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In-House Group Treatment for
Compulsive Hoarding
Maria Watson, MA, RCC
Don Collett, MDiv, RCC, RMFT
Sheila Woody, PhD, RPsych
Outline
Background
About the Clutter Groups
The In-House Clutter Group
The Treatment (& Modifications)
Challenges
Surprising Benefits
A Little Data…
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Background
How the clutter groups got started:
therapists
location
funding
Group Members
Adults, mid 30’s to mid 60’s
Demographics
1st group 2 women 3 men
2nd group 3 women 2 men
3rd group 3 women
4th group 4 women 1 man
Unemployed, with the exception of one member.
All living alone
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Group Format
Initial intake interview (1.5 hrs)
12 group treatment sessions (1.5 x 12 = 18 hrs)
Monthly “booster” sessions, ongoing for the past 3 years.
In-House Clutter Group
Contract from a residential hotel, offering supportive housing for women.
This is a single room occupancy (SRO) hotel purchased by the Province of British Columbia and renovated by BC Housing to provide supportive housing to people who are homeless and at risk of homelessness.
The SRO is designed to provide alcohol- and drug-free housing for women in transition from detox. The residential stabilization and treatment program is designed for woman in the sex trade struggling with addiction and mental health issues. The hotel houses a 20 unit recovery program on the second floor and 21 self-contained units for program grads on the third floor.
Intake assessments with 6 women, proposed by the staff at the residence, 4 of whom wanted treatment, and 3 who were able to attend.
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The Set-up
A group meeting room on the same floor, or one below
the residents’ rooms.
Each room includes a bed, sink, counter, microwave,
phone, TV, and wardrobe.
Shared kitchen/bathroom/laundry facilities.
Rainier Room 1
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Rainier Room 2
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Treatment
Primarily Cognitive Behaviour Therapy (CBT) loosely based on the group tx manual from Boston University (J.Muroff, G. Stekettee, R. Frost, et al) but condensed from 16 to 12 sessions, due to financial constraints. 12 was NOT ENOUGH!
Some systemic, process oriented, therapy was included in most of the sessions
2 therapists. A third therapist sat in during the sessions to take notes, observe and give feedback to the therapists, and assist with in-room cleaning/sorting in the in-house group.
Why CBT and not just a big bin?
Clutter is a product of hoarding (behavioural manifestation)
Physically reducing clutter (tip of iceberg)does not address the hoarding problem (down below)
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Treatment Topics (Sessions 1-12)
1. Intro and Psychoeducation
2. Cognitions (decision making, perfectionism, categorization and organization, memory, beliefs, emotional attachment)
3. Motivation (pros and cons of changing, problems due to clutter)
4. Exposure (feared consequences, replacement behaviours, empowerment and short term goals)
5. Exposure continued
Treatment Topics (cont.)
6. Organization (Defining categories and deciding location,
what to do with discarded items, decision rules for keep vs.
discard, practice making decisions)
7. Barriers to Making Progress (depression, feeling
overwhelmed, distractibility, anger, lack of support)
8. Paper Filing/Organization
9. Maintenance and Letting Go (establishing daily routines)
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Treatment Topics (cont.)
10. Was supposed to be Acquisition (Patterns of acquisition,
advantages of not acquiring /disadvantages of
acquiring, nonacquisition exposure) but because this
wasn’t a big concern for this group we focused on
changing one Behaviour that affects their problem on a
daily basis (examples)
11. Was supposed to be Coping with the Changes (empty
space extra time). This turned out not to be a
problem….worked on Developing New Habits
12. Review and plans for next month
Useful Modifications
The most important modification was being able to enter
each group member’s room for part of a session. Often
30 minutes were spent, one-on-one, cleaning or sorting in
the room, practicing the skills discussed in group minutes
before.
Observing the cleaning/sorting process in the room was
so informative and helpful to the therapists. Some
examples of what we learned….
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Modifications (cont.)
Plastic sleeve folder for handouts. Therapists kept the
folder until the end of the group, and added to it as
weekly homework was returned
Homework was taped up to a visible area in the room, or
to the side of the box that was used to bring clutter from
the room to the group
Worksheets to help break down weekly goals in to daily
steps, including a system to monitor progress (have staff
or support person initial daily items)
Daily Goal Outcome Initial
Wash dishes for 10 minutes
Sort one box of papers
Take out recycling
Package cosmetics to return to Mary
Kay
Mail Mary Kay package
Practice turning off TV after one show
Put all laundry in hamper
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Challenges in working with this
Population
history of evictions and homelessness
physical health problems
financial limitations
severe co morbidity
bugs/rodents
tiny living spaces without storage
easy access to free stuff!
Others?
A normal response to an abnormal
environment?
“food for thought” – if you had lost everything repeatedly, were living on income assistance and lived in a single room (shared kitchen/bathroom, no storage) how would your space look?
Consider:
being forced to give up your hobbies and interests (e.g. cooking)
Having no control over furniture/paint/flooring
Not being allowed to have visitors (would you still clean if no one saw it?)
Having no structure to guide your day and your sleep (no work/social obligations)
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Benefits of Group Treatment for low
income people living in supported
housing
1. Social aspect
2. Structure of weekly sessions
3. Normalizing
1. Social Aspect
So many people who hoard are extremely isolated socially because:
They are unable to invite people to their home
They are too ashamed to show anyone their home
Many are anxious about going out and leaving their belongings
They may be restricted by difficulties finding clothing/sports equipment required for social activities and thus miss opportunities.
The treatment groups were very well attended, and members were eager to share their experiences, and most asked to continue with booster sessions following the end of treatment.
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2. Structure
Many people who hoard are unemployed, and socially
isolated, so there is no external pressure for regular sleep
cycles, getting dressed, going out etc.
Members of the In-House group reported spending up to
8 hours a day watching TV, and losing track of time. They
also reported sleeping well past noon, and staying up
during the night. Some came to group in pajamas,
straight out of bed (without teeth on one occasion!)
Clutter group meetings imposed structure on their week,
and they reported cleaning in preparation for the weekly
cleaning sessions, and someone coming in to their rooms.
3. Normalizing
Other than the TV shows about hoarding, there are very
few opportunities to see the homes of people with
hoarding difficulties. The group members shared
information about their rooms/homes and were visibly
relieved to hear that other people also suffered from:
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Normalizing (cont.)
rodent infestations difficulties sorting and
cleaning being unable to find their
possessions hurting themselves when
slipping and falling over things finding
broken/destroyed possessions being
chronically late avoiding their home by
keeping busy or distracting self spending
money to buy multiples of things
hating/avoiding/losing paper work etc.
Surprising Benefits Specifically for
In-House Group
Surprising benefits that this housing arrangement has for
all three main areas of hoarding treatment:
monitoring and controlling acquisition,
organization/cleaning
discarding/donating
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Surprising Benefits (cont.)
Monitoring by staff members at the front desk, of what is
brought in to the apartment.
Easy access to all the participants’ rooms, making
assessment (including severity rating)& monitoring of
homework more accurate and less time consuming for
the therapist.
Surprising Benefits (cont.)
Ability to practice new skills in the rooms, the same day
that they are introduced in the group.
Fewer missed sessions/problems with lateness.
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Surprising Benefits (cont.)
Using the staff and other group members in the building,
to help with clean up sessions, as well as lending moral
support to the client.
Maintenance of treatment gains by staff who have been
trained to support residents past end of treatment.
Data collection
Pre and post treatment assessment carried out by a
graduate student, not involved in the treatment (1 hr
each).
Measurements included
Hoarding Rating Scale
Clutter Image Rating Scale (self & report)
ADL (Activities of Daily Living) Scale
CES Depression Scale
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Hoarding Rating Scale
1. Because of the clutter or number of possessions, how difficult is it for you to use the rooms in your home? 0 1 2 3 4 5 6 7 8 Not at all Mild Moderate Severe Extremely Difficult Difficult
2. To what extent do you have difficulty discarding (or recycling, selling, giving away) ordinary things that other people would get rid of? 0 1 2 3 4 5 6 7 8 No Mild Moderate Severe Extreme Difficulty Difficulty
hoarding rating scale
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clutter image rating
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Activities of Daily Living - Hoarding
activities of daily living areas of interference
PL: Unable to eat at table, sit in any chairs, find important
papers. Safety issues: trip hazards, emergency response.
KM: No interference beyond moving a few things to
clear space to sit. No safety issues.
DR: Severe mice infestation. Unable to sit in chairs, find
important papers, use sink, prepare food. Safety issues:
emergency response, trip and fall hazards, avalanche
hazard, safety concerns for her dog.
SR: Room was somewhat organized in spite of the large
volume of possessions. Little interference. Safety issues:
emergency response, perhaps avalanche hazard.
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activities of daily living
depression
