Sunday, July 31, 2011

Treating People Who Hoard — What Works for Clients and Families

I want to share this very interesting and helpful article from Social Work Today. It was written by Jennifer Van Pelt, MA. I'm adding the entire article, but please don't hesitate to go to the site for additional information: http://www.socialworktoday.com/archive/051711p14.shtml

TV reality shows can help and hurt people who hoard. Find out why and know what really works best for clients and the families who care about them.

Popular “intervention” TV shows have begun dramatizing the clutter associated with hoarding: newspapers piled from floor to ceiling, clothes and linens stacked on furniture, stuff everywhere with only a narrow path to walk through a house. Extreme cases—where stray animals are packed into a small apartment or so many items have been accumulated that floors collapse—illustrate the severity of some instances of hoarding.

Approximately 3% to 5% of the U.S. population has a hoarding disorder (Tompkins, 2011), but the disorder affects many more, destroying marriages and home life and alienating family and friends.

“Media attention to hoarding has brought it out of the closet. People are more likely to talk about hoarding now,” says Terrence Daryl Shulman, JD, LMSW, ACSW, CAAC, CPC, founder/director of The Shulman Center for Compulsive Theft & Spending and an addictions counselor who works with hoarding cases as well as compulsive spending and theft.

“TV shows like A&E’s Hoarders have brought attention to a very secretive, shameful disorder and therefore have encouraged people and their families to get help,” says Gretchen H. Placzek, MBA, LCSW, MSW, a psychotherapist at East Bay Family Wellness in California who specializes in treating anxiety and works with individuals and families in cases involving hoarding. The show Hoarders depicts follow-up with solid therapeutic assistance and guidance, she says, adding that media attention has possibly even encouraged professionals to research the disorder and gain expertise to better assist people who hoard and their families.

However, the depiction of hoarding on TV has also contributed to misinformation about the disorder and its treatment.

“The negative aspect is that the shows may be seen as exploitive, and they do not always highlight the intense pain and suffering that goes along with a hoarding disorder,” explains Placzek.

Another downside, according to Shulman, is that hoarders may think “I’m not that bad” when viewing the extreme, shocking cases on TV, causing them to avoid or resist treatment.

The hard work needed to change hoarding behavior is downplayed by focusing on sensational cases, says Gail Steketee, LCSW, MSW, PhD, a professor and dean at Boston University who has been researching hoarding since the mid-1990s and has coauthored numerous publications with Randy O. Frost, PhD, a psychologist and professor at Smith College, including their most recent book, Stuff: Compulsive Hoarding and the Meaning of Things.

Her colleague, Christiana Bratiotis, PhD, LCSW, a postdoctoral fellow and Compulsive Hoarding Research Project director at Boston University, adds, “Sadly, these programs often portray an unrealistic intervention that minimizes the role of mental health treatment and sets up unrealistic expectations for hoarders and their families.”

Hoarding is a chronic disorder that gradually worsens, often over a period of decades, says Bratiotis. TV shows give the impression that appropriate intervention can occur in several days and without longer-term cognitive behavioral therapy (CBT).

“Professional organizers and clean-up companies are useful and necessary partners in the work, but they do not begin to be the totality of the intervention, and portraying that as the solution is to diminish the painful and difficult work needed to overcome a hoarding problem,” Bratiotis explains.

Acknowledging the Problem
Hoarding treatment begins with a person acknowledging the underlying problems that fuel hoarding behavior. The reasons for hoarding differ depending on the person, and treatment is challenging because people who hoard often do not realize their behavior is a problem or they are socially isolated and ashamed due to the condition of their home. Sometimes, they resist treatment because they think it will involve simply clearing out the clutter.

“Just cleaning out the stuff does not address the underlying psychological issues,” Shulman says. “It’s not a clutter problem; it’s a perception/thinking problem.” According to Steketee, no single condition causes hoarding. Contributing factors or stressors may include the following:

• being raised in a chaotic home or one with confusing family context, or moving frequently;
• cognitive processing issues that affect decision making and problem solving;
• attention-deficit disorder;
• anxiety and/or depression;
• excessive guilt about waste; and
• genetics and family history because hoarding behavior runs in families.

“Hoarding can also occur in people with dementia, schizophrenia, and obsessive-compulsive disorder [OCD],” says Steketee, “but it is not clear that the features and causes are the same.”

Currently, there is a common misperception that hoarding is caused primarily by OCD or anxiety. But although anxiety or compulsion may contribute to hoarding behavior, researchers now believe hoarding is not a type of OCD, and anxiety is not the primary driving force, Steketee explains.

For example, hoarders may experience anxiety or stress due to obsessive thoughts, such as grief over someone’s death or the loss of important things in their life, or perfectionist thinking. Hoarding helps prevent them from experiencing that anxiety or reduces the severity of it. Accumulating may be calming for the hoarder, Shulman says.

“Focusing on ‘things’ deflects the focus from the thought processes actually causing anxiety,” says Shulman.

“Hoarding may induce feelings of safety and security and/or reinforce identity,” adds Steketee.

The exact causes of hoarding are still uncertain, and research on the physiology and psychology of hoarding is ongoing. Geneticists are working to identify genetic loci related to hoarding behavior, says Steketee. An imaging study found that cerebral blood flow in a patient with OCD and severe hoarding exhibited a certain pattern during the most severe hoarding symptoms, and the pattern changed when the patient’s hoarding behaviors improved (Ohtsuchi, Matsuo, Akimoto, & Watanabe, 2010). A review of epidemiological, neurobiological, and treatment studies concluded that compulsive hoarding may be a discrete disorder with its own diagnostic criteria (Pertusa et al., 2010).

Currently, hoarding is not listed as a separate disorder in the DSM-IV but is mentioned as a symptom/criteria of OCD. However, a revision for the fifth edition, to be released in 2013, proposes that hoarding disorder be listed as a separate disorder under the heading of “OC spectrum disorders.” It is also likely to be removed from the criteria for OCD, says Steketee.

Treating the Behavior
Despite ongoing debate regarding the causes and diagnostic criteria of hoarding, there is no question that therapy is necessary. Hoarding typically leads to social isolation from family members, and involving family in the therapeutic process appears to contribute to improvement of hoarding behavior.

The first and most important component of family therapy is education. “Like any addiction, hoarding is a family disease; everyone is affected and each family member needs to be educated about it,” says Shulman. Families need to understand that hoarding is a disorder, and the treatment process is long.

“Psycho-education is almost always the first step in working with the families of people who hoard,” Placzek says. Family members must be educated about hoarding to have compassion and recognize it as a mental health issue. They need to understand that each accumulated item has meaning and value for the hoarder, she explains.

Addressing support and validation concerning the anger and hurt that many family members feel is another important step. The therapist needs to make sure the family understands that without their support and help, the hoarder is unlikely to get better, only progressively worse, Placzek says.

However, not all hoarders live alone and are socially isolated, and family therapy may be especially helpful when the hoarder lives with the family to deal with daily interactions during these situations. Impatience during the lengthy family therapy process is common, says Shulman. Often, “control drama” will erupt between the person who hoards and other family members, and this needs to be worked out to bridge the communication gap between them.

For married hoarders, additional couples therapy is often required because the hoarder’s partner is often codependent when it comes to the hoarding behavior, says Placzek. Or the partner may be impeding progress for the hoarder undergoing individual therapy, adds Shulman. When the hoarder lives with young children, elders, or people with disabilities, family therapy must address these special family issues, says Bratiotis. “Special protections must be taken to assure that these family members are safe and healthy and that the hoarding is not creating hazards that impact these vulnerable and protected people,” she notes.

Anecdotal reports from practitioners suggest that family therapy can be very successful when addressing hoarding behavior, but currently, no published research exists on the outcomes of family therapy for hoarding. Unpublished research has focused on the value of involving family members to get the loved one who hoards into treatment when that person is reluctant to seek therapy and/or does not recognize the problem, says Steketee.

However, research does support the benefits of cognitive and behavioral methods. Approximately 70% of people who hoard show improvement following 26 treatment sessions, Steketee reports. “Family therapy seems unlikely to be helpful unless the person who hoards also receives CBT to help them learn new skills, modify beliefs, and reduce discomfort that prevents them from discarding hoarded items,” she adds.

Common approaches to individual therapy for hoarders includes motivational interviewing, CBT, and decision-making skill building. “Motivational interviewing is essential since many people do not have good insight into the extent of the problem caused by their clutter and collecting behaviors. We also train skills to address cognitive problems like decision making and organizing as well as problem solving. We help people modify mistaken beliefs about possessions using CBT, and we use behavioral exposures to discarding and to not acquiring to reduce discomfort with these activities,” Steketee explains.

CBT using exposure therapy seems to be the best approach for hoarding treatment, says Placzek. Exposure therapy requires the hoarder to face his or her anxiety by organizing, sorting, and making decisions regarding what should be discarded and what will be kept while at the same time monitoring his or her anxiety level. The hoarder must go through this process to change maladaptive thoughts and, in turn, the hoarding behavior.

Family therapy is adjunctive and supportive for those undergoing CBT for hoarding. “I use CBT to guide the client’s treatment and when I’ve engaged families, it’s been through a family systems perspective. Often family are significantly impacted by the problem of hoarding, especially when living in the home, and are highly invested in the outcome,” says Bratiotis. Family members may be able to serve as behavioral coaches throughout the CBT process, though this may require significant therapeutic work with the family members and the hoarder, she adds.

Recently, researchers and psychologists have suggested using harm-reduction methods in family therapy to address hoarding behavior. Harm-reduction therapy focuses on helping family members develop a management plan for improving the safety and comfort of a hoarder’s home. For example, structural issues from the weight of accumulated items, the potential for fire, mold and dust, and vermin infestation may pose substantial risks to the person who hoards, especially an older adult who lives alone.

According to the researchers who propose this method, harm reduction assumes that it is not necessary to stop all compulsive acquiring or completely clear the hoarder’s home to stop harm. This therapy process involves setting small, achievable goals to reduce the risk of harm in the home (Tompkins). In some cases, enlisting the aid of the local health department may assist the family in communicating the danger of hoarding to their loved one. When a hoarder shares the home with other family members, harm-reduction methods can be used to communicate the potential harm of hoarding behaviors for others in the home.

People who hoard are most likely to improve when family therapy is combined with individual CBT and other interventions, such as medications to treat co-morbid conditions (e.g., depression) or working with a professional organizer in the home. The impact of family cannot be underestimated, though.

“Ultimately, success depends on how supportive, compassionate, and patient the family members are with the hoarder and on the level of motivation and commitment from the hoarder,” Placzek says.

— Jennifer Van Pelt, MA, is a Reading, PA-based freelance writer with 15 years of experience as a writer and research analyst in the healthcare field. She has written on depression, attention-deficit/hyperactivity disorder, schizophrenia, mental wellness, and aging.

References
Ohtsuchi, H., Matsuo, K., Akimoto, T., & Watanabe, Y. (2010). Fronto-limbic abnormalities in a patient with compulsive hoarding: A 99mmTc-ECD SPECT study. Psychiatry and Clinical Neurosciences, 64(5), 580-583.

Pertusa, A., Frost, R. O., Fullana, M. A., Samuels, J., Steketee, G., & Tolin, D. (2010). Refining the diagnostic boundaries of compulsive hoarding: A critical review. Clinical Psychology Review, 30(4), 371-386.

Tompkins, M. A. (2011). Working with families of people who hoard: a harm reduction approach. Journal of Clinical Psychology, 67(5), 497-506.

Resources-
Web
• Children of Hoarders: www.childrenofhoarders.com

• East Bay Family Wellness: www.eastbayfamilywellness.com/hoarding-ocd-too-much-stuff

• International OCD Foundation Hoarding Center: www.ocfoundation.org/hoarding

Books
• Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding by David F. Tolin, Randy O. Frost, and Gail Steketee

• Compulsive Hoarding and Acquiring (therapist guide and client workbook) by Gail Steketee and Randy O. Frost

• Digging Out: Helping Your Loved One Manage Clutter, Hoarding, and Compulsive Acquiring by Michael A. Tompkins and Tamara L. Hartl

• Stuff: Compulsive Hoarding and the Meaning of Things by Randy O. Frost and Gail Steketee

Thursday, July 28, 2011

5 Tips to Help Overcome Hoarding

Compulsive hoarding is a regular and potentially disabling problem, characterized by the gathering of excessive litter, to the extent that parts of a person’s home can no longer serve its intended purpose. It is also referred to as the act of saving many items that have been thrown away by general population. Examples of items that a hoarder might gather are broken appliances, newspapers, bags and magazines.

Hoarding can best be classified as a compulsive disorder in which a person has the potent habit of collecting and keeping useless items that have no value or benefit, but fails to discard them.

Approximately two million people in the United States are affected by compulsive hoarding, patients who display signs of hoarding normally suffer from other diseases, such as dementia, schizophrenia, anorexia and Alzheimer's. It's most present in patients with obsessive-compulsive disorder (OCD). Doctors aren't sure whether compulsive hoarding is a division of OCD or a different disorder.

This behavior is often hard to overcome because most hoarders do not acknowledge that they have this problem. However, the right treatment can in fact make a world of a difference in their life. Here we will look closely at five tips to help overcome hoarding.

1. Assess Your Needs
Ask yourself, "Do I truly need this item?" You may come up with one hundred different reasons why you need a particular item, but the question that you ought to ask yourself is whether you in fact will use it in the present or future. If you haven’t used it for many years, it is very probable that you will never use it again. The best thing for you to do is to discard these items in the trash can or sell them in a yard sale. You also don’t need to keep extras of anything; if you have one, you don’t need another.

2. Be Prepared to Face Your Fears
Overcoming hoarding is not always a simple task. You have to face your fears and stick to your plan of getting treatment to rid yourself of all useless belongings. During this process you may accidentally sell something that was of some worth or value. Just keep in mind that you can always buy a new and possibly better one. Stop worrying that you may discard something valuable, nothing bad will occur if you get rid of some of your belongings.

3. Stop Allowing Junk to Pile Up
Compulsive hoarding cannot be overcome in a few hours or few days, it is a continuous process. Once you have removed the existing mess in your abode, you also need to enforce measures to prevent the junk from piling up again. Be patient with this dilemma. and don’t allow hoarding to overwhelm you again. Clean and organize your belongings on a consistent basis.

4. Get Help and Get Treatment
It is possible to overcome compulsive hoarding. Remember to be yourself. However, receiving some amount of treatment from a mental health practitioner who specializes in this sort of behavior will help you to reach your goal. A psychotherapist specializing in cognitive behavioral therapy can help you to better understand why you accumulate useless things. After a proper diagnosis they will be able help you get rid of all the clutter in your home, and help you to develop your decision making and relaxation skills. Above all a therapist will be supportive if you encounter any setbacks along the way.

5. Reach Out to Other People
Loneliness is one of the main factors that causes hoarding to occur, that’s why it is never wise to confide yourself to your home. This will not aid you in overcoming hoarding.. If you are not comfortable inviting guests to your house because of the mess, make it a point to visit the homes of your relatives and friends.

These five tips for hoarders will greatly aid you to overcome hoarding, which segregates you from your loved ones. If you are knowledgeable that a loved one is a compulsive hoarder, don’t quarrel with them as this will make them more stubborn in their ways. Instead be equipped to listen to them and converse with them about how this behavior is preventing them from reaching their maximum quality of life.

For further info, check out this website: http://www.curiocabinetspot.com/tips-to-overcome-hoarding

Saturday, July 23, 2011

Tomorrow We're Taking Your Leg: Hoarding & Suicide

I want to share this post by my friend & colleague Debbie Stanley, LLPC, NCC, CPO-CD:


My heart is breaking for Spencer Harris as I imagine what this was like for him.


I have often said that forced hoarding cleanouts are the psychological equivalent of involuntary surgery. Many people who hoard view their belongings as an extension of themselves, as Mr. Harris did. He killed himself on May 17, about a week after a 24-hour eviction notice was enforced on him. He was given a day--one day--to get out.


The eviction notice was issued by an official described as "experienced in handling hoarding situations."


News reports say Mr. Harris was given a temporary storage container in which to sort through his things and decide what to keep. In other words, an operatory in which to cut off his own leg, or arm, whichever he preferred.


They gave him a POD and a deadline. What he needed was a mental health professional and a psychologically realistic timeline. The introduction of a therapist truly "experienced in handling hoarding situations" and using the harm reduction approach would have greatly improved Mr. Harris's chances of developing better insight and integrating needed changes into his life, which by friends' accounts was vibrant and active.


24 hours to get gone. What must those 24 hours have been like for him? 24 hours of knowing that tomorrow, they'll be at the door to separate you from a part of yourself. Facing that sentence, perhaps you would flee and get a few states away before they could do it. But if you hoard, you can't carry all of yourself, all at one time. Paraphrasing Erma Bombeck, when you hoard you let your heart live outside your body, but people don't get that. Erma was talking about children. How can anyone care that much about stuff? It's just stuff.


And as long as the people in charge think it's just stuff, there will be more tragic endings.

Sunday, July 17, 2011

HOARDING, COMPULSIVE SHOPPING AND OTHER "INVISIBLE ADDICTIONS"

HOARDING, COMPULSIVE SHOPPING AND OTHER "INVISIBLE ADDICTIONS"

They live in every community in the nation, and are a part of every extended family. In recent years, they’ve even begun making regular appearances on unscripted television shows such as Clean House, Obsessed, and Animal Rescue.

Sometimes they’re referred to as eccentric, strange or weird:

  • Your mother’s uncle, whose “collection” of old newspapers and magazines looks more like a fire hazard than a tribute to days gone by.
  • The friend who can’t seem to stay out of the stores or off the online retail sites, even though her shopping sprees have put her on the brink of financial ruin and her apartment looks more like a warehouse than a living space.
  • The heartbreaking couple you saw on the news last night – the ones who, the health department discovered, had been keeping dozens of animals in their tiny, filthy house.

Hoarding animals and obsessively accumulating objects of no apparent value are two types of relatively common behavioral compulsions that appear to straddle the line between out-of-the-ordinary activities and mental illness.

In an effort to determine what types of extreme actions constitute a mental health concern, an international group of mental health experts met Oct. 1 and 2 in the Ontario (Canada) Science Center to talk about hoarding and other types of compulsive behaviors – commonly misunderstood obsessions that a Sept. 22 Canwest News Service article termed “invisible addictions.”

Misty Harris, who wrote the Sept. 22 article, reported that October’s “Many Faces of Addiction” conference was designed to bring about “the proposal of clinical criteria defining where normal indulgence ends and disordered behaviour begins.”

The challenge, according to Canadian addictions counsellor Anne McLaughlin, is that unlike chemical dependency, "process addiction" tends to have few detectable symptoms, with the behaviour either taking place in secret or being dismissed by family and friends as normal activity.

"It can be very isolating," says McLaughlin, who treats both sex addicts and their partners. "If someone drinks or takes drugs, at least it's visible."

Hoarding & Obsessive Collecting

The “invisible addiction” label may be valid as a means of identifying behaviors that don’t result in intoxication or other obvious forms of impaired motor functioning. But anyone who spends quality time in the presence of a person who cannot control behavioral urges will soon see that the disorder is far from invisible.

For people who are addicted to gambling, sex or the Internet, for example, their compulsions are made visible by financial problems or the inability to participate in normal healthy relationships.

But when it comes to hoarders or obsessive collectors, the evidence may be even more obvious – and, to many people, much more difficult to understand.

According to the website Understanding Hoarding, the following three primary attributes of compulsive hoarding were established in a 1996 article by R.O. Frost and T.L. Hartl, both of whom were then affiliated with the Smith College Department of Psychiatry:

  1. The acquisition of, and failure to discard, a large number of possessions that appear to be of useless or of limited value
  2. Living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed
  3. Significant distress or impairment in functioning caused by the hoarding

In addition to these three diagnostic criteria, Understanding Hoarding also noted that most compulsive hoarders also possess four common personality traits:

  1. Indecisiveness
  2. Perfectionism
  3. Procrastination
  4. Avoidance

“Severe cases of hoarding may truly devastate a person's life if no help is sought,” the website reported. “[Hoarders] feel shame and this shame will gradually evolve into isolation.”

What Compulsive Hoarding Looks Like

In an article on the website of the Obsessive Compulsive Foundation (OCF), Karron Maidment, Program Coordinator/Behavior Therapist of the UCLA OCD Intensive Treatment Program, describes the experiences of the estimated 700,000 to 1.4 million Americans who are afflicted with compulsive hoarding disorder:

Hoarding is defined as the acquisition of, and inability to discard worthless items even though they appear (to others) to have no value. Hoarding behaviors can occur in a variety of psychiatric disorders and in the normal population, but are most commonly found in people with obsessive-compulsive disorder (OCD). …

Compulsive hoarding is not just an enthusiast's passion for collecting stamps, dolls, or baseball cards. … People with compulsive hoarding syndrome may have immense difficulty throwing anything away, from the oldest paper clip, to a used food container, to an out-of-date newspaper, for fear that they might need those items in the future.

Their homes are often full of stuff that the rest of us would call "junk." The most commonly saved items include newspapers, magazines, old clothing, bags, books, mail, notes, and lists.

Though most hoarders amass apparently useless objects, some people who have the disorder become obsessed with animals, bringing dozens – or in some cases more than 100 – dogs, cats or other creatures into their house. Overwhelmed by the logistical challenges of caring for so many animals in a space that was not designed for such a large-scale operation, animal hoarders put their own health and the health of the animals they have “rescued” at risk.

Defining the Problem, Addressing the Disorder


Though Frost and Hartl’s standards have achieved widespread acceptance, hoarding (like
sex addiction, chronic shopping compulsions, Internet addiction and several other obsessive behaviors) has not yet been recognized by the “bible” of the mental health community, the Diagnostic and Statistical Manual of Mental Disorders (DSM).

However, that may soon change.

One of the reasons for the October conference in Ontario was to discuss the possible inclusion of disorders such as these in the next DSM edition, which is scheduled to be released in 2012.

"Pathological gambling is in the DSM … and it really sets up a precedent for these other behavioral addictions," Toronto psychotherapist Edith Townsend told Canwest News.

Even without DSM recognition, compulsive hoarding has been treated via a variety of techniques, including medically assisted therapy (often involving selective serotonin reuptake inhibitors such as Prozac or Paxil) and cognitive behavioral therapy (CBT).

CBT appears to be the most effective approach, though treatment for compulsive hoarding is a notoriously slow process.


This featured article was written by Huge C. McBride, and published on Life Healing Center's site, a Recovery Center located in Sante Fe, New Mexico. For additional information and articles please view their website: http://www.life-healing.com