.
Not applicable.

• Does it offer information or opportunity? How real and important is that?

Yes, it offers the opportunity to travel to interesting places.

It is real but I guess it isn’t important right now because I can’t go right now.

Now, rerate how much you want or desire the item using the following Want to Acquire Scale:

Want to Acquire Scale

----------------------------------------------------------------------
Don’t want Desperate for
Comments and conclusions: I’d like to keep this but I probably have a lot of these mixed in
with my stuff and I can’t really use them right now, anyway. I could make a rule that if I
really plan to go on a trip to the place, I will put the article in a vacation planning file. But if
I don’t plan to go soon, I would get rid of it; I can find it on the web anyway.

Figure 8.2 continued

163
 forced to quit working. Before long he could not tolerate what he believed
to be mistakes in his driving, even though he had never had an accident or
even come close. He quit driving. Soon he became worried about the mis-
takes he made when trying to cook in his kitchen. He quit going into his
kitchen. Then he couldn’t tolerate the mistakes he made in walking down
the stairs. He stayed upstairs. Finally, every action seemed fraught with po-
tential mistakes. He quit moving. He died a perfect man who never made
mistakes. ■

Ask clients to consider the effects of working for a coach or a boss who
has very rigid standards compared with one with a more forgiving and
informative style. This is especially effective when the coach is a power-
ful adult and the player is a child, because clients can easily see that chil-
dren respond best to suggestions and corrections given in a supportive
and encouraging style, rather than rigid rules delivered with harsh criti-
cism and negative labeling (“How can you be so stupid?”). Most clients
can easily apply this metaphor to the effects of their own strict rules and
self-statements on their emotions, thinking, and behaviors.

When clients’ perfectionism centers on memory or knowing informa-

tion, consider comparing people who want to know or keep everything
perfectly with the staff of a library or the curators of a museum. Explore
the consequences of having to store all kinds of details in their head or
keep everything “just so.” Compare this with knowing where to look up
information to find what is needed.

Consider using this next story to generate a discussion of the necessity

of giving up opportunities:

■ One woman felt compelled to take advantage of every opportunity to

learn. Whenever she saw a magazine or newspaper that looked interesting,
she just had to get it. If a lecture was announced, she had to attend, lest she
miss new information. This compulsion got so bad that one day she was
found standing in front of a newsstand unable to move. All she could
think about was all the newspapers and magazines in front of her that
were too numerous to buy and too full of information to read all of it.
She couldn’t decide which ones to buy and which ones to “lose.” ■

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 When progress in treatment seems slow, especially if family members are
pressing for more rapid change, a metaphor that may be helpful is to
suggest that change in very cluttered homes is like losing weight on a
sensible diet. The change is not immediately evident, but the person
feels better and has more energy, although the change in body weight is
hard to see for people who see the person every day. Someone who has
not visited for a few months will see the weight reduction immediately.

Valuing Time

This exercise asks clients to evaluate how well they use time rather than
just focusing on possessions. Many hoarding clients have elaborate plans
for what they are going to do with their things “when I can find the
time.” But they never seem to find enough time. In most cases, clients
seriously underestimate the time required to deal with possessions they
are unable to discard, and they overestimate their capability. We have
mentioned this problem earlier in calculating how long it would take
clients to read all their collected newspapers.

This calculation can begin a discussion about how they want to spend
their time:

“Do you want to spend that much time every day reading old news-
papers?”

“What other parts of your life will you miss or will suffer by doing so?”

“How does this fit with your values and goals? Let’s look back at those
now.”

Assigning a “time value” to possessions might offer a new way of think-

ing about them. For instance, a piece of junk mail might be given a value
of three minutes if that is how long it takes the client to read and dis-
card it. The time value would go higher if it is saved for further consid-
eration at a later time.

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Uncovering Core Beliefs and Finding Alternatives

The downward arrow method and Socratic questioning can be used to

uncover clients’ core beliefs and link them to the interpretations and au-
tomatic thoughts that result in collecting and saving. Socratic questions
that help clients review the evidence, take another perspective, and evalu-
ate the continuum of labels they have given themselves (e.g., inadequate,
stupid) can be used to address their core beliefs by guiding them toward
alternative nonrigid views of themselves. For a detailed review of these
issues, see Wilhelm and Steketee ().

Homework

Various cognitive methods can be assigned as homework. Consider the

following:

✎ Have the client review the Problematic Thinking Styles list to identify
ones commonly used or used during the week between sessions. Ask
the client to identify alternative thinking approaches that avoid the
error.

✎ Instruct the client to use the Questions about Possessions while

sorting.

✎ Remind the client to complete Brief Thought Records or use the

Downward Arrow Form to identify beliefs associated with letting go
of possessions.

✎ Remind the client to use Brief Thought Records to evaluate the accu-
racy of existing beliefs and to consider alternative ones.

✎ Have the client practice specific cognitive strategies learned during the
office visit (e.g., advantages/disadvantages and gaining perspective).

✎ Have the client use the Need versus Want Scales during sorting at
home when decision making seems difficult.

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Chapter 9 Reducing Acquiring

(Corresponds to chapter 8 of the workbook)

Materials Needed

■ Client’s compulsive hoarding model from chapter 

■ Exposure Hierarchy Form

■ Problematic Thinking Styles list

■ Downward Arrow Form

■ Need to Acquire Scale

■ Want to Acquire Scale

Outline

■ Work with the client to develop an exposure hierarchy to reduce

acquiring.

■ Help the client identify and engage in pleasurable, alternative activities.

■ Incorporate cognitive strategies during nonacquiring exposures.

We have already noted that not everyone with a hoarding problem also
has difficulty with excessive acquiring, but in fact most do. A recent sur-
vey of our cases revealed that  to % had significant problems with
acquisition. Most of these involved compulsive buying, but a significant
number had problems with acquiring free things. In chapter  we noted
that excessive acquiring often results from difficulty inhibiting urges to
acquire that have been reinforced by positive emotions (pleasure, enjoy-
ment). This is akin to the “high” people experience when they gamble

167
 or engage in other addictive-like activities, and warrants considering ac-
quiring an ICD. Sometimes acquiring occurs as an attempt to alleviate
bad feelings like depression, distress, loneliness, and other unpleasant ex-
periences. In these contexts, it represents an attempt at self-regulation of
emotion. Like interventions for sorting and discarding, treatment for
this problem requires exposure to situations that provoke acquiring and
modifying acquiring beliefs. The goal is to increase tolerance for these
urges. These exposures focus especially on cues that trigger strong urges
to shop or pick up free things so clients can effectively resist these urges.

We recommend that work on acquiring begin as soon as clients are mo-

tivated to do this (discussed later) so as not to exacerbate the clutter
problem already in evidence. If acquiring is especially problematic, this
might become the first focus of intervention, even before working on
organizing and other skills. However, if it is a mild contributor to clut-
ter, work to reduce acquiring can be concurrent with sorting, organiz-
ing, and getting rid of items, or it can begin after clients have been well
trained in skills in these areas. The decision about treatment depends on
the magnitude of the problem in any of these areas.

Reviewing the Model of Acquiring and Planning Treatment

Of course, intervention for acquiring should be based on the informa-

tion collected during assessment (chapter ) and on the client’s model
(chapter ) for how and when the acquiring occurs and is reinforced.
This will include information about whether clients collect free things
or accept items from others; have subscriptions; order from catalogs, the
TV, or the Web; pick things out of the trash; buy in stores, yard sales, or
flea markets; buy extras; or steal items. Many clients have favorite places
or types of objects they like to acquire. Exposure strategies must be de-
signed to fit the types of contexts and items clients have difficulty resist-
ing. Cognitive methods focus on thoughts and beliefs identified in the
model that make resistance difficult.

In chapter  we recommended having clients visualize one or more of

their most common acquiring situations to ensure clinicians fully under-
stand the elements that lead to and reinforce acquiring before beginning

168
 exposure and cognitive treatment. Because acquiring is accompanied by
pleasurable feelings, helping clients resist their urges will also require
finding alternative sources of enjoyment. This is like helping people with
alcohol problems find other places, activities, and companions instead of
going to the local bar to join their drinking buddies. Similarly, because
acquiring sometimes serves as a coping or mood regulation strategy, al-
ternative methods of dealing with unpleasant emotions must be sought.
Be sure to spend sufficient time identifying replacements for the pleasure
and distress relief associated with acquiring. Failing to do so is an invi-
tation for failure and relapse.

Avoiding Triggers for Acquiring

Sometimes clients who are highly motivated for treatment are able to
stop acquiring early on by simply avoiding the triggers that begin their
acquiring episodes. For example, they don’t go out on Saturday morning
so they won’t see ongoing tag/garage/yard sales. This strategy may prove
effective in the short term as long as clients’ motivation remains high,
but avoidance of acquiring cues is not likely to work in the long term.
Regardless of how well clients can control their acquiring using this
strategy, it will be important for them to learn to control their acquiring
urges when in the presence of significant triggers or cues to acquiring.
This requires exposure to acquiring situations, as discussed later.

Increasing Motivation to Reduce Acquiring

Motivation to reduce acquiring may wax and wane as clients consider

giving up this compelling activity that brings them enjoyment. Help
clients recall their own goals, priorities, and values discussed during early
sessions. As part of the motivational interviewing methods for helping
clients evaluate the importance of doing this and their commitment to
the task, have them weigh the advantages and disadvantages of reducing
acquiring, and have them set rules or goals for when and how much to
purchase or acquire. Of course, this method is designed to change be-
liefs that reinforce acquiring.

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Table 9.1 Disadvantages of Acquiring/Advantages of Not Acquiring
Disadvantages of Acquiring Advantages of Not Acquiring

• Incurring more financial debt
• Feeling anxious about the debt
• Provoking criticism from a spouse/partner
because of financial problems
• Adding to the clutter because there isn’t
enough room for items
• Having more money for other things they
need or value more
• Having more space to display or use things
they truly want
• Having greater control; being able to choose
instead of feeling compelled to acquire

Advantages and Disadvantages

As for other components of hoarding, the clinician and client must first
understand how compulsive acquiring benefits the client, as well as what
clients are avoiding by giving in to their urges. Often clients recognize
that acquiring makes them feel better when they are distressed or de-
pressed. However, they don’t always recognize that this effect is short
lived and that the long-term effects only contribute to their unhappi-
ness. After this process is identified during the case formulation (chap-
ter ), exploring the advantages and disadvantages of acquiring (using
the Advantages/Disadvantages Worksheet in chapter  of the client
workbook) can strengthen clients’ desire to change.

Typical reasons for (advantages of ) acquiring include feeling good or

even “high” after buying something, assuaging guilt about leaving a po-
tential purchase behind, reducing distress or depression, and losing an
important opportunity. Examples of the disadvantages of acquiring and
the advantages of not acquiring are shown in table .. As usual for this
method, help clients examine the number and importance of these ad-
vantages and disadvantages to draw conclusions about their behavior.

Establish Rules for Acquiring

After clients agree they need to acquire fewer things, help them establish
rules to accomplish this goal, especially for items or activities (e.g., going
to tag sales) that contribute heavily to the problem. For example, clients
might decide not to acquire unless they:

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 ■ Plan to use the item in the next month

■ Have sufficient money (not credit) to pay for the item

■ Have an uncluttered place to put the item

Some rules may be temporary. For example, clients could eliminate all
magazine and newspaper subscriptions for the short term and place a
limit on how many of these they will purchase until the clutter is re-
duced below a certain level. The advantage of this strategy is that it
feels less intense for clients while also giving them practice in curtail-
ing acquiring.

Exposures

Like work on clutter, treating acquiring problems requires exposure to

the urge to acquire. Repeated exposure without acquiring will train clients
to tolerate discomfort about not getting desired items and will bring
about changes in the meanings associated with this (e.g., making mis-
takes, not having extras in case of need, and so on).

Nonacquiring exposures should be arranged hierarchically, beginning

with easier experiences and progressing to more difficult ones. Usually
this will mean increasing proximity to favorite acquiring locations and
items.

Clients who accumulate by buying in stores can begin with what we call
drive-by nonshopping, followed by walking through shops without touching
things, and then handling objects without buying them. These exposure
situations should be based on information from the Acquiring Form
(chapter ) and from the acquiring visualization task used in chapter .
After developing a list of possible practice situations with clients, help
them rank items from least to most distressing, or assign this task as home-
work. Figure . shows an example of a completed exposure hierarchy.

After the hierarchy is developed, decide which entries the client can do
alone or with help from coaches (family, friends, and so forth) and which
ones should be done with the clinician because the urge to purchase or
acquire may be too difficult to resist. For example, driving by and stand-
ing outside shops may be relatively easy for clients to accomplish alone

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Practice Exposure Hierarchy for Nonacquiring
Situation Discomfort rating

. Driving past a store in which I’ve bought things 1

. Driving past a tag sale or flea market 2

. Standing outside a store with a good sale sign 2

. Standing near a store in which I’ve bought things 3

. Walking around at a rummage sale without buying anything 4

. Walking into a store I like and not buying anything 5

. Walking into a store with a sale and not buying anything 6

. Seeing a CD I’ve wanted on sale in a record shop and not buying it 7

. Returning an item I spent too much money on 8

. Finding something my size on sale in one of my regular shops 8

. Trying on sale clothing in my favorite store and not buying it 9

. Finding something I’ve wanted for a long time at a terrific price

and not buying it 10

Figure 9.1
Example of a completed Exposure Hierarchy Form.

or with others, but going into shops is likely to be harder. We suggest

clinicians accompany clients into at least one or two shops or other
acquiring settings to ensure that clients are fully exposed to the situa-
tion and learn effective coping skills (e.g., using questions, advantages/
disadvantages, other cognitive strategies described later).

To arrange nonshopping with a partner, identify a willing and helpful

family member or friend and decide whether the clinician should speak
to the helper first before agreeing to the task. This depends on the client’s
confidence in the person’s ability to follow instructions for the task and

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 the clinician’s confidence that the client can explain the task accurately.
When in doubt about either of these, we suggest clinicians speak directly
to the task partner and the client together in person or by phone.

We recommend having clients record their discomfort level on a scale of

 to  (where  is no discomfort and  is the most discomfort ever felt)
about every  minutes, or whenever they notice a change in discomfort.
This can be done on a small card carried in their hand or by telling the
task partner. Work out how long to remain in the setting, depending on
how quickly discomfort abates. The goal is to have clients experience a
noticeable reduction in their discomfort and their urges to acquire items
while still in the shop. However, this may not be possible early during
the exposure process when the sight of items provokes strong urges that
are resisted only because of the presence of the accompanying partner.
Urges will decline with increasing experience of not acquiring/buying and
no adverse outcomes, and with the use of effective coping strategies for
managing discomfort. Be sure to have clients record not only the level of
discomfort throughout the course of the exposure, but also the coping
methods used so that you may discuss in session how well these meth-
ods worked.

Clinicians can plan an intensive period of nonacquiring exposures for

clients who have serious problems in this regard. These exposures can be
intermixed with exposures to other hoarding problems (organizing, sort-
ing, discarding) after clinicians are confident of clients’ capacity to en-
gage in nonacquiring exposures with minimal planning and discussion.
Exposures to all items on the nonacquiring hierarchy should continue
throughout treatment until clients can easily resist inappropriate acquir-
ing in all problematic situations.

Alternative Sources of Enjoyment and Coping

For some clients, shopping or acquiring has become their main source
of enjoyment. For these clients, it is important to find replacement ac-
tivities that become equally enjoyable and fulfilling. During this phase
of treatment, ask clients to identify and engage in alternative activities they
find pleasing and interesting. For example, what would they like to do
instead of going to flea markets or yard sales on Saturday? Ask clients to

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 use their problem-solving skills to brainstorm a short list of likely alter-
natives, especially those that can be done spontaneously, alone, and/or
in the company of friends, and inside and out of the home. See the fol-
lowing list for suggestions:

List of Pleasurable, Alternative Activities

■ Visit a museum or other showplace of interest (historic home,

local fair).

■ Visit a library and check out books to read.

■ Read a book from the library.

■ Watch a film in the theater or at home.

■ Go to a restaurant with friends.

■ Take a walk or hike with friends.

■ Attend a talk or lecture.

■ Take an adult education class at the local high school.

■ Attend a community meeting or gathering of interest.

Ask clients to rate how pleasurable they expect each activity to be using
a scale of  to  where  is not pleasurable and  is the most pleasure
they’ve felt in a long time. Select two or three activities that seem most
feasible, enjoyable, and consistent with personal goals/interests and as-
sign them as homework during the coming weeks, taking care to ensure
clients plan the time for these activities and keep a record of how much
enjoyment (using a scale from –) they expected to experience be-
forehand and how much they actually experienced while engaged in the
activity. This provides a behavioral experiment to determine whether
nonacquiring activities can provide levels of enjoyment sufficient for
these activities to be rewarding.

Equally important is providing clients who acquire to relieve distress or

dysphoria with alternative strategies for coping. Some of the activities
listed earlier may serve this function. Other coping strategies can be gen-
erated using the problem-solving techniques described previously.

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Cognitive Strategies

As for work on sorting clutter, cognitive strategies provide excellent meth-

ods for changing thinking and beliefs, and helping clients cope effec-
tively with nonacquiring exposures. The methods discussed in the fol-
lowing paragraphs are designed specifically to help clients resist urges to
acquire. They can be used during office sessions to plan exposures and
during the actual acquiring situation.

Faulty Thinking Styles

This strategy (described in chapter ) is equally useful when clients voice

views about acquiring. Refer to the Problematic Thinking Styles list in
the workbook as needed.

Downward Arrow

Clinicians can use this method to understand better clients’ reasons for
strong urges to acquire when they are especially hard to resist during an
exposure situation. For example, one client had difficulty resisting a sale
on DVDs in a discount store and wanted to purchase several of them.

Case Vignette

Clinician: Okay, it’s clear this bargain is hard to resist. What are your thoughts
about not buying any of them?

Client: Well, it’s a very good bargain. I’d save several dollars if I bought some
of them.

Clinician: If you didn’t buy them, what would happen?

Client: I’ll be missing a good deal. It’s an opportunity.

Clinician: You’d miss an opportunity. What would that mean?

Client: I’ll miss the enjoyment.

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 Clinician: What’s so bad about that?

Client: I’ll feel bad, left out.

Clinician: What’s the worst part about that?

Client: I know this sounds silly, but it feels like I’ll never get to enjoy myself.
I’ll never feel good.

Clinician: So, I think you are saying that not getting this bargain means that
you’ll never enjoy yourself ? Does that make sense to you?

Client: No, I guess not, but it seems so important at the moment. Like I’m
missing out.

Clinician: Missing out. Where do you think that comes from?

From this point, the clinician and client can explore how not taking ad-
vantage of a sale or bargain became connected in the client’s mind to not
enjoying herself. For example, this might derive from early experiences
of deprivation, although this is certainly not always the case. Further ex-
ploration via Socratic questioning (discussed next) can be used to explore
an alternative approach to resisting bargains that makes more sense to
the client.

Socratic Questioning

Designed to examine the meaning and the evidence for the need to ac-
quire, Socratic questioning is used to focus on whether clients actually
think that not purchasing the item means that an unfortunate conse-
quence will follow (e.g., “I’ll never feel good again,” “My life means
nothing,” “I won’t be accepted by others”). For example, if the down-
ward arrow questioning method had led a client to say, “If I don’t buy
this, I’ll feel stupid” (emotional reasoning), the clinician might use the
following types of Socratic questions to examine the evidence. Notice
that some techniques are used more than once with a slightly different
focus.

■ “Are other people who don’t acquire this also stupid?” (double
standard)

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 ■ “Would you consider me stupid if I did not acquire this?” (using
the clinician as example) “Why not?”

■ “What would be the most accurate way to describe what it would

really mean if you didn’t buy this?”

■ “Do you usually feel stupid when you don’t buy something?”
(generalizing to other situations)

■ “Doesn’t everything you touch represent an opportunity?

Shouldn’t you buy them all?” (devil’s advocate) “Why not?”

■ “When we discussed the advantages and disadvantages of acquir-

ing, I think you concluded that taking advantage of all the oppor-
tunities to acquire things would interfere with your ability to live
your life the way you want to” [recalling incompatible informa-
tion]. “If this is true, how does it fit with the idea that you are
stupid if you don’t get this?” (evaluating the logic)

■ “I am curious to know whether making any kind of mistake

means that you are stupid.” (generalizing to other situations)
“Would you tell me about that?”

■ “What about other people, or me? Should we feel stupid if

we made these same mistakes?” (taking another perspective)
“Why not?”

When clients begin to question their assumptions routinely and chal-

lenge the usefulness and accuracy of labeling themselves as stupid, clini-
cians can ask where they think these ideas originated (e.g., their own
viewpoint or someone influential in their past). This helps consolidate a
different perspective in which the original assumption (“I should buy this
or I’m stupid”) has become questionable. Such changes typically occur
gradually rather than all at once, so clinicians will need to repeat these
methods of questioning before a strongly held belief is relinquished.

Estimating Probability and Calculating Outcomes

It is very common for clients to overestimate the value (attractiveness,

usefulness, benefit) of items they could acquire, and they underestimate
the time it will actually take to use them effectively (e.g., to fix some-

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 thing, create a handicraft). As in chapter  for sorting newspapers, help
clients be realistic about how likely they really are to benefit from the ob-
jects they want to acquire. Specific questions about this can be helpful,
as long as the conversation does not degenerate into an argument. Con-
sistent with motivational interviewing, avoid asking too many questions
in a row, and if clients’ responses suggest resistance, come back to the
issue later or take another approach. Some questions might pertain to
how long it will take them to use  bottles of shampoo weighed against
the space required to store them and their wish to use the same product
for that long a period of time. If clients habitually pick out broken items
from the trash, ask how many they have actually repaired and used (not
made useful, but actually used them, sold them, or completed the origi-
nal plan for the objects). What is the ratio of repaired items versus still
broken ones? At this rate, what will be the outcome over a period of five
more years? For clients with compulsive buying problems, at the current
rate of spending, how much debt will they have accumulated in one or
two more years?

Evaluating Need Versus Want

As for sorting, when clients seem to conflate their needs with their de-
sires or wants in acquiring, follow the same steps outlined in chapter 
for evaluating need versus want. Select an item clients wish to acquire
but appear to have no clear use or need for, and ask them to rate their
need for it on a scale from  (don’t need at all) to  (need it very much).
Help them refine the scale by first asking them to think of something
they cannot live without such as food or water. Draw the following scale
and place these items under the heading “required for survival” at a value
of . Next, ask clients to think of something they might like to have,
but do not need or expect to acquire, like a Mercedes or a diamond neck-
lace. Assign this a value of . Thus, the need scale is redefined as follows:

Need to Acquire Scale

---------------------------- ------------------------------------------
Not needed Required
(for survival) (for survival)

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 It may be useful to specify different dimensions of need, such as safety,
health, employment, financial affairs, and recreation. Now ask clients to
rerate, using this scale, their need for the original item they want to ac-
quire. The rating for the item is likely to go down, now that they have
expanded their view of needed items and their purpose.

Now ask clients to create a Want Scale and rate the item on this scale as
well. For example, a least favorite food (lima beans) and a most favorite
food (chocolate cake) will not receive the same want rating, but they
might receive a similar need rating depending on hunger.

Want to Acquire Scale

-------------- --------------------------------------------------------
Don’t want Desperate for

Ask the following questions to help clients reevaluate their desire for the
item:

■ “How much do you need to get this item?”

■ “Would you die without it?”

■ “Would your safety be impaired without it?”

■ “Would your health be jeopardized?”

■ “Must you have this for your work?”

■ “Do you need it for financial purposes (e.g., tax or insurance

records)?”

■ “Is there some other reason why you need the item?”

■ “Do you actually need this or would it just be convenient to have it?”

After discussing the true value of possessions in relation to other impor-

tant goals in life, ask clients to rerate their desire for the item. If this has
reduced, discuss what aspect of this exercise was useful and how they
might use this method during nonacquiring homework practice.

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Questions for Acquiring

In addition to the previous questions regarding need and want, some

additional questions may be useful in evaluating urges to acquire items
during exposures in stores or other locations where clients acquire free
things. These and the previous questions are included in the workbook.

■ Does it fit with my own personal values and needs?

■ Do I already own something similar?

■ Am I only buying this because I feel bad (angry, depressed, and so

on) right now?

■ In a week, will I regret getting this?

■ Could I manage without it?

■ If it needs fixing, do I have enough time to do this or is my time

better spent on other activities?

■ Will I actually use this item in the near future?

■ Do I have a specific place to put this?

■ Is this truly valuable or useful, or does it just seem so because I’m

looking at it now?

■ Is it good quality (accurate, reliable, attractive)?

■ Will not getting this help me solve my hoarding problem?

Homework

Be sure to select homework assignments clients are at least % confi-

dent they can do (high self-efficacy).

✎ Ask the client to develop a list of potential exposure situations using

the Exposure Hierarchy Form in the workbook and rank these situa-
tions from least to most difficult.

✎ Agree on nonacquiring situations clients will practice before the next

session and ask the client to keep a record of them for discussion dur-

180
 ing a session. Use a separate Practice Form for each practice situation
and record the context and items.

✎ Ask the client to use specific cognitive strategies during nonacquiring

exposures (advantages/disadvantages, estimating probability and out-
comes, need versus want scales, list of questions).

✎ Ask the client to select and plan alternative, pleasurable activities to ac-
quiring to practice during the week and record the degree of pleasure
experienced while doing them.

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Chapter 10 Preventing Relapse

(Corresponds to chapter 9 of the workbook)

Materials Needed

■ Saving Inventory–Revised

■ Clutter Image Rating

■ Saving Cognitions Inventory

■ Activities of Daily Living for Hoarding

■ Client’s compulsive hoarding model from chapter 

■ Client’s treatment goals from chapter 

■ List of treatment techniques

Outline

■ Review the client’s progress up to this point.

■ Work with the client to develop strategies to continue working using

self- and booster sessions.

■ Identify the treatment methods that worked best.

■ Anticipate and develop strategies for coping with setbacks and lapses.

This module presumes that clients have made at least some progress to-
ward meeting their goals, but that more work may be needed to com-
plete the process. This last part of treatment should be planned for the
final two therapy sessions, spaced about two weeks apart. Booster ses-
sions can be added as appropriate to meet clients’ need.

183
Reviewing Progress

During these final sessions it is important to emphasize what clients have

accomplished to foster self-efficacy for maintaining and improving on
gains. This must be an honest appraisal that also considers clients’ weak-
nesses and how to overcome them. Compliment clients on their progress
so far and their use of particular tools from the therapy. Review progress
in therapy and discuss what the client’s future course is likely to be. Most
will not yet have completely achieved their goal of freedom from com-
pulsive hoarding problems and will need to work on remaining clutter
and urges to acquire for some months or even years to come.

We suggest clinicians readminister the assessment forms (Saving Inventory–

Revised, Clutter Image Rating, Saving Cognitions Inventory, ADL-H) to
determine how much change has occurred in all areas related to hoard-
ing. The scores from these forms can be used to discuss how much progress
clients have made so far in each area of hoarding, including organizing,
acquiring, and discarding/clutter. Table . illustrates one way of pre-
senting clients’ changes on these measures to show the percentage of
change on the assessments given at the onset of therapy.

Clarifying how clients accomplished their gains strengthens clients’ self-

efficacy beliefs. Engage clients in a discussion of the specific actions and
strategies they used that seemed to work best. If progress was uneven, we
suggest reviewing the ups and downs with an eye toward what clients might
expect in the future. What would clients predict about future progress in
each of these areas? For clients who tend to underestimate what they
have accomplished and become discouraged, help them avoid day-to-
day comparisons and help them to look, instead, at the big picture.

Table 10.1 Change in Hoarding Symptoms

Measure Pretest Score Posttest Score Change, %

Saving Inventory–Revised . . 

Clutter Image Rating . . 
Saving Cognition Inventory . . 
Activities of Daily Living for Hoarding . . 

184
 If the intervention is time limited, remind clients when their final ses-
sion will occur. If they are worried or frustrated about their progress and
the prospect of losing regular contact with you (the clinician), invite
clients to voice their thoughts and fears. If concerns or thinking seem ir-
rational, use Socratic questioning strategies to evaluate them. It may be
helpful to ask about the advantages of ending treatment (e.g., less de-
pendence on the clinician, a chance to practice learned skills and self-
reliance, more time for other activities, less expense). When appropriate,
reassure clients that they are not alone in their struggles and that work
on hoarding will take more time in the coming months. Remind clients
that you will both review the strategies that seemed to work best and you
will develop a plan for continuing the work.

During the final session, ask clients to reflect over the entire course of
the intervention to describe what they have learned about themselves
and what they need to do to address this. Comment especially on
progress and reinforce clients for their work and learning during treat-
ment. Ask for feedback about the treatment in general. Finally, express
honest feedback to the client: “It was great working with you,” “I’ll miss
working with you,” “I’m so glad our work together helped,” “I have a lot
of confidence in you.”

Continuing to Work With Self- and Booster Sessions

Clinicians can also discuss a self-therapy plan with clients, and actually
implement this during the alternate weeks while clients are tapering treat-
ment sessions. We suggest clients schedule self-sessions on the same day
and time slot when meetings with the clinician usually occurred, so
clients who used to meet their clinician on Mondays at   would now
use this time for their own sessions. Encourage clients to schedule their
self-sessions ahead of time and mark them on their calendar. At the end
of treatment, they may want to start with weekly sessions, and then taper
them to twice a month, once a month, and once a season.

The clinician should review advantages (e.g., ensures that clients remem-
ber techniques when they need them, prevents relapse) and disadvan-
tages and/or fears (“I can’t do it by myself. It takes too much time. I don’t
need to do it.”) of self-sessions. You can also advise clients to reread their

185
 therapy notes during these sessions and at times of stress. Work out a
schedule for resolving clients’ remaining symptoms of organizing, ac-
quiring, and letting go of possessions and plan how to accomplish this
using some of the self-session time. This may require a formal plan to
engage in selected activities (e.g., sorting and filing).

In addition, develop a specific plan for preventing the reaccumulation of

clutter. To do this, first identify how this might happen (e.g., too tired
to put away purchased items, too rushed to open mail that day, saw a sale
and stocked up on needed items). Then decide what the next step should
be, how to implement it, and how to reinforce it. Determine who might
assist clients in solving these problems when they arise.

Other strategies may help clients to consolidate their gains. For example,
clients may want to make a tape recording of procedures or questions
they found helpful and play the tape just before (or during) the time they
have set aside to work on this problem. Alternatively, clients can use their
favorite music to create a pleasant environment for decluttering. We
recommend planning two to three booster sessions that can be sched-
uled at any time during the coming year after first discussing the client’s
progress. We suggest planning the first one for one to two months hence,
and others as needed at the next appointment. Booster sessions are in-
tended to help clients feel connected and motivated to continue their work.
Sessions can focus on any aspects of hoarding that remain problematic,
or on other concerns (comorbid problems, problem solving regarding
old debts, and so forth) that arise after hoarding is under control. Some
clients may benefit from monthly check-ins by phone or even electronic
mail if this helps maintain motivation to work on the problem.

Provide clients with written information about local support groups or

on-line support groups if available. Other sources of support are joining
related organizations such as the Obsessive Compulsive Foundation
(e.g., www.ocfoundation.org/hoarding), reading self-help books like Tolin,
Steketee, and Frost’s Buried in Treasures: A Workbook for Compulsive
Hoarding, Saving, and Collecting, (), and reading research on the
nature of compulsive hoarding (see “Readings and Resources” at the end
of this book). Arrange for follow-up assessments as appropriate.

186
Review Treatment Techniques

Reviewing treatment techniques is a critical activity for preventing re-

lapse and helps remind clients of what they have learned. Begin by re-
viewing the compulsive hoarding and acquiring models developed early
during treatment (see chapter ). Ask clients whether they think these
models are still accurate and whether they would make any changes.
Record all changes and provide clients with good copies of the revised
models for their reference. Ask what the models imply about what they
need to do after treatment ends. Help them recall the general principles
on which they have been working during treatment and formulate them
in a way that emphasizes their own skills and personal goals. Examples
are the following:

■ Begin with easier items and work toward harder ones.

■ Be patient, because change takes time.

■ Don’t ignore small gains.

■ Get help when you aren’t strong enough to do it alone.

■ Be firm but not perfectionistic with yourself.

Next, remind clients of their original treatment goals by examining the

Treatment Goals Form they completed during the treatment planning
phase. In light of their goals, review what clients have actually accom-
plished, including changes in symptoms (e.g., acquiring, clutter, ability
to get rid of things), as well as skills developed (e.g., organizing, resist-
ing impulses to acquire, problem solving, managing attention).

Then, review the techniques learned during therapy by going over the
clients’ Personal Session Forms and material in their workbook. Instruct
clients to review the list of treatment techniques in table . so they
have this list of strategies for use in the future. Use the metaphor of a
toolbox, describing each technique as a tool. Help clients identify the
methods that worked best for them and in which context (e.g., sorting
and organizing clutter, discarding, acquiring). Some of this work can be
assigned as homework between sessions.

187
Table 10.2 List of Treatment Techniques
Identify the methods below that worked best for you. Many of these apply not only to letting go of
possessions, but also to resisting acquiring and to organizing.
Review the model for understanding compulsive hoarding.
Identify your beliefs and emotions by:
• Using the Downward Arrow Form.
• Using Thought Records.
• Visualizing the situation.
• Considering beliefs about comfort, loss, mistakes, identity, responsibility, memory, control.
Review your values.
Review your Treatment Goals.
Use an Organizing Plan:
• Keep supplies on hand for organizing.
• Only handle it once (OHIO).
• Keep decisions simple: Trash, recycle, sell, donate, keep.
• Use an egg-timer to make decisions faster.
• Implement decisions as soon as possible.
• Review questions for deciding on categories.
• Stick to your Organizing Plan and filing system.
• Schedule times to organize and file.
• Keep surfaces clear to prevent re-cluttering.
Review the Rules for Acquiring.
Find other pleasurable activities.
Review list of questions about organizing, acquiring, and letting go.
Review Problematic Thinking Styles about organizing, acquiring, and letting go.
Evaluate emotional thinking.
Evaluate capacity to cope.
List the advantages and disadvantages of acquiring or discarding.
Use cognitive strategies:
• Evaluate actual threat.
• Examine the evidence.
• Conduct a behavioral experiment to test your beliefs and predictions.
• Imagine the worst.
• Take another perspective: friend’s view, your view of others (double standard), advice to
others.
• Value your time.
• Evaluate need versus want.
Gradually practice to reduce discomfort and gain skill in:
• Resisting acquiring.
• Organizing.
• Letting go.
Practice problem-solving skills.
Plan social activities outside your home.
Invite others to visit you at home.
Schedule self-treatment sessions.

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 Remind clients that when they experience discomfort during strategies
that involve exposure to fears (e.g., sorting, nonshopping), it is usually
a sign they have used the method correctly. It is often easier to change
behaviors first and then observe whether attitudes and emotions follow
along. Remind clients that when formal treatment ends, many people
experience an increase in general discomfort, but that long-term gains
are made through perseverance and commitment to continuing work.

If some beliefs and behaviors have not changed as much as desired, a re-
assessment of the worst fears via the downward arrow method may be
useful. Sometimes the worst fears are missed because they are buried
beneath more obvious fears and only emerge when the other fears are re-
solved. Also, some clients may benefit from using problem solving to
gain control over other problem areas. Remind clients of the steps in the
problem-solving process and determine when the process could be espe-
cially useful after therapy ends. Examples might be when certain ex-
pected stressors occur (e.g., someone offers to give them items they do
not want to keep, a plan goes awry and they are disappointed).

Dealing With Setbacks

Address any unrealistic expectations clients might have so they are pre-
pared for uneven progress and have a plan for what to do when they hit
a low point in their progress. In addition, discuss the difference between
a lapse and a relapse:

A lapse is a temporary period during which some of the behaviors re-

turn. A lapse does not necessarily indicate a relapse. Just because some
clutter accumulates or you overbuy does not mean you will return to
where you were before treatment, but it is a warning sign. A tempo-
rary return of symptoms is usually a sign that something stressful is
going on in your life. If you encounter problems you need to discuss,
or if you have questions, what would you do?

Discuss with the clients various strategies for them to manage their set-
backs (e.g., call the clinician, seek help from a friend, review their treat-
ment notes), and stress that it is normal to have low points and that these
usually become fewer and less severe as time passes. Especially if the client

189
 tends to have dependent traits, take care not to imply that the client
must depend on the clinician’s help.

Encourage clients to identify potentially stressful situations that might

exacerbate residual hoarding symptoms. Ask clients to think of stressors
they expect throughout the coming year and come up with strategies to
handle them. Examples might be stressful interpersonal situations or ex-
pectations, extra responsibilities, media information that is disturbing,
or a serious loss. Consider posing an unexpected stressor (e.g., “Suppose
your mother dies unexpectedly and leaves you many of her things. What
would you do?” “Suppose you have a major expense you hadn’t planned
on?”). Ask clients to describe what they anticipate their initial reactions
might be to such circumstances. Identify possible thinking styles or mis-
taken interpretations and inquire about alternative ways of thinking about
the situation. Identify bad habit patterns that might return and discuss
how alternative methods they have learned might apply. Encourage them
to use effective coping strategies from the list in table . to deal with
setbacks. For example, they might conduct experiments to test predic-
tions (e.g., about needing information) in response to these stressors.

For clients whose time has been consumed with hoarding symptoms,
plan what they can do with the extra time available. To identify poten-
tial problems, the clinician should ask: “How is your life different now
from how it used to be?” “How are you spending most of your time?” If
it is evident that they have not found healthy behaviors to replace time
spent acquiring, prompt clients to consider restarting former fun activi-
ties or to begin new ones like joining a gym, working as a volunteer, or
taking a class.

Homework

An important assignment before the final treatment session is to ask

clients to review their workbooks and to make a list of all the methods
they have learned and to highlight those that were most helpful. Other
homework assignments might include listing anticipated stressors, iden-
tifying helpful coping strategies for stressors, and finding potential sources
of informational and emotional support.

190
Appendix A Assessment Instruments

191
Hoarding Interview

Client initials: Date:

. What kind of home do you live in? Who else lives there with you?

. Let’s talk about the rooms in your home. [Use the Clutter Image Rating pictures to deter-
mine the extent of clutter in each room and also in other living spaces like the attic, base-
ment, garage, car, etc.] How much does the clutter interfere with how you’d like to use each
room and which rooms bother you most?

Living room:

Dining room:

Kitchen:

Bedrooms:

Bathrooms:

Hallways:

Basement:

Attic:

Porch:

Garage:

Yard:

Car:

Work or office space:

Other:

. Do you keep any items in other places outside your home like a storage space, another per-
son’s home, etc? How much stuff is there and what kinds of items?

192
. What kinds of things do you save? For example, what would I mainly see in these rooms?

. Tell me about your emotions when you look at or think about the clutter? (e.g., anxiety,
guilt, sadness, pleasure, etc.)

. How much discomfort would you feel if you had to get rid of some of your
(ask about each category of items identified earlier, such as books, junk mail, kitchen trash,
bottle caps).

. Which rooms would you like to work on first? Why? Which one will be easiest and which
one most difficult? Why? (Discuss the pros and cons with regard to the usefulness of space
if clutter is cleared, the quickest visual improvement in the space, the most pressing need
to locate important items, the most reduction of distress, and so forth.)

. Are your possessions organized in some way? How do you decide what goes where? How
well does this plan work for you?

continued

193
Hoarding Interview continued

. How do you acquire new things? Tell me about the most recent things you got—how did
you get them? (e.g., shopping, store sales, yard/tag sales, trash picking, free things)

. Let’s talk about the sequence of thoughts, emotions, and behaviors when you acquire new
items. For example, the [most recent items acquired], how did you feel when you first got it
and what were you thinking? What did you do with it once you got it home?

. What happens if you try to avoid getting something?

. Tell me about why you save these items. (If clients do not mention the reasons below, ask
about each.)

a. Sentimental: Do you save things because they seem sentimental or emotionally signifi-
cant to you? That is, you are so emotionally attached items that you do not want to part
with them? Can you give an example?

194
 b. Instrumental/useful: Are you afraid of losing important information you might need
someday when you try to throw something out? Are you concerned about being wasteful
because the object may eventually be put to good use? Can you give an example?

c. Intrinsic/beauty: Do you save things just because you like them or think they are pretty?
Do you think they will be valuable someday? Can you give an example?

. Do your family members or friends help you get items or store them for you?

Do some people help you organize things you can’t deal with?

What about helping you get rid of things?

Does anyone get upset by your collecting and clutter or do they mostly tolerate it?

Do you prevent others from touching your things?

Are your family members/significant others supportive of treatment? If so, would any of
them be interested in coming with you to a treatment session?

continued

195
Hoarding Interview continued

. Does the clutter present a health or safety problem for you or your family? (If yes) What
kinds of problems? (e.g., falling, fire hazard, hygiene, medical problems, nutrition, insect
infestation) (If no) Do other people think the clutter presents a problem for you or for your
health or safety?

. Has your buying or acquiring things caused any problems? (e.g., family arguments, financial
burden or debt, negative mood such as guilt, depression, anxiety) (If yes) What kinds of
problems? (If no) Do family or friends think buying or acquiring items is causing any prob-
lems?

. Has the clutter affected your social life? (avoids having visitors; avoids going to others home
because can’t reciprocate) Are you interested in having some people come over once the
clutter is less of a problem? Who, for example?

. Do you have any problems with washing, checking, putting things in order, repeating ac-
tions or other mental compulsions? Do these thoughts and behaviors affect the hoarding
problem? (e.g., contamination fears make it difficult to put things away, checking lengthens
the time it takes to put away or discard items)

196
. Do other family members have hoarding problems? Who? Tell me about the saving and clutter.

. When you were young, did you spend a lot of time in any other household (e.g., grandpar-
ents, other family members, friends) that was cluttered?

. Did anyone in the household you grew up in acquire things excessively? Who? What types
of things?

. When you were a child, did you experience any kind of deprivation (e.g., not enough to eat,
not enough clothes, too few toys, no spending money) or serious losses (e.g., death, major
move)? How old were you when this occurred? Do you think it has any relationship to your
hoarding problem?

. When was the first time you noticed that you had trouble acquiring too many things,
throwing things away, or had a lot of clutter in your home? How old were you? Was any-
thing special going on in your life at that time? (e.g., traumatic experience, moving, loss of a
family member, etc.)

continued

197
Hoarding Interview continued

. Have you had any previous therapy (medication, behavior therapy, psychotherapy, family
efforts to help) for hoarding problems? What about for other types of problems? How long
did the treatment last? Did it help? Why or why not? (Later on you will need to give a ra-
tionale for the hoarding treatment that addresses concerns the client may have because of
previous treatment experiences.)

. Have other people tried to intervene in the hoarding problem? Have you ever been con-
tacted by landlords, health department officials, or other officials about problems related to
the hoarding. What happened? What was your reaction?

. Are there other aspects of hoarding you haven’t mentioned, like legal or financial problems,
problems with collecting animals, special embarrassments?

198
Saving Inventory—Revised

Client initials: Date:

For each question below, circle the number that corresponds most closely to your experience
DURING THE PAST WEEK.

------------------------------------------ ------------------------------------------

None A Little A Moderate Most/Much Almost All/

Amount Complete

. How much of the living area in your home is cluttered with     

possessions? (Consider the amount of clutter in your kitchen,
living room, dining room, hallways, bedrooms, bathrooms, or
other rooms).
. How much control do you have over your urges to acquire     
possessions?
. How much of your home does clutter prevent you from using?     
. How much control do you have over your urges to save possessions?     
. How much of your home is difficult to walk through because of     
clutter?

For each question below, circle the number that corresponds most closely to your experience
DURING THE PAST WEEK.

------------------------------------------ ------------------------------------------

Not at all Mild Moderate Considerable/Severe Extreme

. To what extent do you have difficulty throwing things away?     

. How distressing do you find the task of throwing things away?     
. To what extent do you have so many things that your room(s) are     
cluttered?
. How distressed or uncomfortable would you feel if you could not     
acquire something you wanted?
. How much does clutter in your home interfere with your social,     
work or everyday functioning? Think about things that you don’t do
because of clutter.
. How strong is your urge to buy or acquire free things for which you     
have no immediate use?
continued

199
Saving Inventory—Revised continued

. To what extent does clutter in your home cause you distress?     
. How strong is your urge to save something you know you may     
never use?
. How upset or distressed do you feel about your acquiring habits?     
. To what extent do you feel unable to control the clutter in your     
home?
. To what extent has your saving or compulsive buying resulted in     
financial difficulties for you?

For each question below, circle the number that corresponds most closely to your experience
DURING THE PAST WEEK.

------------------------------------------ ------------------------------------------

Never Rarely Sometimes/ Frequently/ Very Often

Occasionally Often

. How often do you avoid trying to discard possessions because it is     

too stressful or time consuming?
. How often do you feel compelled to acquire something you see,     
e.g., when shopping or offered free things?
. How often do you decide to keep things you do not need and have     
little space for?
. How frequently does clutter in your home prevent you from inviting     
people to visit?
. How often do you actually buy (or acquire for free) things for which     
you have no immediate use or need?
. To what extent does the clutter in your home prevent you from     
using parts of your home for their intended purpose? For example,
cooking, using furniture, washing dishes, cleaning, etc.
. How often are you unable to discard a possession you would like to     
get rid of ?

See score key at end of appendix.

200
Clutter Image Rating

Client initials: Date: Therapist:

Using the  series of pictures (CIR: Living Room, CIR: Kitchen, and CIR: Bedroom), please
select the picture that best represents the amount of clutter for each of the rooms of your home.
Put the number on the line below.

Please pick the picture that is closest to being accurate, even if it is not exactly right.

If your home does not have one of the rooms listed, just put NA for “not applicable” on that line.

Number of closest
corresponding
Room picture (1–9)

Living Room

Kitchen

Bedroom #

Bedroom #

Also, please rate other rooms in your house that are affected by clutter on the lines below. Use
the CIR: Living Room pictures to make these ratings.

Dining room

Hallway

Garage

Basement

Attic

Car

Other Please specify:

201
 Figure A.1
Clutter Image Rating Scale: Kitchen.

202
203

Figure A.2
Clutter Image Rating Scale: Living Room.
204

Figure A.3
Clutter Image Rating Scale: Bedroom.
Saving Cognitions Inventory

Client initials: Date:

Use the following scale to indicate the extent to which you had each thought when you were de-
ciding whether to throw something away DURING THE PAST WEEK. (If you did not try to
discard anything in the past week, indicate how you would have felt if you had tried to discard.)

------------------------------------------------------------------------------------------

Not at all Sometimes Very much

. I could not tolerate it if I were to get rid of this.       

. Throwing this away means wasting a valuable opportunity.       
. Throwing away this possession is like throwing away a part of me.       
. Saving this means I don’t have to rely on my memory.       
. It upsets me when someone throws something of mine away       
without my permission.
. Losing this possession is like losing a friend.       
. If someone touches or uses this, I will lose it or lose track of it.       
. Throwing some things away would feel like abandoning a
loved one.       
. Throwing this away means losing a part of my life.       
. I see my belongings as extensions of myself; they are part of       
who I am.
. I am responsible for the well-being of this possession.       
. If this possession may be of use to someone else, I am responsible       
for saving it for them.
. This possession is equivalent to the feelings I associate with it.       
. My memory is so bad I must leave this in sight or I’ll forget       
about it.
. I am responsible for finding a use for this possession.       
. Throwing some things away would feel like part of me is dying.       
. If I put this into a filing system, I’ll forget about it completely.       
. I like to maintain sole control over my things.       
. I’m ashamed when I don’t have something like this when I need it.       
. I must remember something about this, and I can’t if I throw       
this away.
. If I discard this without extracting all the important information       
from it, I will lose something.
. This possession provides me with emotional comfort.       
. I love some of my belongings the way I love some people.       
. No one has the right to touch my possessions.       

See score key at end of appendix.

205
ADL Scales

Client initials: Date:

A. Activities of Daily Living:

Sometimes clutter in the home can prevent you from doing ordinary activities. For each of
the following activities, please circle the number that best represents the degree of difficulty
you experience in doing this activity because of the clutter or hoarding problem. If you have
difficulty with the activity for other reasons (for example, unable to bend or move quickly due
to physical problems), do not include this in your rating. Instead, rate only how much diffi-
culty you would have due to hoarding. If the activity is not relevant to your situation (for
example, you don’t have laundry facilities or animals), circle the Not Applicable (NA) box.

Can do Can do Can do

it with a it with it with
Activities affected by clutter Can do little moderate great Unable Not
or hoarding problem it easily difficulty difficulty difficulty to do Applicable

. Prepare food      NA
. Use refrigerator      NA
. Use stove      NA
. Use kitchen sink      NA
. Eat at table      NA
. Move around inside      NA
the house
. Exit home quickly      NA
. Use toilet      NA
. Use bath/shower      NA
. Use bathroom sink      NA
. Answer door quickly      NA
. Sit in sofa/chair      NA
. Sleep in bed      NA
. Do laundry      NA
. Find important things      NA
(such as bills, tax
forms, etc.)
. Care for animals      NA

206
B. Living Conditions:
Please circle the number below that best indicates how much of a problem you have with the
following conditions in your home:
Somewhat/
Problems in the home None A little moderate Substantial Severe

. Structural damage (floors,

walls, roof, etc.)     
. Presence of rotten food items     
. Insect infestation     
. Presence of human urine or feces     
. Presence of animal urine or feces     
. Water not working     
. Heat not working     

C. Safety Issues:
Please indicate whether you have any concerns like those described below in your home.
Somewhat/
Type of problem Not at all A little Moderate Substantial Severe

. Does any part of your house     

pose a fire hazard? (for example,
stove covered with paper, flam-
mable objects near the furnace,
etc.)
. Are parts of your house un-     
sanitary (bathrooms unclean,
strong odor)?
. Would medical emergency per-     
sonnel have difficulty moving
equipment through your home?
. Are any exits from your home     
blocked?
. Is it unsafe to move up or down     
the stairs or along other walk-
ways?
. Is there clutter outside your     
house (porch, yard, alleyway,
common areas if apartment
or condo)?

See score key at end of appendix.

207
Obsessive-Compulsive Inventory—Revised

Client initials: Date:

Pre-Tx Sess Post-Tx -Mos. -Mos. -Yr

The following statements refer to experiences that many people have in their everyday lives.
Circle the number that best describes how much that experience has DISTRESSED or
BOTHERED you during the PAST MONTH. Use the following scale:

------------------------------------------ ------------------------------------------

Not at all A little Moderately A lot Extremely

. I have saved up so many things that they get in the way.     

. I check things more often than necessary.     
. I get upset if objects are not arranged properly.     
. I feel compelled to count while I am doing things.     
. I find it difficult to touch an object when I know it has been     
touched by strangers or certain people.
. I find it difficult to control my own thoughts.     
. I collect things I don’t need.     
. I repeatedly check doors, windows, drawers, etc.     
. I get upset if others change the way I have arranged things.     
. I feel I have to repeat certain numbers.     
. I sometimes have to wash or clean myself simply because I feel     
contaminated.
. I am upset by unpleasant thoughts that come into my mind against     
my will.
. I avoid throwing things away because I am afraid I might need     
them later.
. I repeatedly check gas and water taps and light switches after     
turning them off.
. I need things to be arranged in a particular order.     
. I feel that there are good and bad numbers.     
. I wash my hands more often and longer than necessary.     
. I frequently get nasty thoughts and have difficulty getting rid     
of them.

See score key at end of appendix.

Copyright  by Edna B. Foa. Reprinted with permission.

208
Scoring Keys

Saving Inventory–Revised Scoring

Clutter Subscale (Nine Items)

Sum items: , , , , , , , , 

Difficulty Discarding/Saving Subscale (Seven Items)

Sum items:  (reverse score), , , , , , 

Acquisition Subscale (Seven Items)

Sum items:  (reverse score), , , , , , 

Total score ⫽ sum of all items

Saving Cognitions Inventory Scoring

Subscales

Emotional Attachment ( items): , , , , , , , , , 

Control (three items): , , 

Responsibility (six items): , , , , , 

Memory (five items): , , , , 

Total score ⫽ sum of all items

209
ADL-H Scoring

ADL-H yields three scores:

Below we give a suggested guide to interpretation of scores on the ADL.

This scale and the scoring system below have yet to be validated, so the
instrument and its scoring should be considered preliminary. Examina-
tion of individual item scores may be very helpful to detect specific areas
of most concern for individual clients. At present, the questionnaire yields
three scores.

A. Activities of Daily Living: These questions assess the extent to

which clutter causes problems in daily functioning at home.

Step : Add scores for items –, excluding items with NA (not
applicable) ratings.

Step : Indicate the number of questions in items – that have a

numeric score (that is, not an NA rating).

Step : Divide the first number by the second number.

For example, if the total score for items – was , and numeric rat-
ings were given for  items (meaning there were  NA ratings), the score
would be  ⫼  ⫽ ..

B. Living Conditions: These questions examine the extent to which

the home is deteriorated or uninhabitable.

Step : Add the scores for items –.

Step : Divide that number by .

For example, if the total score for items – was , the score would be
 ⫼  ⫽ ..

C. Safety Issues: These questions ask about the degree of unsafe con-
ditions caused by clutter.

Step : Add the scores for items –.

Step : Divide that number by .

210
 For example, if the total score for items – was , the score would
be  ⫼  ⫽ ..

Each of these three scores can range from  to . Although the scale has
not yet been fully validated, we recommend classifying the scores as:

.–. Minimal

.–. Mild

.–. Moderate

.–. Severe

.–. Very severe

OCI-R Scoring

Subscales

Checking: , , 

Hoarding: , , 

Neutralizing: , , 

Obsessing: , , 

Ordering: , , 

Washing: , , 

Total score ⫽ sum of all items

211
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Appendix B Clinician Session Form

213
Clinician Session Form

Client: Session #: Date:

Basic Session Content:

Agenda:

Homework report:

Degree of homework compliance (1 to 6):

( ⫽ did not attempt;  ⫽ attempted but did not complete;  ⫽ did about %;  ⫽ did about
%;  ⫽ did about %;  ⫽ did all homework)

Symptoms and topics discussed during session:

Intervention strategies used or reviewed:

214
Clinician Session Form continued

Homework assigned:

Comments on client’s summary and feedback:

Goals for next or future sessions:

215
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References

Abramowitz, J.S., Franklin, M.E., Schwartz, S.A., & Furr, J.M. ().
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the research. Clinical Psychology Review, , –.
Steketee, G., Frost, R.O., & Kim, H.-J. (). Hoarding by elderly people.
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 Summerfeldt, L.J., Richter, M.A., Antony, M.M., & Swinson, R.P. ().
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Tolin, D., Frost, R.O., & Steketee, G. (). Buried in treasures: Help for
compulsive hoarding. New York: Oxford.
Wells, A. (). Cognitive therapy of anxiety disorders: A practical guide. New
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Oakland, CA: New Harbinger.
Wincze, J.P., Steketee, G., & Frost, R.O. (in press). Categorization in com-
pulsive hoarding. Behaviour Research and Therapy.
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chiatry, , –.
Zhang, H., Leckman, J.F., Pauls, D.L., Tsai, C.-P., Kidd, K.K., Rosario–
Campos, M., & Tourette Syndrome Association International Consor-
tium for Genetics. (). Genomewide scan of hoarding in sib pairs
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Readings and Resources

Selected Professional Readings on Compulsive Hoarding

Frost, R.O., & Steketee, G. (). Issues in the treatment of compulsive

hoarding. Cognitive and Behavioral Practice, , –.
Frost, R.O., Steketee, G., & Greene, K.A.I. (). Cognitive and behav-
ioral treatment of compulsive hoarding. Journal of Brief Treatment and
Crisis Intervention, , –.
Frost, R.O., Steketee, G., & Grisham, J. (). Measurement of compul-
sive hoarding: Saving Inventory–Revised. Behaviour Research and Ther-
apy, , –.
Hoarding of Animals Research Consortium. (). Public health implica-
tions of animal hoarding. Health and Social Work, , –.
Kim, H.–J., Steketee, G., & Frost, R.O. (). Hoarding by elderly people.
Health and Social Work, , –.
Steketee, G., & Frost, R.O. (). Compulsive hoarding: Current status of
the research. Clinical Psychology Review, , –.
Steketee, G., Frost, R.O., & Kyrios, M. (). Cognitive aspects of com-
pulsive hoarding. Cognitive Therapy and Research, , –.
Steketee, G., Frost, R.O., Wincze J., Greene, K.A.I., & Douglas, H. ().
Group and individual treatment of compulsive hoarding: A pilot study.
Behavioral and Cognitive Psychotherapy, , –.

Therapist Guides for Problems Related to Hoarding

Kozak, M.J., & Foa, E.B. (). Mastery of Obsessive–Compulsive Disorder.

San Antonio, TX: The Psychological Corp.
Safren, S.A., Perlman, C.A., Sprich, S., & Otto, M.W. (). Mastering
your adult ADHD: A cognitive–behavioral treatment program. New York:
Oxford University Press.
 Self-Help Books on Organizing and Hoarding

Hemphill, B. (). Taming the paper tiger: Organizing the paper in your life.
Washington, DC: The Kiplinger Washington Editors.
Kolberg, J., & Nadeau, K. (). ADD—Friendly ways to organize your life.
New York: Routledge.
Neziroglu, F., Bubrick, J., & Yaryura–Tobias, J. (). Overcoming com-
pulsive hoarding. Oakland, CA: New Harbinger.
Smallin, D. () Organizing plain and simple: A ready reference guide with
hundreds of solutions to your everyday clutter challenges. North Adams,
MA: Storey Publishing.
Tolin, D., Frost, R.O., & Steketee, G. (). Buried in treasures: Help for
compulsive hoarding. New York: Oxford University Press.
Waddill, K. (). The organizing sourcebook: Nine strategies for simplifying
your life. New York: McGraw–Hill.

Report on Animal Hoarding

Patronek, G., Loar, L., & Nathanson, J. (Eds.). (). Animal hoarding:
Structuring interdisciplinary responses to help people, animals and commu-
nities at risk. Hoarding of Animals Research Consortium. www.tufts.edu
/vet/cfa/hoarding

Web Resources

Obsessive Compulsive Foundation, www.ocfoundation.org

Hoarding of Animals Research Consortium, www.tufts.edu/vet/cfa/
hoarding

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About the Authors

Gail Steketee, PhD, is professor and currently dean ad interim at the

Boston University School of Social Work. She received her MSW and
PhD from Bryn Mawr Graduate School of Social Work and Social Re-
search. Dr. Steketee has conducted a variety of research studies on the
psychopathology and treatment of obsessive–compulsive and related
spectrum disorders. Her recent research, funded by the National Insti-
tute of Mental Health, focuses on diagnostic and personality aspects of
compulsive hoarding, and tests a specialized cognitive and behavioral
treatment for this condition. Additional funded research interests include
cognitive therapy for obsessive–compulsive disorder (OCD), developing
treatment for body dysmorphic disorder, and familial factors that influ-
ence treatment outcomes for OCD and panic with agoraphobia. She is
also a member of the Hoarding of Animals Research Consortium, which
studies compulsive hoarding of animals. Drs. Steketee and Frost co-chair
an international research group—the Obsessive–Compulsive Cognitions
Working Group—dedicated to the study of cognitive aspects of OCD.
She has published more than  journal articles, chapters, and books on
OCD and related disorders, including When Once Is Not Enough (),
Treatment for Obsessive–Compulsive Disorder (), Overcoming Obsessive–
Compulsive Disorder (), and with Dr. Frost, Cognitive Approaches to
Obsessive–Compulsive Disorder: Theory, Assessment and Treatment ().
Upcoming books that she has co-authored on OCD and compulsive
hoarding include Cognitive Therapy for Obsessive Compulsive Disorder
() and Buried in Treasures: A Self-Help Guide for Compulsive Hoard-
ing (Oxford University Press, ).

Randy O. Frost, PhD, received his degree in clinical psychology from

the University of Kansas in  after completing his doctoral internship
 at the University of Washington School of Medicine. Currently he holds
the Harold Edward and Elsa Siipola Israel Professorship at Smith Col-
lege. He has published more than  scientific articles and book chap-
ters on OCD and compulsive hoarding, as well as on the pathology of
perfectionism and related topics. With Gail Steketee he has co-edited
one book, Cognitive Approaches to Obsessions and Compulsions: Theory,
Assessment, and Treatment (), and has another upcoming, Buried in
Treasures: A Self-Help Guide for Compulsive Hoarding (Oxford University
Press, ).

Dr. Frost co-edits the Obsessive Compulsive Foundation (OCF) website

on hoarding, and serves on the OCF Scientific Advisory Board. To-
gether with Dr. Steketee he is co-coordinator of an international group
of researchers studying beliefs in OCD—the Obsessive–Compulsive
Cognitions Working Group. He is also a member of the Hoarding of
Animals Research Consortium and has been consultant to various hoard-
ing task forces, including those in New York, New York; Ottawa, Can-
ada; and Hampden, Hampshire, and Franklin counties in Massachusetts.
He has given hundreds of lectures and workshops on the topic of hoard-
ing nationally and internationally. His research on hoarding has been
supported by the National Institute of Mental Health and the OCF.

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