By Carol R. Hevia, PsyD
Hoarding is a mental health disorder characterized by a persistent and powerful difficulty in getting rid of collected items, regardless of their value. Left untreated, this behavior can lead to a variety of damaging emotional, social, financial, and physical effects—for both the hoarder and their family members.
It is also important to distinguish between hoarding and collecting. Collectors are proud of their collections and enjoy displaying them. Hoarders, on the other hand, are ashamed.
Reasons Why People Hoard
Hoarding, like most mental health behaviors, is complex. Researchers initially thought that it was primarily connected to obsessive compulsive disorder (OCD), and, indeed, many patients who hoard also have OCD—but not all. Hoarding can also occur in isolation, but it is more common to see a patient who hoards have at least one other diagnosed mental health condition.
Researchers and clinicians now believe that hoarding can be associated with many different types of problems. Therefore, it is very important for a mental health provider to understand each patient’s unique background in order to better home in on what may be fueling a hoarding behavior.
It may, for instance, be tied to major depression accompanied by anhedonia—an inability to experience pleasure. Such patients are unable to take care of themselves, and simple tasks seem insurmountable. Its origins also may be connected to dementia, attention deficit hyperactivity disorder, or impulse control problems.
Once hoarding has become an issue, certain factors can exacerbate the problem. For instance, hoarding can often cause interpersonal difficulties, as collected items ultimately infringe and overtake living space. Hoarders and their family members may not be able to sit in a chair, sleep in a bed, or use a shower because they are filled with hoarded items. This often causes stress between the hoarder and their family members. However, instead of compelling hoarders to fix the problem, this stress serves to raise their anxiety levels and intensify the hoarding.
Treatments for Hoarding
Treatment approaches for hoarding should have a cognitive behavioral therapy (CBT) element, with exposure and response prevention (ERP) therapy often being the primary CBT tool. Exposure therapy requires patients to face their fears, which can temporarily heighten anxiety. This anxiety, however, diminishes over time, and hoarders learn to be more flexible about their beliefs and belongings.
For hoarders, exposure therapy means facing the painful possibility of getting rid of things—or not acquiring things—and the specific type of exposure therapy employed, as well as its intensity, varies according to each patient’s situation.
For some patients, we help by establishing goals. We first ask them to estimate how much they are willing (or want) to throw away. We then work with them to organize their belongings into three categories: stuff that you are going to keep, stuff that you are going to donate, and stuff that you are going to throw away.
I like to begin by priming the pump. The first item that a patient considers should be something destined for the throwaway pile. This is because as the keep pile grows, it becomes more difficult for patients to put things into the throwaway pile. Conversely, as the throwaway pile grows, the patient feels less anxious about adding to it. In the end, we have found that this type of exposure helps our patients to discard more than they anticipated.
For another type of exposure, I ask a mental health coach to touch all of a patient’s belongings. If the hoarder collects newspapers, I will tell the coach to touch every single paper in the pile and the patient has to sit and watch. This can be very stressful for some hoarders, but as the process is repeated over and over, their anxiety continues to wane.
Acquisition exposures are effective for treating compulsive shoppers, who feel like an item for sale is theirs once they touch it. We start this exposure by having the hoarder drive by their favorite store without stopping. Next, they are told to walk past the store without going in. This progresses to having them walk into the store and not touch anything. Finally, the patient has to go into the store and touch the products they want, but they cannot return later on to purchase any of the items.
These are just a few of the strategies, and we continue to explore other options as we learn more about hoarding. We find that being flexible in our treatment approaches benefits our patients.
Eliminating the Stigma Associated With Hoarding
Unfortunately, people with hoarding disorders often fail to seek treatment for years because of the stigma and shame attached to it. This is why we need to better educate the public about the devastation that hoarding can cause and the difficulties involved in treating it—particularly when it is not treated early.
Hoarding is not a personality quirk. It is a mental health disorder that can cause great emotional and financial damage to a hoarder and their loved ones, and it can take many years—including a lot of hard work and patience—to get the behavior under control.
It is also important for the public to realize that none of us is immune to developing a mental disorder. I continue to be fascinated by the number of mental health professionals, including my colleagues, whose experiences with treating patients has helped them to recognize and address their own formative hoarding issues.
Carol R. Hevia, PsyD, is an assistant psychologist at the Obsessive Compulsive Disorder Institute at McLean Hospital and an instructor in psychology in the Department of Psychiatry at Harvard Medical School.
Find more information about confronting mental health stigma through Deconstructing Stigma, McLean Hospital’s anti-stigma public awareness campaign.