Connecting through Clutter :

1. Connecting through Clutter: How to Help Those Who Hoard Presented by Matt Hunter, MS, LPC, NCC of the The Anxiety & Stress Management Institute 770-953-0080; www.stressmgt.net Derived in large part from Dr. Rebecca Beaton’s workshop on the treatment of Hoarding Disorder

2. These slides cover: • What is hoarding? (symptoms & diagnosis) • What causes it and who tends to hoard? • How is hoarding treated and what can loved ones do? Need more info? • mhunter@stressmgt.net • Intake and Consultation appointments: 770-980-9229 • Confidential voicemail: 770-953-0080 ext. 308

3. What is Hoarding Disorder? DSM-5 Definition • Persistent difficulty discarding or parting with personal possessions, even those of apparently useless or limited value, due to strong urges to save items, distress, and/or indecision associated with discarding. • The symptoms result in the accumulation of a large number of possessions that fill up and clutter the active living areas of the home, workplace, or other personal surroundings (e.g., office, vehicle, yard) and prevent normal use of the space. If all living areas are uncluttered, it is only because of others’ efforts (e.g., family members, authorities) to keep these areas free of possessions. • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). • A difficulty in letting things go that leads to enough clutter that functioning is impaired.

4. What is Hoarding Disorder? DSM-5 Definition (continued) • Rule these out: • D. The hoarding symptoms are not due to a general medical condition (e.g., brain injury, cerebrovascular disease). • E. The hoarding symptoms are not restricted to the symptoms of another mental disorder (e.g., hoarding due to obsessions in Obsessive-Compulsive Disorder, lack of motivation in Major Depressive Disorder, delusions in Schizophrenia or another Psychotic Disorder, cognitive deficits in Dementia, food storing in Prader-Willi Syndrome). • Specify: • With excessive acquisition? • Level of insight: good, fair, poor, delusional

5. What Causes It? It’s Complicated… • Nature or nurture: 84% of compulsive hoarders report hoarding behaviors in at least one first-degree relative—is this genetics or learned behavior? • Neurobiology: elevated activity in areas of the brain that are important for the visual processing of emotional material, memory search & retrieval, associating memories with objects, processing of unpleasant emotions, and decision-making—does the brain configuration shape the behavior or does the behavior shape the brain? (neurons that fire together, wire together) • Comorbidity: personality disorder, ADHD, generalized or social anxiety, trauma, OCD, addiction—are these all subtypes or is this a complex of diagnoses that when combined bring on hoarding? • Without a clear cause, therapists tend to conceptualize treatment based on how it presents.

6. Cognitive View: What Are They Thinking? • Obsessive Thoughts—OCD-Based Hoarding: • Obsessive and distressful thoughts drive up the anxiety. • There is no pleasure or emotional attachment in the hoarded items. • Information Processing Difficulties with: • Attention & Decision-Making (anxiety based?) • Categorizing (their own possessions, but often not others) • Memory (spatial, not by function) • Elaborative Processing (discerning and viewing objects in relation) • Underlying Beliefs: • Values & beliefs about waste and personal eco-responsibility • Concern with future need, loss, availability, poverty • Perfectionism, catastrophizing, victim/martyr • Objects represent sentimental duty, identity, security, completeness

7. Emotion Focus: What Are They Feeling? • Anxiety Model • “Stinking thinking” drives up anxiety. • Anxiety feels bad; relief through avoidance feels great! • Strong positive reinforcement of avoidance leads to deterioration of self-efficacy & motivation, which generates more “stinking thinking.” • Addiction Model • High from acquiring, finding bargains • Mood control through clutter (turn to your stuff to feel better) • Hoarding worsens over time (building tolerance?) • Problems develop in relationships, at work, and with authorities • Attachment Model • Neglect, conditional love, abuse/trauma  disordered attachment style • Hard to see the value of human attachments (avoidant) • Turn to safety and consistency of things/animals to provide a positive image of self and a buffer against the harsh world

8. Who Tends to Hoard? • Generally begins in childhood or early adolescence and gets worse over time: • 5% recognized at 5 years old or younger • 10% recognized from 6 to 10 years old • 10% recognized from 11 to 15 years old • 2-5% of the American population (6-15 million people) have severe enough hoarding to impact their daily lives. • 2X more common in men • 3X more common in people 55 and older • 4X more common among low income earners (<$20,000/year) • Frequently, there is a history of clutter which is made much worse by a loss or trauma. • Those who hoard tend to be conscientious, kind, intelligent, and creative, possibly to their detriment.

9. The Human Side of Hoarding • 6% have been fired due to hoarding • 77% report one or more severe health conditions. • Up to one in 55 have had a child removed from the home. • 13% have been evicted or threatened with eviction. • Those who hoard tend to feel shame, fear, and guilt that leads to isolation from the very people and resources that they need. Often the systems (familial, legal, societal) in which they live perpetuate these feelings.

10. How Do Therapists Help? • Treating Anxiety = Cognitive-Behavioral Therapy, specifically Exposure and Response Prevention. • Treating Addiction = Motivational Interviewing, assess clients’ stage of change and meet them where they are; build self-efficacy and create value and meaning for making the change. Replace short-term coping with meeting of authentic needs. • Treating Attachment = Consistent care and concern with unconditional positive regard (love) and encouragement. • Treating Trauma = Process the traumatic event to contextualize it in the past, ease hypervigilance, and promote a survivor stance supported by affirmative meaning and understanding of the event. • Treating the Information ProcessingConcerns= Support, skills, education, and harm reduction techniques. • Treating the System = Get family and friends involved such that perpetuating behaviors are minimized and replaced with support and encouragement. Replace isolation with connection. Educate the public and promote compassion.

11. How Can Family & Friends Help? Do Your Work: • Read and follow new information. • Address your own distressful feelings of anxiety, shame, resentment, and guilt. • Model functional skills and good decision-making. • Recognize and resist enabling and/or perpetuating behaviors. My belief is that most people tend to engage with (rather than avoid) a relaxed person with clearly good intentions.

12. How Can Family & Friends Help? Offer a Secure Attachment: • Be consistent in your availability. • Listen, validate, encourage; do not fix. • Express your care, concern, hopes, love out loud & often. • Reflect a positive image back to your loved one focusing on their strengths and their value as a person. • Create loving boundaries. • Engage and fully participate in productive conflict to foster trust and belonging.

13. How Can Family & Friends Help? Assist in Exposure Work with Love: • Recognize that what is logically simple is not emotionally easy; acknowledge small steps for the emotional importance they represent. • Check your agenda at the door. • Meet your loved one where s/he is, reinforcing his/her goals, taking it at her/his pace. • Encourage continuous exposure work with the statement “I believe you can handle your anxiety.” • Ask permission to touch, and wait until asked to proceed. • Help your loved one stay focused.

14. How Can Concerned People Help? Recommend Help: • Suggest “support,” not “therapy for hoarding.” • Provide support options. • “State the dilemma” to increase insight and solidarity. Lessen the Shame: • Don’t label or criticize. • Don’t fire or alert the authorities unless really necessary. • Correct misinformation or shaming statements by others. Contribute: • Volunteer • Donate packing materials, temporary space, repairs

15. Questions? Call The Anxiety & Stress Management Institute at 770-980-9229 for more information about guest speakers, consultations, and/or therapeutic services.