Deconstructing the Hoarding
A Holistic Approach (Part I of II)
by Lisa Wessan MSW, LICSW
Chairperson of the NASW Northeast Private Practice Shared Interest Group.
Wessan, L. (2014). Deconstructing
the Hoarding Spectrum: A Holistic Approach.
National Association of Social Workers. FOCUS. Vol. 41, No. 4.
ďAnything that you cannot relinquish when it has outlived its usefulness possesses you, and in this materialistic age a great many of us are possessed by our possessions. We are not free.Ē†
†††† ~Mildred Norman Ryder1
††††† (aka the Peace Pilgrim, 1908-1981)
For this article, letís refer to clutterers and hoarders on the same hoarding spectrum. Both clutterers and hoarders suffer from Clutter Blindness, a perceptual-distortion phenomenon. Picking a behavioral label is often just a matter of degree,3† since many symptoms and behaviors are identical in the two groups. To help you make your initial diagnosis, I would like to distinguish hoarders from the more common clutterers in three ways.
(1)† Hoarders suffer from CHAOS (Can't Have Anybody Over Syndrome). When a hoarder reaches this point, regardless of how much stuff is actually in the home, we understand that social isolation, depression, anxiety and other imbalances are crippling the client's life.†
Usually, a hoarder will not ask for help until the situation becomes critical, e.g. an eviction notice is received, nursing home placement is required, there is a pending relocation, or when the sale of a home is infeasible due to hoarding complications. To reach this crisis point, the client situation has gone beyond CHAOS to another level.
For example, some of my elderly clients have suffered from upper respiratory illnesses and rashes, due to black mold and other contaminants in the home. Elderly hoarders are especially at risk for injurious falls, and being crushed or immobilized by the hoarding pile is another common risk. In the end stages, vermin and dead animals are often found in the hoard. It may be very difficult for the hoarder or for family members to recognize that such physical conditions are actually life-threatening.†
The new DSM V has recognized this by making hoarding a stand-alone behavioral diagnosis, where in the past it was lumped broadly into obsessive and compulsive behaviors.4
It is very common for the hoarding client to be eligible for a dual diagnosis, as well as possessing a strong codependent streak.† Hoarders often have very good intentions, "saving this for someone who might need it."† This exaggerated tendency to rescue and save is complex, and has psychodynamic and attachment issues that should be uncovered in treatment.
(2)†† To meet criteria for a hoarding diagnosis, the client must achieve a rating of two or more on the National Study Group on Disorganizationís Clutter Hoarding Scale,5 an excellent diagnostic tool. The NSGCD scale has five levels -- clutterers are diagnosed at Level I. Hoarders are diagnosed at Levels II through V.
(3)†† Clutterers Anonymous, a 12 Step spiritual fellowship based on the principles of Alcoholics Anonymous, has a useful set of screening questions which can help your client identify and self-select treatment for this diagnosis.6† (Hoarders are typically unwilling to get help, and are often resistant to change even when they enroll themselves†† in therapy or programs.7)
Once you have established that you are indeed working with a hoarder, you should assume the client has a very complex set††† of disorders to work through.† You will encounter one or more of the following complications: addictions, chemical imbalances, eating disorders or malnutrition, ADD, ADHD, OCD, and severe social isolation, at the least.† Most hoarders also have an Axis III (medical) diagnosis and will often need medication and psychiatric supervision.
Clutterers do not necessarily present with dual or multiple disorders, nor do they always need medication. Their home or office may be visitable and physically non-toxic. †Some amount of clutter or sub-par organization and storage is common: even hoarding expert Dr. Robin† Zasio, admits to having a make-up drawer that is "out of control."8
Now letís begin to explore the treatment of clutterers and hoarders from a clinical perspective. This work will always call for a holistic approach Ė uni-dimensional treatment or help for cluttering and hoarding is not effective. For example,† forcibly restraining, removing, or deceiving the subject while his or her place is rapidly cleaned out, "the big clean out" is a common lay approach -- it is the opposite of a safe approach to these diagnoses.
For this article, I will share some useful insights on the Inner Journey.† In a second article (Part II), I will elaborate further on the Outer Journey, which is task oriented.
The Inner Journey has two components: One part takes clients through a series of exercises that bring them back to the source of their clutter, and usually involves grief work.† The second part is a series of forgiveness exercises and assignments.
Some participants can trace the onset of their clutter, e.g. due to a relocation, death,† divorce or illness.† These traumatic events can block the healthy flow of filing, storing and discarding.† When left untreated and unsupported, over time the Level I Clutterer can move along the NSGCD spectrum to become a Level V Hoarder, due to this original unprocessed catastrophic event and the isolation it can trigger.
Group work is especially helpful for people on the Hoarding Spectrum.† While individual treatment is not contra-indicated, I have found that groups have a special healing dynamic and help to diffuse toxic shame much quicker.9
To get to the core issues, I use an array of tools for the Inner Journey segment, including forgiveness meditations, writing, sharing in dyads, homework and journaling between sessions. It can take a few weeks in group for participants to feel safe enough to open up, but then these structures are very productive.
Dr. Bradley Nelson's energy medicine methods are very effective for processing trauma in groups. His work has set new standards for methods to process trauma† and PTSD.10
To foster cohesiveness in the group, I encourage members to snap their fingers when they identify with something someone is sharing. This creates an accepting, convivial atmosphere that makes it safer to share "crazy stuff" about clutter. When a room full of nice people are snapping away as you share about your mess, it quickly becomes less painful and daunting.
Working this way, there is a lot of laughter with the tears, and this helps diffuse toxic shame so members can feel more connected in the group.
Shame is a huge component of the forgiveness journey. How many times I have heard people say, "I should know better. I'm so embarrassed that I just can't do this. Why is it so hard for me to throw things away?"
To that I respond, "What is Shame?† Should Have Already Mastered Everything? Nay, nay, I say. You do not have to be an expert at anything yet.† You are perfectly fine just where you are NOW! Learning to forgive oneself and let go of things not done is part of your advanced psycho-spiritual training. Banish the word SHOULD from your thoughts and words. Let's end this suffering now!"
When I say these words, there is a palpable sigh in the room, sometimes tears. People on the Hoarding Spectrum need to feel forgiven, and unconditionally accepted.
Another part of the Inner Journey is seeking to find out "What is the payoff of having your clutter?"† Clients are often startled by this question. But after we talk about the "benefits" and how it's working for them, they begin to uncover their deeper reasons for maintaining their clutter, e.g. fear of intimacy; or loneliness and unresolved grief.
After one closed-eye exercise -- part hypnotherapy and part visualization -- a client realized that the reason she could not throw out her stuff is that she would also want to throw out her husband! There was a strong connection between her clutter and her junky husband.† "They all need to be put out!" she said to the group, as she laughed and cried out her tears from this realization.
(Continued in Part II, The Outer Journey, in the May issue of FOCUS.)
Edited by Bet MacArthur MSW LICSW† Member, SWTRS.
Wessan, L. (2014).
Deconstructing the Hoarding Spectrum: A Holistic Approach. National
Association of Social Workers. FOCUS. Vol. 41, No. 4.