As clinicians, we want what’s best for our patients, but what happens when regular talk therapy isn’t working? What happens when patients are preoccupied with their worst fear and trying to convince them otherwise seems impossible? What if that worry is about discarding objects in their home, despite the fact that they can no longer walk through their halls safely?
If you have a patient that has difficulty throwing things away, constantly bringing home seemly useless materials, and has a home that has become completely cluttered with collections, you may be working with a patient suffering from hoarding. This patient may not like others touching their belongings and will have a hard time getting rid of their possessions, while others may interpret their collections as useless. A common worry for someone who hoards is: “one day I will need this object, and if I throw it away now, then I will not have it when I need it later.”
Unfortunately, many individuals don’t seek treatment on their own and may sometimes deny that their collection poses an increased risk. However, it is not uncommon for family members to seek treatment for their loved one.
Hoarding can be treated with behavioral therapy, specifically, Exposure and Response Prevention (ERP). In ERP, hoarders purposely discard items in order to face their fears and overcome anxiety without engaging in self-soothing behaviors (e.g., buying more items, replacing discarded items, etc.) to avoid any discomfort. The goal for treatment is to get to a place where the patient can tolerate the uncertainty of not knowing if she/he will need their discarded object. This can be done in three steps.
- Imagery practice: Begin by writing a detailed and present-focused narrative that includes the patient’s feared consequence. This narrative can then be recorded for the purpose of listening until distress to the fear is decreased. The patient can listen to this narrative daily until they no longer feel discomfort.
- Create a list: Consider helping the patient create a list as a visual inventory and to begin a hierarchy of objects they have collected and need to discard. Moving from a moderate level on their list, to the most difficult will ensure the patient is not flooded but can learn to tolerate the discomfort in a systematic way.
- Enlist support team: It is very difficult to discard objects that feel very important to you. One thing that can help with this is having a family member or friend present to support the patient in the process and assist in the task between sessions.
Hoarding is a distressing disorder due to the nature of comfort collecting provides; and when a patient seeks treatment the hoarding may have been developing over many years. If a patient feels severe discomfort without an object, it is no wonder that they will want to collect as much as possible! Therefore, as clinicians it is our goal to help the patient tolerate and decrease discomfort of uncertainty. Although it is important to understand the intense anxiety that comes along with discarding objects for these patients, and the value that patients have assigned to each object, it is equally important in recovery to increase distress tolerance and accepting uncertainty.