Question 1

Are there any books you can recommend for children who have a parent who is a hoarder?

Gail Steketee · Accepted Answer

These are nearly always adult children who recognize a hoarding problem somewhat later in their parent’s life. We recommend Digging Out by Michael Tompkins and Tamara Hartl which was written specifically to help adult family members talk with their loved ones about hoarding problems. We are not aware of books written for young children about hoarding behavior.

Question 2

What is the best thing other family members can do to deal with day to day hoarding challenges?

Christiana Bratiotis · Accepted Answer

Family members should have a private conversation with their loved one about their specific concerns. For example, “Mom, I just can’t leave you alone here with that pile of flammable items so close to the stove.” “Dad, I’m really worried that you will fall on the stairs when your cane catches on one of those piles up there.” Begin the conversation with a focus on health and safety first, and then on how to meet your family member’s needs and improve their quality of life. If previous interactions among family members have been contentious, family members may want to enlist help from others, such as members of a hoarding task force or staff at a local service agency that helps older adults.

Question 3

Are CBT treatment models the same for older vs young people?

Gail Steketee · Accepted Answer

Generally, yes, but with some modification of the cognitive parts of treatment for older adults. The treatment model focuses on factors that make people vulnerable to hoarding (for example, family history, early experiences, personal losses, beliefs) and how that reinforces excessive acquiring and saving and difficulty discarding. The treatment plan for adults across the lifespan includes resisting acquiring, learning sorting and organizing skills, and practicing letting go of unneeded items. Younger adults also benefit from modifying their beliefs about objects, whereas for older adults , changing beliefs may be less helpful than learning skills that improve memory, planning, cognitive flexibility, and problem solving. Of course, these skills are useful for adults of any age.

Question 4

Why is hoarding more common in older than younger adults?

Christiana Bratiotis · Accepted Answer

In fact, hoarding begins early in life, most often during adolescence or early adulthood, and the clutter worsens gradually over time. Hoarding may seem worse in later life as the clutter accumulates to a level that threatens health, safety, and usability of the home. Older adults may also suffer more health problems and are therefore unable to manage the clutter as well as they did when they were younger.

Question 5

When do you think Child Protective Services need to get involved in a hoarding situation? If bathrooms can be used and the kitchen is functioning, is having to step over things enough to call in CPS?

Gail Steketee · Accepted Answer

Clutter is not necessarily problematic, so long as the children are safe and their basic educational, social and emotional needs are met. The important part is to consider the best interests of the child, as there are no clear rules for deciding how much uncluttered space is needed to meet their needs. It is very important to talk openly with the parent or guardian to make sure they understand the specific issues that require the clinician to protect the child’s welfare.

Question 6

How is hoarding different from compulsive buying?

Christiana Bratiotis · Accepted Answer

Compulsive buying or shopping may occur among people with hoarding disorder, but it may also be a separate problem unaccompanied by the hallmark features of hoarding which are difficulty discarding and clutter that interferes with using living spaces. Compulsive buying occurs across the life span, but most commonly in young women who purchase excessive amounts of clothing and personal items well beyond their needs. The act of buying feels exciting and may relieve immediate feelings of anxiety and depression.

Question 7

Is hoarding linked to childhood neglect and developmental trauma?

Gail Steketee · Accepted Answer

People with hoarding disorder often report histories of traumatic events, but not usually the types of life-threatening events that lead to a diagnosis of post-traumatic stress disorder. Personal losses, especially of loved ones, may trigger hoarding symptoms among people who are vulnerable, but most cases of hoarding do not seem to be caused by traumatic experiences or childhood neglect.

Question 8

My mother is 78 years old and every day she thinks she will somehow "fix" her place.  It's clear it will never happen and she has even has no energy anymore.  She won't let anyone in.  Suggestions?

Christiana Bratiotis · Accepted Answer

It is not uncommon for adults with hoarding disorder to convince themselves that they can simply clean up the home if they only apply themselves to the task. Of course, this is much less likely to happen for older adults who are less capable of sorting, organizing, and getting rid of items they have accumulated. Your mother may be ashamed of the condition of her home and fear others’ judgement and that’s why she won’t let anyone in. Talk frankly with her about your fears for her safety and well-being and ask her to allow you to help identify some resources in her local area, possibly through the Department of Aging or a local community hoarding task force.

Question 9

My brother who is the best brother in the world and a wonderful human being, is also a hoarder.  His tendencies were in check until my parents died, how do I support him?

Gail Steketee · Accepted Answer

Tell him that you are concerned about his behavior and his future because of his saving and inability to get rid of items. Be specific about your fears and your wishes for him. Ask him if you can help set a timeline and develop a plan with gradual steps for making changes that will improve his quality of life. Focus on his safety and needs and on your relationship, especially at first. Increased focus on letting go of items and removing clutter can follow later.  Investigate the hoarding resources in his community and go with him to learn more about help that may be available.

Question 10

How does the hoarding CBT protocol differ from standard CBT or ERP? Does it emphasize cognitive restructuring or exposure or both?

Christiana Bratiotis · Accepted Answer

Standard treatment for obsessive compulsive disorder (OCD) involves exposure and response prevention (ERP). This means confronting feared situations without engaging in rituals or avoiding the situation, so that discomfort is tolerated until it declines naturally over time. Hoarding disorder (HD) is different from OCD, though some people may have both problems. Treatment for HD relies on motivational enhancement efforts to help people keep their goals in mind while they learn skills and practice not acquiring and discarding. It includes training in skills like sorting, organizing, problem solving, and making decisions about what to keep and discard. Daily practice of these skills means that the person confronts their fears and gradually modifies the beliefs that maintain their acquiring and saving behaviors. They gradually become more comfortable letting go of items they don’t need or want and more skilled at organizing things so clutter does not accumulate.

Question 11

When does 'stocking up' or 'saving' become hoarding?

Gail Steketee · Accepted Answer

Saving things does not become problematic until so many things are kept that the furnishings (tables, chairs, floor space) and living areas in the home cannot be used as intended. Many people keep extra items in their storage areas, using them regularly and replacing them when needed and space is available. This sort of “stocking up” that doesn’t interfere with living spaces is not considered hoarding.

Question 12

Does hoarding first begin in the mind or the home?

Christiana Bratiotis · Accepted Answer

Hoarding begins in the mind and shows up in the home when clutter accumulates and gets in the way of living. This “home” problem originates in people’s beliefs about objects which are often related to the usefulness, sentimental attachment, and aesthetic qualities of their possessions. So, All of these – hoarding beliefs, emotions, and behaviors are important targets during treatment.

Question 13

Do you have advice for differentiating hoarding from OCD?

Gail Steketee · Accepted Answer

Obsessive-compulsive disorder (OCD) is characterized by recurring intrusive thoughts, images or impulses that lead people to engage in rituals or compulsive behaviors like checking, washing, and putting things in a particular order to prevent some sort of harm (contamination, accidents to others, etc.). Hoarding disorder does not fit this profile, as it requires the physical manifestation of clutter that results from excessive acquiring, urges to save and inability to discard unneeded items. Both conditions may be caused by high anxiety or guilt, but the resulting behaviors are quite different and require different treatment.

Question 14

Do you know what might be causing the decision making deficits in hoarding? How can treatment target this?

Christiana Bratiotis · Accepted Answer

Decision-making problems seem to be a hallmark feature of hoarding disorder, although we are not really sure why this cognitive processing problem occurs. People with HD often seem to see usefulness and creative possibilities in objects (“I hate to waste this. I could fix it. One day I could use this in a craft project”) to the point that they cannot decide to get rid of it even when others would do so. They also become emotionally attached to items, worrying that if they discard something they will be disrespecting emotional connections to someone who gave it to them, or magical thinking that as soon as they get rid of it, they will find they need it after all. Thus, avoiding waste and feelings of loss or regret are motivators for keeping things. Cognitive behavioral treatment focuses on making decisions in light of current goals and personal values, taking into account what the person already owns and uses. Practicing decision-making is an essential part of the therapy process.

Question 15

Is hoarding actually about the types of items and collecting the items or is it more about the inability to throw them away?

Gail Steketee · Accepted Answer

Hoarding is about both. Saving items and difficulty parting with them are essential features of hoarding disorder, but people vary a lot in what types of items they save. Some people save ordinary items like clothing, toiletries, newspapers, and everyday household objects. Others save things like food wrappers or things that appeal to them aesthetically. The reasons for saving items provide clues about how to correct the attachment to objects that has gotten in the way of living.

Understanding Hoarding Behavior

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