Cognitive Behavioral Therapy for Hoarding Disorder in an Older Female

1 Theoretical and Research Basis for Treatment

Collecting items is a common feature of contemporary life, and relationships toward these objects can be part of healthy development (Jarrett, 2013). However, problems may develop when collecting becomes excessive or when the individual has difficulty getting rid of the accumulated items. Hoarding disorder (HD) is defined as an enduring difficulty in discarding possessions as result of a need to save these items, and significant distress linked to disposing of them (American Psychiatric Association [APA], 2013).

To be classed as HD, the hoarding should not be better explained by another mental health disorder or medical condition. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013) suggests specifying whether an excessive level of accumulating items is present and whether the individual has insight to the hoarding-related cognitions and behaviors being problematic (APA, 2013). HD is currently estimated to have a prevalence of 2.5% in the general population (Postlethwaite et al., 2019) with higher prevalence in older adults (Samuels et al., 2008).

HD is thought to develop in early adolescence, and hoarding difficulties tend to increase over an individual’s lifespan (Dozier et al., 2016) following a chronic course without intervention (Ayers et al., 2015). Qualitative research has identified three potential themes which may contribute to increasing difficulties in older adults. These include reductions in health interfering with household management, social losses leading to a loss of support in discarding items or inheritance of additional possessions, and moving to new accommodation where possessions remain unpacked (Eckfield & Wallhagen, 2013). Hoarding can have a huge impact on the individual and the people around them. For example, excess clutter can be a risk factor for fire and falls (Diefenbach et al., 2013) and can lead to the inability to use rooms for their intended purpose (Rodriguez et al., 2012). Older adults face heightened risks, as they can be less resilient to hazards (Ayers et al., 2012), and the consequences of HD in this age group, such as social isolation, medical complications, and cognitive deficits, can both impact, and be impacted on, by HD (Diefenbach et al., 2013). These complicating factors commonly found in older adults with HD are critical to consider when assessing an individual and developing a treatment program (see Segal et al., 2018 for further discussion).

Traditionally conceptualized as a subtype of obsessive-compulsive disorder (OCD), HD has only recently been acknowledged as a disorder in its own right in the DSM-5 (APA, 2013). Consequentially, the evidence-base for intervention is still in early stages. Common interventions include medication such as serotonin reuptake inhibitors (Saxena & Sumner, 2014), family therapy (Chasson et al., 2014), self-help (Tolin et al., 2007), and cognitive-behavioral therapy (CBT) (Steketee & Frost, 2014). A literature review looking at all current interventions found a modest reduction in hoarding symptoms, with the majority of individuals remaining within a clinical range.

Hoarding difficulties are still covered by the clinical guidelines for OCD (National Institute for Health and Care Excellence, 2005), which recommend utilizing psychological therapy at the client’s home. At present, the psychological intervention with the strongest evidence-base is individual CBT. A recent meta-analysis demonstrated a significant reduction in HD symptoms (Tolin et al., 2015). Although promising, rates of dropout were high, and difficulties persisted for more than half of all clients, suggesting that further research is required.

Despite the prevalence of HD in older adults, to-date, there have been no large-scale studies looking at the efficacy of CBT in this population. Preliminary research has found that older adults are able to tolerate a full course of CBT with low attrition rates, leading to reductions in hoarding severity. However, these reductions were not always clinically meaningful or sustainable for a long term (Ayers et al., 2011; Turner et al., 2011). The authors suggest that existing protocols could be enhanced to take into account the difficulties common in this population such as a longer, more intensive intervention period to target the chronic nature of HD, and skills training to target neurocognitive deficits. Other suggested adaptations, such as focusing on exposure, setting concrete homework tasks, and reducing the focus on cognitive restructuring, are supported by qualitative research conducted with both therapists and clients (Ayers et al., 2011).

The use of CBT with older adults has a growing evidence-base across various difficulties, contradicting the traditional view that older adults are unable to engage in psychotherapy (Gallagher-Thompson et al., 2008). The American Psychological Society (American Psychological Association, 2014) has published guidelines for working psychologically with older adults, highlighting the parameters unique to working with this population. The guidelines cover six areas; competence and attitudes, knowledge about aging and development, clinical issues, assessment methods, intervention and consultation, and professional issues. Although not mandatory, the APA suggests that the guidelines are used as a “frame of reference” (p1) for providing clinical work in this population, to ensure good professional practice.

2 Case Introduction

The client (“Lucy”) was a 67-year-old Caucasian lady who was referred to the Psychology team within a secondary care mental health service for older adults. The referral from the service’s psychiatrist stated that Lucy presented with long-standing difficulties with hoarding, anxiety, low mood, and a suspected personality disorder. Lucy identified that she wanted to focus on the treatment of her hoarding behaviors, as this was the area that was having the most impact on her life.

3 Presenting Complaints

In this case study, the client is referred to as Lucy: This is not her real name. Other nonessential details have been altered to preserve confidentiality. Two years ago, Lucy and her husband moved house to be closer to their family. The move had not worked out as anticipated, and this was contributing toward difficulties in Lucy’s mood. She described that she had not seen her family as often as she had expected, and felt lonely and isolated due to being unfamiliar with the new area. Lucy had struggled to unpack her belongings as a result of low levels of motivation and physical restrictions caused by her physical health difficulties.

As a consequence, each room in the house contained boxes of unpacked items. Surfaces were cluttered with piles of paperwork and miscellaneous items such as books and ornaments. This restricted the extent that rooms could be used for their intended purpose. For example, there was no space on the dining table to eat meals on, and Lucy and her husband relied on ready-meals as there was not enough room in the kitchen to prepare fresh food. The boxes were unlabeled, meaning that Lucy was unable to find items related to her hobbies, such as baking equipment and fabric for dressmaking.

The hoarding was also having wider consequences in Lucy’s life. It was a source of friction between herself and her husband, causing frequent arguments about the clutter in the home. Lucy required a downstairs bathroom due to her physical health problems, and although she had obtained permission for one to be installed, the building work could not go ahead until the garage was clear of clutter. The planning permission was due to expire in a few months time, putting pressure on Lucy to organize this soon.

Lucy displayed good insight into her hoarding. She realized that it was problematic and appeared motivated to engage in therapy to make changes to the hoarding behaviors.

4 History

Lucy was born with cerebral palsy, and as a result, her mother was very overprotective of her when she was younger. Lucy was bullied at school due to a speech impediment caused by the cerebral palsy, but did not feel that this had an impact on her as the majority of pupils in the class were supportive toward her. She recalled that when she was younger, her family was poor and her mother often had to forego her own needs so that the children had access to food and clothing. As a teenager, Lucy rebelled by trying out new things such as painting and making her own clothes. When Lucy started her first job, she was finally able to afford things that “looked nice” and items related to her interests, including books, records, and fabrics to make clothes.

Due to the speech impediment, Lucy was unable to pursue her dream career of teaching. She traced her low mood back to this point and reported that her mood had fluctuated since then. Instead, Lucy became an administrator—a role that she found challenging but rewarding. During her first post, Lucy alleged that she was bullied by a colleague and was forced to leave this role. She reported having a nervous breakdown during this time and recovered from this with support from a social worker and a community psychiatric nurse (CPN). Lucy recalled one major episode of anxiety in her thirties; when she took her driving test. She had experienced mild symptoms of panic intermittently since then, triggered by situations that cause her to feel overwhelmed.

Lucy married her husband when they were in their twenties, and they had two adult sons together. Lucy recalled that her first year of marriage had been a particularly stressful period. A friend who had recently separated from their partner asked Lucy and her husband to temporarily care for their two children. At this time, Lucy was pregnant with her first son, who was born with cancer and required intensive medical treatment. Shortly after the birth, Lucy’s grandmother, who she was close to, passed away. Lucy was unable to work while she cared for her sons and her friend’s children, meaning the only source of income came from her husband’s wages. Lucy managed using second hand items and mending the family’s existing belongings. She recalled that this was a very difficult time for her and she responded by becoming very controlling, giving the example of having the children’s school clothes laid out the night before.

Initially, Lucy stated that the problems with hoarding had started when she moved into her current home. On further exploration, she acknowledged that the excessive accumulation and hoarding behaviors could be traced back to her first job, when she was finally able to afford to treat herself. Despite this, it had not become a problem until a few years prior to the move, when her physical health had deteriorated. Although she had greatly reduced the accumulation of new items, she was now left with a large amount of clutter that had become unmanageable due to the volume of items and her physical limitations.

5 Assessment

Assessment took place over three sessions in the client’s home. The initial session was a general assessment, and the following two sessions focused on the hoarding difficulties, guided by hoarding guidelines (Holmes et al., 2015; Steketee & Frost, 2014). A battery of self-rated psychometric measures was completed to provide further information (Table 1). In line with service requirements, Lucy completed a measure of psychological well-being, the Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM; Evans et al., 2000), which indicated a severe level of distress. A number of HD-specific measures were also completed. Scores indicated that Lucy displayed clinically significant levels of hoarding behaviors that interfered with daily life. HD-related cognitions and accumulation difficulties were present, but not to a clinically significant level. As Lucy described difficulties with planning and executing tasks, she was referred to another member of the Psychology team for neurocognitive assessment. The tests did not show up any clinical concerns.

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Table 1.

Outcome Measure Scores.

Outcome measure	Assessment	Final session	HD cut-off
CORE
Total	83 (severe)	56 (moderate)
HRS
Total	16 a	20 a	14
Clutter	4 a	4 a	3
Difficulty discarding	4 a	4 a	4
Acquisition	2 a	3 a	2
Distress	2	4 a	3
Interference	4 a	5 a	3
SI-R
Total	38	52 a	41
Clutter	21 a	23 a	17
Difficulty discarding	11	16 a	14
Excessive acquisition	6	13 a	9
SCI
Total	42	39	95.9
Emotional attachment	11	12	37.7
Control	12	7	15.8
Responsibility	11	15	22.3
Memory	8	5	20.3
ADL-H
Total	1.67 (mild)	1.07 (none-minimal)	2.2
CIR
Living room	5	3	3.7
Kitchen	2	2	3.4
Bedroom	3	3	4.1
Hallway			—
Bathroom	1	2	—
Garage	6	6	—

Note. HD = hoarding disorder; CORE = clinical outcomes in routine evaluation; HRS = Hoarding Rating Scale; SI-R = Saving Inventory–Revised; SCI = Savings Cognitions Inventory; ADL-H = activities of daily living for hoarding; CIR = Clutter Image Rating.

a

Denotes score that meets HD cut-off.

At the end of therapy, the results of the outcome measures varied. There was a significant decrease in psychological distress, from 83 (severe) to 56 (moderate). Lucy felt this was accurate. She reported that her mood had improved, she was not crying as much, and was able to enjoy things more. Lucy had begun reading novels again, which was something that she had not felt up to doing since moving into the new house. Lucy attributed this improvement down to the progress she had made with the decluttering.

The majority of HD-specific measures remained at a similar level, and some increased. Lucy felt that this was not due to an increase in HD symptoms, but because she had developed more insight into the extent of the problem:

6 Case Conceptualization

The results of Lucy’s assessment scores and clinical interview supported the diagnostic criteria for HD. In line with recommendations, two types of formulation were used (Steketee & Frost, 2014). A model specific to HD helped to develop a shared understanding of Lucy’s difficulties, and to guide intervention. During sessions, smaller cycles related to specific incidents were used as a means of functional analysis (Figure 1).

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Figure 1.

Functional analysis of a specific incident.

The HD-specific model developed by Steketee and Frost (2014) proposes that hoarding is a complex behavior, resulted from a number of difficulties such as personal and family difficulties, problems with information processing, unhelpful cognitions about items, learned behaviors, and emotional responses (Figure 2).

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Figure 2.

General conceptual model of hoarding (Steketee & Frost, 2014).

7 Course of Treatment and Assessment of Progress

A total of 10 weekly CBT sessions were offered by a trainee clinical psychologist, under the supervision of a senior clinical psychologist. The sessions were guided by the treatment manual “Treatment for Hoarding Disorder” (Steketee & Frost, 2014), which is based on cognitive and behavioral strategies to address difficulties with the acquiring and discarding of items. Lucy’s personal goal was to organize the clutter to improve the relationship with her husband, to make her new house finally feel like “home,” and most importantly to allow the installation of a downstairs bathroom. To do this, we planned to focus on the hoarding behaviors, and the related cognitions around objects.

At the start of therapy, we agreed to work on decluttering one room. The rationale being that focusing on one discrete area would allow us to identify any skill deficits that Lucy had in relation to organizing the clutter, so that therapy could be used to help her to develop skills to overcome these difficulties. These could then be utilized by Lucy to declutter the remaining rooms in the house. The task of organizing the house was something that Lucy had avoided since moving in, so it was hypothesized that starting with an area that was relatively easy would help to reduce feelings of being anxious and overwhelmed by providing exposure to an avoided task. Lucy reported that she had engaged in similar work with her CPN in the past, but her mobility and motivation had acted as barriers. She described wanting “everything done at once,” and the slow progress had reinforced her low levels of motivation. Taking this into account, we agreed that we would set small, achievable homework tasks, so that organizing did not become too tiring or overwhelming. Lucy felt that creating a specific to-do list for each day would help her to achieve these goals. We also added in tasks that Lucy enjoyed, such as gardening, to help maintain motivation. Each session began with by setting an agenda in collaboration with Lucy, which would typically cover a brief check-in, review of the homework task, and then the main focus of that day’s session. All sessions included an element of psycho-education, reformulation, cognitive challenging, and behavioral interventions.

During the first few sessions, psycho-education was provided around the intervention which Lucy was in agreement with. Initially, Lucy identified that she would like to focus on the entrance hall. Lucy admitted than usually she would walk through the hall and ignore the clutter. We completed a visualization task where initially Lucy was asked to look at the clutter and talk through how it made her feel. She disclosed feeling guilty and thinking “I shouldn’t have this mess” as it was upsetting for her husband. To build motivation, Lucy was then asked to look at the corner and visualize it as being tidy and organized, which made her feel “happy.” Lucy was able to make a to-do list, creating small, specific tasks, including contacting a charity to ask them to uplift some books, asking her cleaner to help with some heavy lifting, and clearing out a small chest of drawers. We compiled a small list of questions that would help Lucy to make decisions about what to do with the items, such as “do I want it? Do I need it?” Items would then be placed into a bag of things to keep, and a bag to donate to charity. Lucy was encouraged to treat this like an experiment, noting down what had went well and what was more difficult. It was planned that the space in the hallway could then be used as an interim storage area for items when Lucy began to declutter the remainder of the house.

During the second session, Lucy reported that she had successfully booked the uplift of six bags of books by a charity and was pleased with herself for having accomplished this. Lucy had not organized the drawers as planned, instead going into the garage where she had found some teddy bears that had belonged to her mother, which she had decided to donate to charity. We discussed that the garage was the most cluttered space in the home, and although it was promising that Lucy had spent some time in there productively, we knew from the formulation that if she became overwhelmed, then she would respond by withdrawing from the task, and we wanted to reduce the risk of this happening. We also revisited the rationale that if we could focus on one discrete area, it would help us to identify the skills that would be helpful for Lucy to develop. When compiling the to-do list for the following week, Lucy felt that she had done enough in the hall and wanted to focus on the sitting room instead, starting with the table. Lucy reported that there was a large incentive for doing this—that it would make her husband happy to be able to eat his meals off the sitting room table. We used this as an opportunity to explore Lucy’s decision-making skills, and discussed why Lucy had been able to decide what to do with the bears, but found it more difficult to decide what to do with the objects on the table. Lucy reported that the table consisted mainly of paperwork, and she would have to sort through it to decide what was important, which involved a lot more cognitive exertion. Lucy came up with a to-do list, that consisted of moving items that were clearly no longer needed from the table, then work through the remaining items, putting them into boxes for “charity donation,” “discard,” and “keep” continuing to use the same questions identified previously. She would then sort through the paperwork, filing important documents into folders and then putting the folders into a cupboard for storage. Lucy admitted to feeling overwhelmed at the thought of doing this, but the anxiety decreased when she had made a specific plan. We agreed that if Lucy felt overwhelmed, she would continue for 20 min to see how she felt, with the hypothesis that the anxiety would reduce once she “got into the swing of things.”

During the first two sessions, Lucy reported “splashing out” on some new purchases, including some garden decorations. We completed a functional analysis of both situations to ensure that the accumulation of items was not a bigger problem than had originally been assessed for. The functional analysis supported the hypothesis that Lucy used items as a way of managing difficult emotions, but was able to resist purchasing the extensive amount of items that had been an issue in the past.

By the third session, there were signs that Lucy was not managing to engage in the organization tasks to the extent that she had anticipated. However, Lucy was planning a holiday to visit her friend and stated that she always returned from visiting this friend feeling refreshed and capable of dealing with her problems. Lucy reported that her husband had an appointment for some health investigations, and depending on the results may require surgery. This had motivated her to want to organize the house, so that he would have a tidy home to return to. Lucy had managed to make a start on the to-do list that she had set, organizing a large amount of the items from the table. However, despite the incentive previously described, she reported that a number of obstacles had prevented her from making progress. For example, when sorting through the paperwork, she had been unsure how long she was meant to keep certain documents for, meaning she did not know whether to keep or dispose of them. Lucy knew that she had saved a magazine article that had advice on this, but was unsure where the magazine was. We used a solution-focused approach, by exploring what a friend whom she greatly admired would do in this situation. Lucy decided that she would look for the information online and made a plan to do this before our next appointment. As it was the school break, Lucy had been asked to care for her grandchildren and felt this had impacted on how much time she could spend organizing. We used a solution-focused approach to generate ways of overcoming this. Lucy recalled that her grandchildren enjoyed helping out in the garden if she gave them a small financial incentive, so she could try this approach with tidying, asking them to move heavier items such as books. As we were ending the session, Lucy admitted that she had hidden a box of China tableware in the corner of the room, so that she would not have to deal with it. We spoke about the theory behind exposure, and we discussed looking at it next week in-session as an opportunity to gather further information on Lucy’s decision-making processes, to prevent avoidance and to identify skill deficits.

By the fourth session, Lucy had made progress in organizing the sitting room, by sorting through the pile of documents on the table. She had also done some organizing in the bedroom, including hanging up clothes, and donating unwanted clothes to her cleaner. Lucy brought up concerns about her weight, and the impact this was having on her mobility. Although she had attended physiotherapy, she had been unable to utilize the exercises outwith sessions. We explored how this was similar to our hoarding work—that Lucy has good intentions, but finds it difficult to complete homework tasks. Using cognitive techniques, we explored what she would tell a friend (“do what you can, make a list”) and completed a cost–benefit analysis to look at the pros and cons of exercising. Lucy was able to identify a number of benefits (I would feel better, one step closer to being mobile, get strength back, mobility is important in case my husband’s health deteriorates). The disadvantages to not exercising were that would she continue to feel stuck. We generalized this to the hoarding, in that Lucy knows what she wants to do, but finds it difficult to initiate these plans. Lucy felt she was not yet ready to face looking at the box of China tableware, so we agreed that she would look at some items for our next session that were moderately difficult to decide what to do with. The aim was to use these to complete a sorting exercise where we could further explore Lucy’s decision-making processes and any barriers that may arise. Before we finished, Lucy was encouraged to complete a to-do list for the week ahead, which she completed with little input from the therapist. This included finishing organizing the documents into folders and filing these into the cupboard, and asking her grandson to take books from the storage box in the sitting room to the bookcase upstairs. Lucy stated that she wanted to make a plan to clear the garage, but once we discussed this in terms of the hierarchy and terms of formulation, we agreed that this could be kept until she is feeling more confident.

Following this, a review session was held with Lucy, the trainee clinical psychologist, and the senior clinical psychologist. Lucy was still packing for her holiday and was due to leave shortly after the review, so the review was kept brief. We spoke openly and recognized the progress that Lucy had made, but acknowledged that it was not as much as she had hoped to achieve at this stage. Lucy reflected that she had to “be brave,” by which she meant she had to “get rid of it all.” Lucy felt that although she had not made progress as hoped, there had been an improvement in her general well-being. She was not as tearful, and was getting more enjoyment out of life. We agreed to persevere with the plan of tackling one room, using sessions to develop and skill deficits. Lucy felt that she would feel able to engage in more challenging tasks following the holiday and decided that she would create her own to-do list to complete before the next session.

During sixth session, Lucy reported that she had returned from her visit to her friend feeling refreshed; however, following a family disagreement, she had been left feeling upset and isolated from her family. This had led to her spending time in the garden in an attempt to lift her mood. Lucy felt that she would feel more motivated to tidy once the builder had been booked to install the downstairs bathroom. We discussed the time limit of therapy and completed a cost–benefit analysis about whether to continue with the organization as planned. Having an organized sitting room would make the house feel more like a home, cheer her husband up, and make it easier to find things. The drawbacks to tidying included that the work was exhausting, it could be hard to think what to do, the clutter would get worse before it got better, and poor mobility impacted on progress. Lucy decided that the best action would be to continue to organize, and to be brave and ruthless in doing so. We discussed broad goals for the week ahead, and Lucy agreed to spend time after the session breaking these goals down into smaller tasks. Lucy had not had a chance to look out items required to complete a sorting task in-session, and was encouraged to do so before next week.

During seventh session, Lucy reported that she had reflected on the cost–benefit analysis and realized that it was important for her to engage with the hoarding intervention, otherwise her situation would not change. During the week, Lucy had engaged in some clearing of the clutter in the sitting room and was pleased that she had identified a handbag she would give to charity. Using functional analysis to explore this example, we recognized that Lucy had easily identified what she would do with the item, but had not taken any further steps once the decision had been made. This meant that the bag was still in the original location, and there was no visual difference to the amount of clutter in the room. Lucy decided that she would act on decisions as soon as she made them; for example, she would put the handbag in the charity bag in the hallway. It was hypothesized that being able to see progress in the sitting room would act as a reinforcer and improve motivation levels. Lucy had worked toward clearing the side cabinet, but had not managed to completely clear the surface as planned. She reported that she had had other commitments to attend to, including appointments and spending time in the garden to prepare it for winter, which had exacerbated her levels of fatigue. Lucy was asked to estimate how long she had spent tidying this week, and she concluded this was around 30 min. We explored whether the planned time of 1 hr was too much, but Lucy felt that she would still like to keep 1 hr as her target.

Lucy reported feeling guilty about spending time gardening, although this is her main source of enjoyment and achievement. By challenging these cognitions, Lucy planned that next time she felt this way, she would reassure herself “next time, enjoy it.” Lucy spoke about the gardening she had done, and showed me a to-do list, where she had broken down the tasks into smaller steps and delegated them to other people such as her grandson and friend. We explored the skills she had used in planning and executing the gardening tasks, and discussed how these could be transferred to organizing her belongings. Lucy recognized that progress had been slow due to her motivation and fatigue, but stated that her thinking had changed around how she made decisions related to organizing, and she felt she was reaching the point where she would be able to put these changes into practice. We completed a sorting task, where Lucy chose a video. Lucy described the thoughts she was having in relation to the item and what to do with it. She held the belief that if it was tidied away, then she would forget about it. We spent time exploring and challenging the belief, exploring what would happen if she kept all important items on view. Lucy stated “I would be back at the start.” We explored other solutions, which included having a place for every item so that if she needed to find it she would know where it was. Lucy has been considering some practical solutions, such as taking medications 1 hr earlier so she is not so tired in the morning. Lucy was pleased with her progress, stating that a few months ago she would have been unable to face up to this decision. Lucy was given responsibility for putting the item away as a form of exposure, and decided to do this after the therapy session. Lucy was asked to consider before our next appointment whether further sessions would be helpful, and if so, what the focus of these should be.

During eighth session, the CORE-OM was completed to monitor if there had been any change in Lucy’s psychological well-being. The score had decreased from 83 to 56, which demonstrated a significant improvement. Lucy put this improvement down to the progress she had made in organizing her house. Lucy had completed some of the tasks we had agreed during the previous session, such as gathering items that her children may make use of and moving items for charity donation to the interim area in the hallway. She had also spent time tidying the bedroom with the help of her cleaner, and organizing the garden. We explored how she had made progress in the garden, which had involved making a specific to-do list, and adjusting the plan as necessary to combat barriers that she faced, such as asking a friend for help with moving an object that was too heavy for Lucy to lift. We used this as a further opportunity to explore how Lucy could generalize the skills she uses with gardening to help with tidying. For example, when Lucy came up against an obstacle in the garden, she would be motivated to resolve this, whereas when tidying, she would become overwhelmed, which then led to avoidance of the task.

Lucy had looked out some items that would be moderately difficult to discard, and we used these to continue with the sorting task from last week. One item was a camera that her husband had purchased for her when they were first married. At the start of the task, Lucy rated her anxiety as being 3/10 (10 highest), which quickly rose to 8/10 when asked to dispose of the camera. Lucy was encouraged to speak openly about the thoughts she was having around the camera, for example, the item is valuable, and it represents a big part of her life. It still contains film which Lucy would like to finish off. The camera represented her family history, and her husband had spent time saving up money for it. Lucy spoke about a number of thoughts related to the decision-making, for example, her family would not want it as they all use the cameras on their mobile phones, and she would not want to give it away to charity as it was valuable in that it had played a big part in her life. Lucy spoke about having memories of using it, and we used cognitive techniques to explore if throwing it away would mean throwing away the memory. Lucy had not been able to come to a decision prior to the task, as she could not decide what to do with the camera. However, she was able to make a decision quickly after talking through her thoughts, and decided she would use up the film later that day when her grandchildren came over. Lucy then planned to donate the camera to a photographer she knew who would make use of it. Following the task, Lucy’s anxiety levels had reduced to 3/10. We used this to reinforce that anxiety rises when she begins tidying, but if she continues with the task, this will then reduce gradually. We reflected on the task, and Lucy advised she felt ashamed to have not made the decision before. We continued the sorting tasks on two more items—a metal hoop that was used to cover a potpourri bowl and an ornamental Buddha head. Lucy decided that she would donate these to a local charity, using the decision framework of “do I really need it? what will I do with it?” We reflected on the quick decisions that Lucy had made, and explored how to ensure that items got to their destinations once Lucy had made these decisions. Lucy decided to write down her decisions in a notepad and tick them off as she goes along, providing a visual measure of her progress.

During ninth session, Lucy reported that she had met with a builder during the week, who had suggested that the downstairs bathroom could be built outside the home rather than in the garage. Although this news had improved Lucy’s mood as it meant that the bathroom would be installed sooner than she thought, there was no longer the pressure to clear out the clutter from her house. Despite this incentive being removed, Lucy still wanted to continue with organizing, as this would improve her life and her relationship with her husband. Lucy reported that she had continued to make progress with the organization of the sitting room. She had looked through the box of items, begun to organize her books, removed paperwork from the windowsill, disposed of any letters she no longer needed, and collected unwanted jewelry into one box for her sons to look at. We added up how long Lucy had spent organizing this week, and it totaled 30 min to 1 hr. Lucy had started looking through a box of items and had taken some items to a local charity for donation. However, she had then got stuck when looking at some dusty books as she had been unsure how to clean them. Lucy had managed to use her delegation skills to ask her grandson to move a shoe rack and had made a to-list for this week. We broke this down into a “vicious circle,” Lucy has good intentions during session and wants to organize her house → when attempting homework, feels tired, motivation is poor, and other things come up → unable to make as much progress as planned. We looked at ways of breaking this cycle, reflecting on what could have been done differently during the past week. Lucy identified that she would have spent more time organizing the sideboard and the windowsills, which would have resulting in feeling more confident and motivated. We completed a problem-solving exercise to help Lucy to overcome the decision-making difficulties that lead to avoidance. Lucy had reduced her medication with guidance from her CPN, as she felt it was having an impact on her mobility. Lucy reported her mobility had increased; however, she was more tired in the morning so she planned to take it earlier on to see if this makes a difference. Lucy reported that her husband had suggested that she should keep the camera, but she had been able to stick to her decision of donating it to a photographer.

Tenth session was the final session. Lucy reported that her mobility had continued to improve following a reduction in her medication. She had spent time organizing her sitting room, moving items to the relevant area once she had decided what to do with them, and there was a visible difference to the surfaces. Lucy had begun Christmas shopping and had already used her skills to identify an area to keep the gifts in. She realized this would mean she knew where they were and also it would keep the house tidy. She had used the problem-solving worksheet to explore what to do with her China tableware, a task she had put off during therapy and had found this a helpful approach. Lucy felt that a CBT approach had been helpful and she had now reached “a turning point” in how she addressed her belongings. She identified that the most helpful thing had been talking through the process of decluttering. We created a plan to help her to continue with the progress. Lucy identified that if she felt overwhelmed, she would persevere for 20 min to allow the anxiety to subside rather than avoiding the feelings. She would write a to-do list for each week, planning to work for an hour at a time. She would use another notepad to record her progress, to enhance motivation. Lucy felt her concentration had improved and she had begun to read novels again. She planned to use this as a reward to help her to remain motivated. Lucy had completed the hoarding outcome measures and we explored how some of these had shown a decline. Lucy felt that her hoarding difficulties had improved, but now she was now more aware of the extent of the hoarding. Lucy was offered further sessions with another psychologist in the team, but felt she had learned enough to be able to continue independently.

8 Complicating Factors

Although Lucy subjectively reported that therapy had been helpful, there were a number of complicating factors commonly found in an older adult population that may have had an impact on the effectiveness of the intervention.

As mentioned previously, Lucy had physical health difficulties that resulted in pain and fatigue with overexertion. This impacted on how much time and effort she was able to put toward the organization of her house. Lucy would prioritize spending time in the garden preparing it for the winter months, meaning that she would then feel in too much pain the following day to engage in homework tasks.

Second, Lucy reported low levels of motivation as a result of her mood. Although motivational interviewing techniques were used throughout therapy, this had only a small impact on engagement in tasks.

Another factor was the emotional dysregulation that Lucy experienced. When Lucy had disagreements with her husband or other family members, the emotional repercussions would often last for a number of days. As a result, Lucy would remain in bed or would choose not to engage in tasks as she felt too upset to focus.

Lucy found it difficult to make decisions, plan, and execute tasks, although neurocognitive testing had not uncovered any clinical concerns. This made it difficult for her to engage in decluttering tasks, which was likely to have contributed to her feeling overwhelmed.

Near the end of the treatment, Lucy met with a builder and realized it was no longer necessary for her garage to be cleared of clutter for the work to go ahead. The main incentive for organizing the house was therefore removed.

A final complicating factor involves the use of outcome measures. Numerous outcome measures for HD exist, but none have been developed specifically for older adults. Only two of the outcome measures had been validated for use with older adults; the CORE-OM (Barkham et al., 2005) and the CIR (Dozier & Ayers, 2015), while the SI-R has shown strong psychometric properties for this population (Ayers et al., 2017). Although the outcome measure scores were congruent with Lucy’s self-report, it is possible that the other measures were not sensitive enough to identify any change, or the clinical cut-offs were not appropriate for this population.

9 Access and Barriers to Care

The intervention was provided by a trainee psychologist working with the Psychology service of a Community Mental Health Team (CMHT). This meant that sessions took place with Lucy at her home, and there was no cost for these sessions. At the same time, Lucy was also receiving support from a CPN from the CMHT, who also visited her at home. This made it easier for Lucy to access and engage in care.

As a consequence of the treatment being provided by a trainee psychologist with limited time on placement, Lucy’s appointments were restricted to once per week. One of the suggestions from the preliminary research has been to provide older adults with more intensive treatment. However, there is no conclusive evidence that additional sessions would have helped to maximize the results, and may in fact have been detrimental due to the comorbid health difficulties.

10 Follow-Up

It was not possible to obtain objective follow-up data. Lucy was discharged from the psychology team after the final session and was due to be discharged from the CMHT shortly afterward.

11 Treatment Implications of the Case

The strengths of this case included adhering to good practice guidelines by working with the client at their home, focusing on the client’s personal goals, and using a formulation-driven evidence-based intervention (Holmes et al., 2015; Steketee & Frost, 2014). A multidisciplinary approach was utilized, meaning that the second psychologist could focus on the neuropsychological assessment, the CPN could continue to monitor medication, and the therapist could focus on the HD intervention.

Although Lucy reported that the intervention had been helpful, the therapist was concerned about the slow progress she was making. There was evidence that avoidance levels were higher than acknowledged, for example, Lucy changed the focus of the decluttering from the hall to the sitting room, and did not fully adhere to the planned homework. The therapist was able to broach this, but Lucy had explanations for the slow progress, including pain caused by her physical health, or being too distressed following family disagreements. On other occasions, the weather had been nice, and Lucy made the decision to spend time in the garden instead, preparing it for winter. As mentioned, comorbidity is common in older adults with HD, and it may be that a slower pace of progress should be expected.

Taking into account the existing research, outcomes may have been improved if Lucy’s family had felt able to participate in the intervention, acting in a supportive role, or if Lucy had accepted further sessions with another psychologist once the therapist left the placement. (Steketee & Frost, 2014). Intervention lasted for 10 sessions, whereas 26 sessions over 12 months is recommended, which seems more reasonable in approaching cognitions and behaviors that may have been reinforced for a number of decades (Steketee & Frost, 2014).

Although CBT is currently the intervention with the strongest evidence-base, it has been recognized that outcomes could be improved and that further research should be conducted. Individuals with HD are more likely to experience difficulties in emotion regulation (Tolin et al., 2018), which was a factor in Lucy’s presentation. Teaching skills such as mindfulness to help to tolerate difficult emotions may have been helpful, so that she was able to engage in decluttering when feeling overwhelmed or following a family argument. HD symptoms correlate with how highly emotionally attached the individual is to objects and so integrating a therapy with a more relational basis such as Cognitive Analytic Therapy (Denman, 2001) may have helped to form a deeper understanding of these attachments. These two recommendations could be considered in future research, as “add-ons” to traditional CBT.

12 Recommendations to Clinicians and Students

CBT is currently the therapy with the strongest evidence-base in treating HD. Lucy’s case demonstrates that there was some level of progress, but it was a slow and difficult process for both the client and therapist. Lucy found the model to have high face validity, and it helped her to identify that the hoarding was a bigger issue than she had initially recognized.

It was important to make adaptations to CBT, in line with the complexities often found within an older adult population. This included skills training to help with subclinical neurocognitive deficits, and a focus on exposure and concrete homework tasks. Comorbidity is high in HD, and it was important for the therapist to recognize Lucy’s comorbid difficulties, including both mental health difficulties and physical difficulties, and take into consideration the impact these may have on Lucy’s capabilities and pace of working.

Although using the Steketee and Frost model was helpful, the client may have made additional progress if additional factors had been taken into account. As mentioned previously, this could include mindfulness-based strategies to use if she was becoming overwhelmed, or integrating a relational-based therapy to gain a deeper level of understanding about the emotional attachment to the objects.

Finally, clinicians should carefully consider the outcome measures that would be appropriate for the individual. As discussed earlier, only one hoarding-related measure has been validated in an older adult population (the CIR), and one more has shown strong psychometric properties (SI-R). Other difficulties frequently found in older adults with HD, such as executive functioning impairments, should also be taken into account when deciding if commonly used HD measures are suitable.