By Gail S. Steketee, MSS, PhD
Gail Steketee, PhD is the Dean of the Boston University School Social Work. Her recent research, funded by the National Institute of Mental Health, focuses on diagnostic and personality aspects of compulsive hoarding and on effective treatments. She and Randy O. Frost, PhD, of the Smith College School of Psychology are co-authors of the book Stuff: Compulsive Hoarding and the Meaning of Things published in 2010.
Q. Dr. Steketee, what is the average age of a person who hoards? Is it mostly senior citizens who remember The Great Depression and now can’t bring themselves to throw anything away? Also, is there an average age of onset or some sort of mental tipping point?
Hoarding begins in adolescence and becomes a significant problem for most people in their 30’s. However, the average age of people seeking treatment is about 50, ranging mainly from early 40s’ to elderly adults. Although many people who hoard are over 65, most did not experience deprivation such as that from the Great Depression, so this does not appear to be a major cause of hoarding. On the other hand, we have some evidence that people who hoard may experience more disruptions early in life (one example is moving frequently as a child). Perhaps these experiences lead them to trust people less than the objects around them.
Q. How does this disorder breakdown by gender?
Epidemiological studies indicate that hoarding occurs more often in men than women, but treatment seekers are mainly women. This suggests that men are less likely to seek help. We are not sure if they are less likely to recognize that they have a problem or just less interested in treatment.
Q. What is the difference between someone who hoards common objects versus someone who has, for example, 40 cats in their home?
We don’t really know the answer to this question. We know quite a bit about hoarding of objects, but rather little about people who collect and do not take adequate care of animals. However, we have some evidence that animal hoarding may stem from a failure to develop strong attachment to people early in life and a higher frequency of stressful life events during childhood. These factors might contribute to limited ability to cope effectively with adverse personal situations in childhood and later on in adulthood so they don’t function well in work and social activities during adulthood. Therefore, they turn to animals for unconditional love and support.
Q. Have you seen instances where patients will steal items to hoard?
Yes, stealing occurs in up to 10 percent of people who hoard.
Q. Can hoarders be good spouses and parents? Can they devote their time and attention to relationships?
It is true that people who hoard tend to live alone and not to marry more than other people, but many do maintain strong relationships with others. However, as many children of hoarders can attest, some (but by no means all) parents who hoard do not attend as closely as they should to the developmental needs of their children (e.g., for play space alone and with friends) and other social needs.
Q. Dr. Steketee, what motivates someone who is hoarding to come to you for treatment? For example, can someone wake up one day and decide he or she is just plain exhausted by the effort it takes to hold on to so many things? Or do the hoarding behaviors themselves prevent them from patients from confronting even more painful issues?
I’m not really sure how to answer this and truth is, we have never studied what motivates people to seek help. I suspect we will find a range of motivations that range from sudden urgency – waking up one morning and finding the house too unpleasant to live in and remembering that it was not always that way, to trying to satisfy a live-in family member who insists the home be cleaned up or they are leaving.
Q. Can individuals stop hoarding “cold turkey?”
I’m sure this is possible, but of course, if that has occurred, we would not be seeing this person for clinical treatment.
Q. Can medication stop the behaviors without being combined with psychotherapy?
At this time we do not know of medications that are consistently helpful for hoarding. A couple of studies suggest that some serotonergic reuptake inhibitors may be helpful, but these findings have not been replicated. It is not clear what hoarding symptoms medications would target – difficulty making decisions? Attention deficits? Impulsivity in acquiring? Since up to half of people with hoarding disorder also have major depression, medications might improve depressive symptoms, but that action would not be specific to hoarding itself.
Q. How common are relapses?
Our individual treatment data indicate that people who improve with CBT do not relapse noticeably within the first year of treatment, nor do they improve further.
Q. What is involved in treating these patients and how long does therapy last typically?
We have developed a reasonably effective cognitive and behavioral treatment for hoarding and have published a therapy guide and client workbook on this topic with Oxford University Press. This treatment uses 26 sessions that can be delivered in a combination of office and home visits; group treatment is also an option. Treatment takes 6-12 months (and sometimes more for severe clutter) and includes motivational strategies to overcome ambivalence about discarding and not acquiring items, skills training for organizing and decision-making, cognitive therapy to change faulty thinking, and extensive practice reducing excessive clutter and acquiring. We are continuing to seek ways to improve the outcomes of this treatment which leaves about 75 percent of people who complete it feeling much or very much improved.
Please click here to see images of compulsive hoarding provided by the International OCD Foundation.