Hoarding disorder: a therapist's manual

This programme is a treatment manual written for mental health professionals. It assumes clinical training in cognitive behavioural therapy, the possibility of working in the person's home, and a supervision framework. It replaces neither your clinical judgement nor your professional responsibility, and it does not exempt you from your country's legal duties regarding the protection of children and vulnerable adults. Diagnostic criteria are reformulated in our own words and never reproduced: refer to the original manuals for the wording itself. It is written neither for the people concerned nor for those close to them: if a home presents a serious danger today — a fire risk, someone trapped, a child or a vulnerable person in danger — contact your country's emergency services.

1. The programme at a glance

Indication. Hoarding disorder in adults: persistent difficulty letting go of possessions, clutter that prevents the home from being used, with or without excessive acquisition, whatever the level of awareness of the problem.

Reference model. Cognitive behavioural therapy for hoarding, based on the model of Frost and Hartl (1996) and set out by Steketee and Frost (2013): motivational interviewing, sorting and decisions in the home, training in not acquiring, exposure to letting go, work on beliefs about possessions, and organising skills training. For older people, the adaptations arising from the work of Ayers and her team.

Format. Twenty individual sessions, over five to six months. Eleven at the practice, of 60 minutes. Eight in the home, of 90 minutes. One non-acquiring outing. Then three booster sessions, at one month, three months and six months — the last one in the home. The sessions in the home are part of the protocol: sorting discussed at the practice is not sorting.

Mechanism targeted. Not emptying a home, but changing what the person does when faced with an object: deciding instead of putting off, letting less in, letting more out, and discovering that the distress of letting go comes down on its own and that the regret she dreads rarely turns up.

Session	Focus	Session output
1	Welcome and measure	Baseline measures, immediate dangers screened
2	First visit to the home	Room-by-room picture photographed, risks graded
3	What matters to you	Written goals, first area chosen
4	Understanding	Personal model written out
5	Make safe and organise, in the home	Urgent risks lifted, plan for the first room
6	First sorting, in the home	One area sorted, sorting rules written
7	Acquisition	Record of acquisitions, triggers identified
8	Not acquiring, in the situation	First exposure without acquiring
9	Letting go, in the home	Written hierarchy, two categories out
10	Usefulness, waste, responsibility	Beliefs rated, first experiment
11	Attachment, memory, identity	Second experiment, beliefs re-rated
12	The possessions that matter, in the home	One heavily charged category sorted
13	Deciding, organising, keeping it up	Storage system and routines written
14	Giving a room back its use, in the home	One space used for its function
15	Paperwork	Route for post and papers
16	Those close to the person	Written agreement
17	Sorting without me, in the home	Session led by the person
18	Getting things out, keeping the routine	A route out that works
19	Measuring, in the home	Photographs compared, measures repeated
20	Preventing relapse	Written plan, booster sessions dated

What the person takes away. Nine printable worksheets, listed in section 47: my home today, my safety first, what matters to me, my sorting rules, my sorting log, before I acquire, what I believe about my possessions, the corner for those close to me, my plan for what comes next.

What distinguishes this programme from the other manuals on this site. Three things. The safety of the home, which is assessed on the spot and can change the order of the sessions. The rule that nobody discards on the person's behalf, and the sharp distinction between a forced clearance, which does harm, and a limited intervention for serious danger, which is prepared. And honesty about outcomes: most people remain symptomatic at the end of treatment, hence the place given to maintenance and to harm reduction.

2. Before you begin

Who this programme is for

This text is written for psychologists, psychiatrists, psychotherapists, mental health nurses and clinical social workers trained in cognitive behavioural therapy. It assumes that you can stay for an hour and a half in a very cluttered home, sometimes a squalid one, without reacting, and that you have access to supervision. It is written neither for the people concerned nor for those close to them.

The four preliminary decisions

Does the home present a serious danger today? A blocked exit, a heat source surrounded by combustible material, a possible collapse, squalor that threatens health. That is section 11, the only one that can overturn the order of the programme.

Does anyone else depend on this home? A child, a dependent partner, a disabled person, animals. Their safety is not negotiated at the pace of treatment.

Does another disorder account better for the picture? Neurocognitive disorder, psychosis, severe depression, self-neglect without attachment to possessions. Sections 3 and 9.

Who is asking? The person, someone close to her, a landlord, social services. A person referred under pressure begins with motivation and harm reduction, not with sorting. Sections 43 and 45.

What this programme does not treat

Self-neglect without hoarding, which calls for a different assessment (section 3). Hoarding secondary to advanced dementia, which calls for medical and social care (section 42). Hoarding driven by a delusion, which calls first for a psychiatric opinion. Animal hoarding on its own, which requires coordination with veterinary services (section 43). And the child, whose hoarding is assessed in another framework.

How to use it

Read the whole text before the first session, in particular sections 7, 11, 17, 39 and 45: what sets this disorder apart from OCD, safety, the framework for working in the home, sorting, and harm reduction. Each session follows the same frame: the aim, the steps, what you say, common mistakes, and the criterion for moving on.

Three warnings specific to this presenting problem.

The home is a part of the person. A movement of recoil costs more than a poor technique.

The request is often somebody else's. You work with the person, not for her family and friends, and not for her landlord.

And progress is slow. What changes in twenty sessions is the way of deciding; the home follows, more slowly.

3. Four pictures not to be confused

1. The collection

What you observe. Objects of one precise category, sought out, organised, often on display, which the person talks about with pleasure. The living space remains usable.

What it implies. Nothing, unless the collection invades the living rooms to the point of making them unusable. A collection is put away; hoarding overflows.

2. Hoarding disorder

What you observe. Difficulty letting go of very varied possessions, including ones of little value, rooms that no longer serve their purpose, often repeated acquisitions, and distress at the thought of discarding. The person keeps things because she wants to keep them.

What it implies. This is the programme described here.

3. Clutter secondary to another disorder

What you observe. Clutter explained by something else: a depression that stopped all tidying, a neurocognitive disorder that prevents organising, a delusion that gives objects a function, an OCD where nothing is discarded for fear of contaminating or causing harm.

What points to it. An onset that is often recent and linked to the other disorder, and the absence of any particular attachment to the possessions.

What it implies. The other disorder is treated. Section 9.

4. Self-neglect, or Diogenes syndrome

What you observe. Extreme neglect of the self and of the home, often in an isolated older person who refuses help, with or without hoarding.

What points to it. Neglect dominates attachment. The original description concerned older people admitted to hospital for an acute condition, living in extreme filth of which they showed no shame, half of whom had no identified psychiatric disorder (Clark et al., 1975). A later review found, among people living in severe squalor, mainly dementia, alcoholism or schizophrenia, and proposed that hoarding be spoken of only when possessions are kept on purpose (Snowdon et al., 2007).

What it implies. A medical and cognitive assessment first, and coordinated medical and social care. This is not an indication for this programme as it stands.

The three sorting questions

"What happens when you try to let go of something?" It isolates the distress of letting go, which defines the disorder.

"Can you use your kitchen, your bed, your bathroom?" It measures the impact without talking about possessions.

"How long has it been like this, and what changed at that time?" It separates a long-standing disorder from recent clutter that should prompt a search for another cause.

4. The three dimensions of the disorder, and insight

Difficulty letting go

What you observe. The impossibility of discarding, giving away, selling or recycling, including possessions that are worn out, duplicated or of no use. The person puts it off, moves things from one pile to another, or does not start.

What needs to be made clear. What is dreaded: losing something useful, wasting, forgetting, letting go of a piece of oneself, or simply feeling the distress. This is the main target of treatment.

Clutter

What you observe. A table nobody eats at any more, a bed nobody sleeps in any more, a bath full of things, narrow passages, doors that no longer open fully.

What misleads. A clear home proves nothing if someone clears it regularly. And the clutter has sometimes been moved to a garage, a car, a storage unit or a relative's home.

Excessive acquisition

What you observe. Purchases, but also free things, salvaged objects, samples, gifts accepted. In a large online survey, about 85% of people with clinically significant hoarding reported excessive acquisition, and 61% met criteria for compulsive buying (Frost et al., 2009).

What counts in practice. Sorting that moves forward while acquisitions continue leads nowhere. Sessions 7 and 8.

Insight

What you observe. A continuum, from the person who knows and suffers to the one who is convinced that all is well and that the problem is other people's interference.

What you need to know. It is often weak in this disorder, and it collapses when discarding is threatened. In a survey of public health services, only half the people who were the subject of a complaint acknowledged that their home was unsanitary (Frost et al., 2000). Recognition of the problem comes considerably later than the first symptoms (Grisham et al., 2006). Frost, Tolin and Maltby (2010) treat it as a therapeutic obstacle in its own right.

What it changes. Weak insight is not a contraindication. It is a target, hence the place of motivational interviewing in every session.

Two forms apart

Animal hoarding. More animals than can be fed, cared for and housed, with a failure to recognise their condition. In a series of 54 cases reported to animal protection services, animals were found dead or in poor condition in 80% of the situations (Patronek, 1999). Section 43.

Associated squalor. Out-of-date food, waste, pests, unusable sanitary facilities. It is not always present, it is measured separately, and it changes the degree of urgency. Section 11.

5. What keeps the disorder going

Avoiding decisions

Deciding what to do with an object has a cost: it has to be categorised, its value estimated, the possibility of being wrong accepted. Putting it off brings immediate relief. Every undecided object joins a pile, and every pile makes the next decision harder. This is the central mechanism. Its quieter forms: moving things without deciding, creating piles "to be sorted" that never are, promising to sell, waiting to find the right person to give something to.

The reinforcement of acquiring

Acquiring brings real pleasure: the bargain, the find, the sense of being provident, sometimes relief from sadness or boredom. The cost — space, money, shame — comes later.

Beliefs about possessions

Their possible usefulness: "it might come in handy". The duty not to waste and to take care of things. Their role as memory: "if I throw it away, I forget". Their link to identity and to people. The need for control. These beliefs have been described and measured (Steketee et al., 2003), and their modification accounts in part for the effect of treatment (Tolin et al., 2019).

Information-processing difficulties

Attention that scatters, categorisation that is too fine — every object becomes unique —, difficulty deciding, doubt about one's own memory. The model of Frost and Hartl (1996) places them on the same footing as the beliefs. They explain why a motivated person cannot manage alone, and they justify session 13.

The full circle

An object presents itself — to be acquired or to be discarded. The belief gives it a value. The idea of letting go of it triggers distress. The decision is put off, or the object is acquired. Relief or pleasure reinforces that choice. The clutter grows, sorting becomes harder, shame isolates, and isolation leaves more room for possessions. This is the diagram you draw in session 4.

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