CBT for Hoarding Disorder 9781119159254, 1119159253, 9781119159261, 1119159261, 9781119159278, 111915927X

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CBT for Hoarding Disorder

CBT for Hoarding Disorder A Group Therapy Program Therapist’s Guide

David F. Tolin Blaise L. Worden Bethany M. Wootton Christina M. Gilliam

This edition first published 2017 © 2017 John Wiley & Sons Ltd All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions. The right of David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam to be identified as the authors of this work has been asserted in accordance with law. Registered Offices John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Office The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com. Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats. Limit of Liability/Disclaimer of Warranty While the publisher and authors have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Library of Congress Cataloging‐in‐Publication data applied for ISBN Paperback: 9781119159230 Cover Design and Illustration: Wiley Set in 10.5/13pt Minion by SPi Global, Pondicherry, India

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Contents

Part I  Introductory Information for Clinicians

1

What is Hoarding Disorder? 3 Diagnosing Hoarding Disorder 3 What Causes Hoarding Disorder? 7 How Do We Target These Factors in Treatment? 12 Implementing Group CBT for Hoarding Disorder 18 Does This Treatment Work? 18 What Does the Group Look Like? 20 Who Is This Group Designed For? 24 Use of the Manual 25 Troubleshooting Common Problems 26 Measuring Outcomes 31

Part II  Treatment Manual

33

1

Welcome to the Class 35 1.  Welcome to the Declutter Class 38 2.  Class Rules and Guidelines 42 3.  What is Hoarding Disorder? 46 4.  What Will I Learn in This Class? 47 5.  How Well Does the Declutter Class Work? 48 6. Homework 49

2

Why Do I Have So Much Stuff? 54 1.  Homework Review 57 2. Rewards 58 3.  Meet the “Bad Guys” 60 4.  Setting Goals 66 5. Homework 68

vi Contents 3 Making Decisions and Solving Problems: Part 1 71 1.  Homework Review 73 2.  Making Decisions and Solving Problems 74 3.  Making Decisions and Minimizing Distractions 75 4.  Making Decisions and Improving Organization 81 5.  Putting Skills Together to Discard Better 84 6. Homework 85 4 Making Decisions and Solving Problems: Part 2 86 1.  Homework Review 87 2.  Making Decisions: Acquiring 88 3.  Solving Problems 92 4.  Discarding Practice 96 5.  “Bad Guy” Re‐evaluation 96 6. Homework 97 5 Intense Emotions: Part 1 98 1.  Homework Review 99 2.  About Intense Emotions 100 3.  Tackling Intense Emotions That Lead to Acquiring 104 4. Homework 106 6 Intense Emotions: Part 2 108 1.  Homework Review 109 2.  Tackling Intense Emotions That Get in the Way of Discarding 109 3.  “Bad Guy” Re‐evaluation 114 4. Homework 115 7 Unhelpful Thinking: Part 1 118 1.  Homework Review 119 2.  How Thoughts Influence Emotions 119 3.  Identifying Unhelpful Thoughts 121 4. Homework 124 8 Unhelpful Thinking: Part 2 126 1.  Homework Review 127 2.  Tackling Unhelpful Thoughts 128 3.  “Bad Guy” Re‐evaluation 131 4. Homework 132 9 Waxing and Waning Motivation: Part 1 133 1.  Homework Review 134 2.  Improving Motivation 134 3.  Acting on Your Top Goals and Values 136 4. Homework 139 10 Waxing and Waning Motivation: Part 2 142 1.  Homework Review 143 2.  Improving Motivation to Discard 144 3.  Being Motivated By Your Values 145

Contents vii 4.  Checking In on Long‐Term SMART Goals 146 5.  “Bad Guy” Re‐evaluation 146 6. Homework 147

11 Putting It All Together: Part 1 148 1.  Homework Review 149 2.  Troubleshooting Common Barriers 150 3.  Putting It All Together 151 4. Homework 153 12 Putting It All Together: Part 2 154 1.  Homework Review 155 2.  Troubleshooting Common Barriers 155 3.  Putting It All Together 158 4. Homework 159 13 Putting It All Together: Part 3 160 1.  Homework Review 161 2.  Troubleshooting Common Barriers 162 3.  Putting It All Together 163 4. Homework 164 14 Putting It All Together: Part 4 165 1.  Homework Review 166 2.  Troubleshooting Common Barriers 167 3.  Putting It All Together 168 4. Homework 169 15 Staying Clutter Free in the Future: Part 1 170 1.  Homework Review 171 2.  Reviewing Progress 172 3.  Practice Discarding 174 4. Homework 174 16 Staying Clutter Free in the Future: Part 2 176 1.  Homework Review 177 2.  Maintaining Motivation 177 3.  Wrap‐Up and Questions 179 Appendix A: Clock Sign 180 Appendix B: “Bad Guy” Reminder Cards for Participants 181 References183 Index190

Part I

Introductory Information for Clinicians

What is Hoarding Disorder?

Diagnosing Hoarding Disorder Hoarding Disorder (HD) was first afforded diagnostic status in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM‐5; American Psychiatric Association, 2013). The DSM‐5 diagnostic criteria for HD include: 1. Difficulty discarding or parting with possessions due to strong urges to save items and/or distress associated with discarding. 2. Clutter that precludes activities for which living spaces were designed. 3. Significant distress or impairment in functioning caused by the hoarding. Prior to the publication of the DSM‐5, hoarding behaviors were informally c­onsidered to be a syndrome or subtype of obsessive‐compulsive disorder (OCD). However, as evidence mounted about the differences between hoarding and OCD (Pertusa et  al., 2010), it became increasingly clear that hoarding represented a unique syndrome that had not been adequately categorized. Epidemiological research has suggested that the prevalence rate of HD is between 2 and 5% (Frost, Steketee, & Williams, 2000; Iervolino et  al., 2009; Mueller, Mitchell, Crosby, Glaesmer, & de Zwaan, 2009; Samuels et al., 2008), making HD a very common condition.

CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

Understanding the Symptoms of Hoarding Disorder Difficulty discarding.  The hallmark symptom of HD is reluctance to discard personal possessions, including objects that non‐hoarding individuals might consider to be worthless or having little intrinsic value. Although the reasons for saving objects tend to be s­imilar to those described by non‐hoarding ­individuals (Frost & Gross, 1993), for individuals with HD these beliefs are more intense and rigid, and applied to a greater number of possessions. Attempts to discard usually cause substantial emotional d­istress, and therefore are ­f requently avoided. Excessive clutter.  Excessive clutter is the most visible feature of compulsive hoarding. Unlike normatively “messy” or disorganized individuals, those with HD commonly describe significant difficulty using the living spaces of their homes due to clutter. For example, individuals with HD often have clutter that may cover beds, chairs, or tables, r­endering them unusable. In severe cases, the clutter prohibits movement through the house or access to certain parts of the home. Excessive acquiring.  Although acquiring is not a DSM‐5 diagnostic criterion for HD, research suggests that most individuals with HD do engage in excessive acquiring (Frost, Tolin, Steketee, Fitch, & Selbo‐Bruns, 2009). Excessive acquisition can include compulsive buying, collection of free items, inheritance of items, and rarely, stealing. Many report spending many hours each week searching for and acquiring objects (e.g., excessive shopping, rummaging through trash bins). Individuals with HD therefore may also present with distress related to overspending or debt as a result of compulsive shopping behaviors.

Understanding Hoarding‐Related Impairment Health risks.  Clutter can lead to substantial personal impairment or injury, and has the potential for fatal consequences. Clutter’s interference with basic home functions such as cooking, cleaning, moving through the house, and even sleeping can make hoarding dangerous, increasing the likelihood of fire, falling, poor sanitation, and pest infestation (Steketee, Frost, & Kim, 2001). Clutter poses a major fire risk both to those who live in the home and to neighbors. A study analyzing residential fires over a 10‐year period indicated that hoarding accounted for 24% of all preventable fire fatalities (Harris, 2010). Blocked egress, such as doors and windows, may prevent individuals from escaping home fires, and can prevent emergency personnel from entering the home when needed. Elderly individuals in particular may be injured by falling objects or even trapped by collapse of clutter or other structural elements of the home. Health



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risks to c­hildren who live in the home may include the presence of mold, contributing to respiratory difficulties such as asthma. Children or elderly may become ill from keeping and ingesting expired food. Plumbing or heating may be inoperable; or other repairs may be needed but avoided due to concern about others entering the home. Due to the potential for harm, clutter may lead to protective removal of children or elderly from the home (Tolin, Frost, Steketee, Gray, & Fitch, 2008). Involvement of government agencies, such as child or elderly protective services, fire marshals, police, or public health departments, is not uncommon. Clutter may also lead to threats of eviction by housing authorities. Psychological impact.  Individuals with HD are likely to be particularly susceptible to isolation. Embarrassed by their clutter or avoidant of criticism, many individuals with HD avoid inviting friends, family, or repair workers to their homes, contributing to social isolation (Rasmussen, Steketee, Tolin, Frost, & Brown, 2014). HD may also increase rates of intrafamilial conflict and rejection of the hoarding individual. Family members may be upset by excessive time spent on acquiring or in response to financial debt related to compulsive buying. Family members may become frustrated with the patient’s reluctance or inability to change. In one large survey (Tolin, Frost, Steketee, & Fitch, 2008) of family members of hoarding individuals, scores on a measure of rejection of hoarding individuals were higher than family rejection scores for clients with schizophrenia, especially if the hoarding individual was p­erceived as having little insight into their problem. Many individuals with HD describe impaired work and role functioning. Individuals who self‐identified as having HD reported missing more work due to psychiatric reasons than individuals with depression, anxiety disorders, or substance use (Tolin, Frost, Steketee, Gray, et al., 2008). Hoarding may also have a negative psychological impact on children who are raised in the hoarding environment. In the Tolin, Frost, Steketee, and Fitch (2008) survey, children who identified as having grown up in the home of a parent with HD described lower satisfaction with their childhood than individuals who did not grow up in the cluttered home. Specifically, children raised in the hoarding home reported embarrassment of the home and avoidance of having peers in the home, along with increased conflict within the home. Financial cost to society.  In addition to the health risks, HD also presents a high financial cost to society. Individuals with HD tend to be high utilizers of services, including medical, mental health, and social welfare services. In one study (Frost, Steketee, & Williams, 2000) approximately 64% of surveyed public health officials reported receiving at least one complaint of hoarding during a five‐year period. The majority (88%) of the cases concerned unsanitary conditions. The City of San Francisco conservatively estimated that HD costs service providers and landlords in that city $6.4 million per year (San Francisco Task Force on Compulsive

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

Hoarding, 2009). The Melbourne Fire Department study found that the average cost of firefighting hoarding‐related fires was eight times greater than that of hoarding‐unrelated fires (Harris, 2010).

Understanding Comorbidity in Hoarding Management of hoarding cases tends to be complicated by a high presence of co‐occurring mental health and medical concerns. As many as 92% of individuals with HD meet criteria for co‐occurring psychiatric conditions (Frost, Steketee, & Tolin, 2011). As noted previously, the link between hoarding and OCD is not as strong as previously thought, although a significant minority (approximately 18%) of HD clients will also meet diagnostic criteria for OCD (Frost, Steketee, et  al., 2011). Depression and anxiety are highly common among those with HD, with Major Depressive Disorder (53%), Social Anxiety Disorder (24%), and Generalized Anxiety Disorder (24%) among the most common co‐occurring diagnoses in treatment‐seeking HD clients (Frost, Steketee, et al., 2011). Hoarding is also associated with relatively high rates of personality disorders and maladaptive personality traits. Although excessive saving of potentially low‐ value items is a criteria for the diagnosis of Obsessive‐Compulsive Personality Disorder (OCPD), most HD clients do not meet criteria for OCPD when the hoarding criterion is removed (Frost, Steketee, et al., 2011). However, Dependent, Avoidant, Paranoid, and Schizotypal Personality Disorders appear fairly common in hoarding samples (Frost, Steketee, Williams, & Warren, 2000; Samuels et al., 2008). Research increasingly suggests a link between hoarding and Attention‐Deficit/ Hyperactivity Disorder (ADHD), or a similar symptom profile. Hoarding clients often report significant problems with attention and executive function that resemble those seen in people with ADHD. Individuals with hoarding symptoms commonly obtain high scores on self‐report ADHD measures, and in one study, 20% of HD clients, compared to 4% of OCD clients and 3% of community controls, met full DSM‐IV‐TR diagnostic criteria for ADHD (Frost, Steketee, et al., 2011). These data comport with those of a study of OCD clients, in which those with hoarding symptoms had a risk of ADHD almost 10 times higher than those without hoarding (Sheppard et  al., 2010). Studies of neuropsychological performance in hoarding clients have yielded mixed results, although ­individuals with HD appear to have more specific deficits in the areas of problem solving, organization, and sustained attention (Woody, Kellman‐McFarlane, & Welsted, 2014). It is important to be aware that hoarding behaviors such as saving, excessive acquiring, or disorganization may be present in a variety of disorders beyond HD. Hoarding behavior has been noted in clients with OCD (Matsunaga, Hayashida, Kiriike, Nagata, & Stein, 2010) and schizophrenia (Luchins, Goldman, Lieb, & Hanrahan, 1992), as well as after certain neurological insults such as damage to



What is Hoarding Disorder?

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prefrontal and orbitofrontal cortex (Eslinger & Damasio, 1985; Volle, Beato, Levy, & Dubois, 2002) and dementia (Hwang, Tsai, Yang, Liu, & Lirng, 1998). Therefore, in cases of severe clutter and saving behavior, it is important to consider whether alternative diagnoses may better explain the hoarding problem. At this point, this manual has not been tested with individuals without a formal diagnosis of HD.

What Causes Hoarding Disorder? Our treatment model is based on the idea that the most effective interventions are those that target the active mechanisms of the problem – that is, the reasons why the person engages in the behavior.

Etiology: Why Did These Symptoms Begin? Research points to certain etiologic factors that might help explain why hoarding occurs in the first place. One such factor is a history of traumatic or stressful life events. Individuals with HD report a high frequency of lifetime traumatic events (Cromer, Schmidt, & Murphy, 2007; Hartl, Duffany, Allen, Steketee, & Frost, 2005; Tolin, Meunier, Frost, & Steketee, 2010), and in many cases, these stressful life events coincide with the onset or worsening of hoarding symptoms. Some have suggested that hoarding behaviors develop, in part, as a means of strengthening one’s sense of safety following a trauma or a chaotic childhood environment (Cromer et al., 2007; Samuels et al., 2008). We note, however, that hoarding is often present in individuals without any reported history of trauma, and most individuals with trauma histories do not engage in hoarding behaviors. Trauma, therefore, seems to have limited explanatory power in our estimation. Hoarding symptoms appear to have a strong familial component, suggesting influences of both modeling (learning by observing) and genetics. HD likely has a high heritability rate; in one study of rates of HD in twins raised in the same residence, genetic factors were estimated to account for 49% of the variance in diagnostic (HD vs. no HD) status (Iervolino et al., 2009). Most individuals with HD describe at least one first‐degree relative as a “packrat” (Winsberg, Cassic, & Koran, 1999), and family members of individuals who hoard are likely to report indecisiveness (Frost, Tolin, Steketee, & Oh, 2011; Samuels, Shugart, et al., 2007), suggesting that decision‐making problems might be an inherited vulnerability factor. Many clients with HD report being taught or observing in their parent, from early in life, beliefs and behaviors associated with hoarding. For example, their parents would condemn “wasteful behavior,” or the individual would observe excessive acquiring behaviors by the parent. Additionally, certain genetic abnormalities have been identified in families with hoarding behavior (Samuels, Shugart, et al., 2007).

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

Maintenance: Why Do These Symptoms Persist? One limitation of understanding HD according to the various etiological factors is that such a model does not provide us with clear, actionable targets for treatment. We cannot, for example, go back in time and undo traumatic or stressful life events, nor can we alter a person’s genetics or family history. We therefore place greater emphasis on understanding maintenance mechanisms; that is, the ongoing processes that keep the behavior in place and cause them to recur day in and day out. Our CBT model explicitly aims to identify and interrupt the mechanisms that maintain hoarding behavior. Below, we will describe the maintenance mechanisms that are our targets for intervention. Target 1: Problems of decision‐making and other cognitive processes.  We believe that HD is maintained in large part by a breakdown in the person’s decision‐making p­rocess. People with HD report high levels of indecisiveness (Frost, Tolin, et  al., 2011; Samuels et al., 2002), and we suspect that much of the difficulty discarding seen in HD stems from the fact that sufferers cannot make effective and efficient decisions about their possessions. Indeed, in one of our studies, the degree of self‐ reported indecisiveness was negatively correlated with the number of possessions discarded during a task (Tolin, Stevens, et al., 2012). When a decision to d­iscard a possession is successfully made, it is often a result of time‐consuming and emotionally draining deliberation and doubt. One possible contributor to the presence of decision‐making deficits is impairment in basic cognitive processes such as attention, memory, and executive function. As discussed previously, clients with HD frequently report notable problems with sustained attention. These self‐reports are corroborated by results of standardized tests of attentional capacity, in which hoarding is associated with diminished nonverbal attention, greater variability in reaction time, and poorer ability to detect target stimuli (Grisham, Brown, Savage, Steketee, & Barlow, 2007; Tolin, Villavicencio, Umbach, & Kurtz, 2011). Many hoarding individuals describe themselves as having poor memory, and report keeping certain possessions due to fears that they will forget relevant information or lose an important memory if they discard an object. Standardized tests of memory functioning have revealed that individuals with HD show impaired delayed recall (both verbal and visual), and use less effective visual recall strategies, than do healthy control participants (Hartl et  al., 2004), although the degree of  memory impairment is less pronounced than the degree of attentional impairment. Some research suggests that clients with HD perform more poorly than do control participants on standardized tests of executive functions such as planning and problem solving (Grisham, Norberg, Williams, Certoma, & Kadib, 2010; Woody et  al., 2014). The ability to categorize possessions  –  a key skill in maintaining ­organization – appears to be compromised in those with HD. When asked to sort their personal possessions, individuals with HD took longer, and created more



What is Hoarding Disorder?

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categories (with a smaller number of items per category), than did healthy controls or participants with OCD (Wincze, Steketee, & Frost, 2007). Similarly, our experience has been that HD clients often exhibit poor problem‐solving abilities. Seemingly minor roadblocks, such as a scheduling conflict or inability to find space to sort, become insurmountable obstacles. This makes it very easy for progress to stall as the patient may have difficulty seeing that a goal can be accomplished via alternative routes, or that different options are available. Target 2: Maladaptive beliefs about possessions and discarding.  Individuals with HD commonly hold maladaptive, exaggerated beliefs about possessions and discarding. Many describe a heightened sense of responsibility for possessions (Frost, Hartl, Christian, & Williams, 1995) – for example, exaggerated beliefs that they are responsible for finding an appropriate “home” for an object. For many, simply imagining a potential use for a possession implies that it must be saved for that purpose, even if its use is unlikely. Clients with HD show particularly strong beliefs about the need to acquire and save objects because of a strong aversion to wastefulness and fears of losing important information (Frost, Steketee, Tolin, Sinopoli, & Ruby, 2015). Clients with HD may also exhibit an exaggerated need to maintain control over their possessions, which is often demonstrated by an aversion to others moving, sharing, or touching their possessions; such actions appear to be perceived as a threat to personal autonomy, or disruptive of visually-based organizational systems. Perfectionism beliefs may also inhibit discarding by rendering individuals fearful of making decisions due to concerns about making a mistake (e.g., discarding the wrong item). Target 3: Difficulty with emotion regulation.  The prospect of discarding generally evokes strong feelings in individuals with HD. Many report strong emotional attachments to items (e.g., an over‐appreciation for the aesthetics or sentimental value of objects). In some cases, clients have reported feeling a greater sense of attachment to objects than to people. In some cases, that emotional attachment is expressed in terms of anthropomorphization (imbuing inanimate objects with human qualities such as thoughts and feelings), in which c­lients are excessively concerned about making sure that the possession “goes to a good home” and is unharmed. In other cases of emotional attachment, objects are associated with fond memories of people, places, or activities  –  so much so that the object becomes “fused” in the person’s mind with that person, place, or activity. In still other cases, possessions serve as a visual representation of the person’s desired identity – for example, a collection of books to define oneself as knowledgeable. Discarding possessions, therefore, is sometimes equated with losing a loved one, a symbol of an important time in the person’s life, or part of the person’s own i­dentity. Relatedly, many clients with HD describe their emotional reaction toward discarding as sadness or grief, in addition to anxiety. We propose that HD is characterized by poor emotion regulation. Though emotion regulation has been defined in various ways, we favor the model offered by Gratz and Roemer (2004), which suggests that people with poor emotion regulation

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

show (a) lack of awareness, understanding, and acceptance of emotions; (b) lack of access to adaptive strategies for modulating the intensity and/or duration of emotional responses; (c) an unwillingness to experience emotional distress as part of pursuing desired goals; and (d) the inability to engage in goal‐directed behaviors when experiencing distress. The unwillingness to experience emotional ­distress (or low emotional distress tolerance) appears to be particularly important in HD. Individuals with HD often report exaggerated fears about the consequences of distress and low confidence in their ability to tolerate emotional distress. For example, they may worry that they “will never recover” if an important item is discarded, that they “will never stop thinking about the item” or that “the emotion arising when discarding] would be intolerable.” sadness [or other ­ Research on college ­volunteers (Timpano, Buckner, Richey, Murphy, & Schmidt, 2009; Timpano, Shaw, Cougle, & Fitch, 2014) suggests that low self‐reported distress tolerance is associated with hoarding behaviors. Hayes, Wilson, Gifford, Follette, and Strosahl (1996) use the term experiential avoidance to describe an unwillingness to experience strong, generally negative emotions, accompanied by efforts to avoid such distressing emotions. In HD, this can be seen in the avoidance of discarding because it is likely to cause a negative emotion, or acquiring an item in order to feel a more pleasant emotion (Wheaton, Abramowitz, Franklin, Berman, & Fabricant, 2011). Target 4: Saving as avoidance.  From the discussion above, it is not hard to understand why an individual with HD would want to avoid discarding; the process is cognitively demanding and stirs up strong negative feelings that the person then has difficulty tolerating. Put simply, the very idea of discarding can be overwhelming. As is the case with many forms of avoidance, however, avoidance of discarding serves to maintain the problem. In HD, the avoidance is theorized to allow maladaptive beliefs to persist (e.g., if the person believes they could never recover after discarding a possession, avoidance prevents that belief from being disconfirmed), c­ontribute to excessive negative emotion (discarding seems more threatening the more the person avoids it), and, of course, allows for the buildup of excessive clutter. Target 5: Acquisition as impulsivity.  Clients with HD often identify acquiring as one of their most enjoyable activities, elaborating that acquiring elicits various positive emotions (“exciting”) and cognitions (“I feel thrifty and smart”). In these instances, acquisition behaviors are positively reinforced appetitive behaviors. This difficulty exerting control over one’s impulses and urges (sometimes termed poor self‐control) appears high among individuals with hoarding behaviors (Frost et al., 2009; Timpano & Schmidt, 2013) as well as among those with compulsive buying (Billieux, Rochat, Rebetez, & Van der Linden, 2008). Indeed, some studies have found a correlation between hoarding behavior and impulse control disorders (Frost, Meagher, & Riskind, 2001; Frost, Steketee, et al., 2011).



What is Hoarding Disorder?

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Target 6: Poor problem recognition and motivation.  Some individuals who hoard display a striking lack of awareness of the severity of their behavior, sometimes denying the problem and/or resisting intervention attempts. Others may defensively rationalize their acquiring and saving (Frost, Tolin, & Maltby, 2010; Samuels et al., 2002; Tolin, Fitch, Frost, & Steketee, 2010). Research reports indicate that many individuals with HD do not consider their behavior unreasonable (Samuels et al., 2002), and that recognition of a problem with hoarding typically does not occur until at least a decade after onset (Grisham, Frost, Steketee, Kim, & Hood, 2006). In a large survey of family members of hoarding individuals, the family members described their relatives with HD on average as having fair to poor insight, with more than half described as having “poor insight” or “lacks insight/delusional” (Tolin, Frost, Steketee, & Fitch, 2008). We have found that many HD clients can verbalize the problem and consequences, but when faced with d­iscarding, show strong beliefs resistant to disconfirming evidence, which are sometimes near‐delusional in intensity. Relatedly, clients show variable motivation to change their behavior. Among r­esidents reported to health departments due to unsanitary housing conditions from hoarding, less than one third were willing to cooperate with health officials to improve the condition of their home (Frost, Steketee, & Williams, 2000). Treatment‐ interfering behaviors, such as poor attendance and noncompliance, are common (Christensen & Greist, 2001), even among individuals who seek treatment willingly. Many clients attend treatment only at the behest of others, and may passively resist the intervention. Perhaps not surprisingly, this limited insight and motivation, coupled with a high rate of treatment‐interfering behavior, can lead to frustration on the part of clinicians and social service personnel. When we surveyed professionals about their work with both hoarding and non‐hoarding clients, we found that they reported that the working alliance was weaker for the hoarding clients, and that they were more likely to harbor negative attitudes about their hoarding clients than other patients. (Tolin et al., 2012). Target 7: Poor organizational skills.  When one visits the home of someone with HD, one is immediately struck not only by the sheer volume of clutter, but also by the disorganized manner in which the possessions are typically stored. Food items might be in the living room; clothing might be in the bathroom; or auto parts might be in the kitchen. This disorganization may be due, in part, to the executive functioning (e.g., categorization) deficits described above. Potentially because of difficulty deciding on the relative importance of items and where they should be stored, items of varying importance may be placed together. It is not uncommon for participants in our treatment groups to find uncashed checks or other important documents (e.g., a birth certificate or mortgage bill) in a pile of newspapers or other less important paperwork/items. Such disorganization complicates efforts to intervene: Clients are often r­eluctant to discard a

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

stack of newspapers, insisting on going through each one, page by page, before letting go of it. While we might attribute some of that problem to emotional attachment, it is also likely that the person’s poor organizational skills have led to a greater‐than‐average likelihood that they actually will find something important in the stack. The disorganization in the home also compounds sufferers’ memory deficits by forcing them to rely on a memory‐based approach to finding objects, rather than using the category‐based approach favored by non‐hoarding individuals. Normally, when wanting to remember where an object is, humans use a categorical rule‐based system of recall. For example, if one wants to remember where a favorite sweater is, one may recall that sweaters are stored in the third dresser drawer. If one wants to remember where last year’s tax form is, one may recall that tax forms are stored in a file on the bookshelf. By contrast, individuals with HD often attempt to organize and find items based on visuospatial recall. They often believe that if an item cannot be seen, it will not be remembered. That is, to find a sweater or a tax form, the individual must reconstruct a visual image of the object, reconstruct a visual image of the living area, and try to remember where the item was last seen. As might be imagined, this is a highly inefficient process that overtaxes an already compromised cognitive system. We can see the disorganization play out when we ask individuals with HD to sort and discard possessions in their homes. Often, they will pick up an item, think about it, inspect it, and after a laborious decision‐making process, place the item on a pile. Then they move on to the next item, and so on. At the end of the process, the piles stay where they are. Frost and Steketee (2010) refer to this process as churning: simply moving items from one pile to another, without actually removing anything from the home. Difficulties with disorganization and determining the relative importance of stimuli is also reflected in the speech patterns of individuals with HD. Speech patterns are frequently circumstantial and tangential. We have often found that our clients tell lengthy and often over‐detailed stories, respond to questions with nonsequiturs, or skip from topic to topic. It is as if in their speech, as with their possessions, they have difficulty distinguishing the important from the unimportant, the relevant from the irrelevant.

How Do We Target These Factors in Treatment? Having identified several important maintaining mechanisms, we then aim to use CBT strategies to undermine those mechanisms. Although individual clients may vary in the extent to which each mechanism supports the persistence of the problem, we have found that these strategies apply reasonably well to most of the people who attend our treatment program. By undermining the mechanisms, we hope to decrease the client’s reliance on maladaptive behaviors and develop skills for healthier patterns.



What is Hoarding Disorder?

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Target 1: Improve Decision‐Making and Other  Cognitive Processes CBT for HD strives to improve the effectiveness and efficiency of decision‐making by minimizing, rehabilitating, or compensating for executive functioning deficits common to the disorder (Ayers et al., 2013). We ask clients to bring a bag or box of possessions from their home to every session, and in most sessions, we dedicate time to sorting and discarding those possessions. Throughout the process, the therapist uses a variety of challenging questions (e.g., “Is this something that you really need and will use?”) to help adjust the client’s thinking. It is anticipated that over time, clients will be able to discard a greater proportion of items, and will do so more rapidly. Clients are instructed to do similar tasks as daily homework between sessions. We also strive to simplify the decision‐making process. In theory, decisions about whether to keep or discard an object can be infinitely complex, depending on the number of variables one wishes to consider. We have often found that people with HD greatly overcomplicate the process, sometimes creating seemingly impossible dilemmas (Tolin et al., 2014). In this program, we teach a straight­forward basic fficient decision of keep, donate, and trash/recycle, thus practicing more e­ categorization. Given the high level of inattention and other cognitive impairments in HD, our treatment is more highly structured and didactic than many other group CBT programs. Information is provided to clients in small “chunks,” with plenty of repetition. Clients also use a workbook of all of the information from the session to help them remember the content. The executive functioning deficits seen in many people with HD contribute to poor problem solving. Our program includes formal problem‐solving training (Nezu, Nezu, & D’Zurilla, 2013), which includes fostering a positive problem orientation, identifying the problem, brainstorming potential solutions, selecting and implementing one or more solutions, and re‐evaluating to determine whether the solution was effective.

Target 2: Decrease Maladaptive Beliefs About Possessions and Discarding Classic cognitive theory proposes that the way that we think about a situation, rather than the situation itself, determines how we will feel about that situation (e.g., Beck, 1976). Learning to challenge one’s maladaptive thinking has been shown to be an effective treatment approach for a wide range of psychological onditions. Typically, cognitive restructuring involves direct challenging of c­ faulty  cognitions through techniques such as examining the evidence for and against the belief, and the use of behavioral experiments to test the accuracy of the belief.

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

Our work with HD clients has led us to modify the cognitive restructuring process substantially. In one study, Frost, Ong, Steketee, & Tolin (2016) asked people with HD to make a decision about whether to keep or discard an item. Half of the people were asked to engage in cognitive restructuring with a clinician, and half were asked to simply list their thoughts without being challenged. Surprisingly, people who engaged in cognitive restructuring were less likely to discard the object than were people who simply verbalized their thoughts. It seemed that challenging distorted thinking patterns had actually backfired. This may relate to the issue of therapeutic reactance (Brehm, 1966), a topic we will discuss in more detail later. In brief, however, therapeutic reactance refers to a tendency to push in the opposite direction of the clinician. Therefore, we take a much lighter approach to maladaptive beliefs than would a traditional cognitive therapist, often asking clients to simply verbalize their thoughts, rather than challenging them directly. We often find, as we did in our research study, that simply expressing one’s thoughts in the group context is enough to help the client recognize that the thoughts may be exaggerated or irrational. To the extent that cognitive restructuring is used, it is relatively scaled down based on p­articipant feedback that they found such strategies confusing and overly time consuming.

Target 3: Improve Emotion Regulation Skills CBT aims to improve emotion regulation in several ways, and uses techniques that have been shown to be effective in other disorders (e.g., Mennin & Fresco, 2013). First, clients are taught about emotions, how they affect us, and practice accurate emotion identification. We emphasize that emotions – even negative ones – are perfectly normal and valuable. However, we also note that our reactions to emotions can become problematic, such as when we allow emotions to override our logic, control our behaviors, and detract us from our goals. This CBT program places substantial emphasis on the concept of emotional distress tolerance. Borrowing from acceptance‐based CBT strategies (e.g., Hayes, Strosahl, & Wilson, 1999), we remind clients that even strong emotions are neither devastating nor permanent, and encourage them to observe their emotions without engaging in unnecessary struggles with them. The distress tolerance exercises can also be conceptualized as exposure exercises often used in treating anxiety disorders and OCD, in which clients gradually confront anxiety‐provoking triggers with the goal of experiencing anxiety reduction. Participants are asked to make decisions about and discard possessions that are valuable to them, while practicing nonjudgmental tolerance of negative emotions that arise. Participants are likely to find exposure techniques (in‐session sorting and discarding) to be one of the most challenging, but valuable, aspects of the treatment program (Ayers, Bratiotis, Saxena, & Wetherell, 2012). Clients often report a strong desire for in‐home s­orting and discarding sessions, and while this has been done in many research



What is Hoarding Disorder?

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studies (e.g., Steketee, Frost, Tolin, Rasmussen, & Brown, 2010; Tolin et al., 2007), it is unclear whether in‐home sessions truly add to treatment outcomes other than patient satisfaction (Muroff, Steketee, Bratiotis, & Ross, 2012; Tolin, Frost, Steketee, & Muroff, 2015). Given the time‐consuming nature of home visits, they were not included as an intervention in this treatment manual. In our experience, in‐session discarding appears to be as effective as in‐home discarding without the drain on the clinicians’ time. We also emphasize the importance of engaging in goal‐directed behaviors even (perhaps especially) when experiencing distress, rather than “waiting to feel better” before taking action. Importantly, this involves clarification of the participant’s larger goals and values, and reminding them to keep their behavior in accord with those goals and values even when negative emotion threatens to pull them off track.

Target 4: Decrease Avoidance of Discarding We aim, from the very beginning of CBT, to combat clients’ strong tendency to avoid discarding. As described previously, we sort and discard possessions in nearly every session, and challenge excessive saving. Homework noncompliance is addressed directly and promptly: after repeated instance of noncompliance, participants are required to meet individually with one of the group leaders to review their progress, and to problem solve barriers to at‐home sorting and discarding. There is a delicate balance here. On one hand, we know that excessive interpersonal pressure to discard may lead to therapeutic reactance, in which the person defends the need to keep the object even more strongly than before. On the other hand, we know that breaking through this avoidance is critical to the person’s success in treatment. We have minimized the interpersonal aspect of the dilemma by implementing strict rules about homework compliance and continued involvement in the group.

Target 5: Decrease Impulsive Acquisition We borrow our impulsivity interventions from tested treatments for impulse control problems such as compulsive buying (Müller & Mitchell, 2011). We discuss “triggers” for acquiring, including mood states, locations, situations, and specific items. Participants are encouraged to avoid high‐risk situations when possible. However, we also recognize that complete avoidance of tempting situations is neither possible nor desirable. We therefore implement stimulus control procedures, in which the person attempts to alter the environment to make it less conducive to impulsive acquisition, or to help the person apply “brakes” such as asking him/herself challenging questions about items he/she wishes to acquire, refraining from acquiring until 24 hours have passed, and other strategies.

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

Target 6: Improving Problem Recognition and Strengthening Motivation Some strategies of motivational interviewing (MI; Miller & Rollnick, 2013) are employed throughout the CBT program. The aim of MI, in brief, is to help the client resolve ambivalence and to gently tip the decisional balance toward behavioral change. To this end, we avoid engaging in direct confrontation or argumentation – we do not attempt to convince clients that they have a problem or that they need to change. Rather, we encourage them to discuss their own pros and cons of changing, and to identify how hoarding has affected them. We also, however, use the MI strategy of developing discrepancy, in which we contrast the person’s behavior with his/her previously stated goals and values, helping the client to recognize the self‐defeating aspects of his/her behavior. MI calls for a liberal dose of empathy. We encourage those providing services for hoarding individuals to keep in mind that HD is a legitimate mental health issue that likely has neurobiological underpinnings. It is not a result of stubbornness or laziness. It is not uncommon for individuals with HD to report histories of decades of having to defend their behavior and decisions to family and friends. A key task of the group, therefore, is to providing a supportive, nonjudgmental audience in which ambivalence for change is normalized. As a side note, we caution against clinicians assuming that behavioral noncompliance is an inherent sign of inadequate motivation. We often find that participants in treatment verbalize strong levels of motivation to change. However, difficulties completing homework, discarding possessions in the group, and attending treatment consistently, rely on executive functions that may be under­ performing for individuals with HD. The treatment should pinpoint and target these deficits if the clinicians suspect that they are leading to noncompliance. For example, a participant may voice that she is highly motivated to work on her hoarding problem, but fails to complete homework. After questioning, it becomes apparent that she views several other life tasks including taking care of a relative, traveling, charity involvement, religious activities, and a weight loss group as a similar priority and “life got in the way.” It is likely that she is simply trying to accomplish too many goals and has difficulty prioritizing. A focus of treatment may then be to practice the values module which aims at (a) assessing current motivation level for decluttering and (b) developing skills to prioritize values/goals and allocate time and effort appropriately. In addition to attempting to boost intrinsic motivation for decluttering, the protocol also includes self‐administered rewards and group rewards. This is a basic behavioral concept informed by contingency management programs, such as those for substance use disorders (Petry, Martin, Cooney, & Kranzler, 2000) and other impulsive behaviors such as pathological gambling (Petry, Weinstock, Ledgerwood, & Morasco, 2008). These programs attempt to maximize the reinforcement value of the desired behavior relative to undesired behaviors. In this case, participants are encouraged to reward themselves as they complete personal goals, and the group is



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given a group reward (e.g., a post‐treatment pizza party) when goals are met. In our preliminary work using contingency management protocols with individuals with HD, clients have shown improved outcomes and clients generally reported liking this aspect of the program.

Target 7: Improving Organizational Skills Although we are not professional organizers, we nevertheless spend a fair amount of time teaching basic organizational strategies and have adapted some strategies from the professional organizing community (e.g., Varness, 2012), as well as from CBT protocols used for ADHD (Safren, Sprich, Chulvick, & Otto, 2004) and cognitive remediation strategies used for cognitive impairment (Ayers et al., 2014; Twamley, Jeste, & Bellack, 2003). We teach a categorical rule‐based system of organization, with simple guidelines for where things should be placed, and provide rules of thumb such as “OHIO” (Only Handle It Once). We watch for “churning” of possessions and provide guidelines about how and when to remove sorted items from a living area.

Implementing Group CBT for Hoarding Disorder

Does This Treatment Work? Cognitive‐behavioral therapy (CBT) for HD is an evidence‐based treatment, with many studies supporting its efficacy. In the first open trial of individual CBT for HD, clients received 26 individual sessions, including frequent home visits, over a 7‐ to 12‐month period (Tolin et al., 2007). Clients showed significant decreases from pre‐ treatment to post‐treatment in hoarding severity. At post‐treatment, 50% of treatment completers were rated “much improved” or “very much improved.” Adherence to homework assignments was strongly related to symptom improvement: At post‐treatment, 80% of clients who were rated at or above the median on home­ work completion were rated as “much improved” or “very much improved,” whereas only 20% of those who were rated below the median on homework completion received this rating. This initial open trial was later followed by a randomized controlled trial of individual CBT vs. wait list (Steketee et al., 2010). Given the apparent importance of motivation and treatment compliance in the open trial, motivational interviewing strategies were emphasized to a greater extent in the controlled trial. Participants completing the treatment showed a pre‐ to post‐treatment decrease of 24.7% on the primary outcome measure, the Saving Inventory‐Revised (SI‐R; Frost, Steketee, & Grisham, 2004). At post‐treatment, 80% of participants rated themselves as “much improved,” and 69% received this rating from their clinicians. Next, the CBT protocol was translated into a group format. Three open trials of group CBT have now been conducted (Gilliam et  al., 2011; Muroff et  al., 2012; Muroff et  al., 2009). Results of these trials show that clients’ hoarding severity CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.



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decreased significantly using this format, with improvement comparable to those obtained using individual CBT. Particularly encouraging is a recent study by Muroff and colleagues (Muroff, Steketee, Frost, & Tolin, 2014) examining long‐term follow‐up (up to 12 months) after CBT for HD. At follow‐up, 62% of clients were rated “much improved” or “very much improved” by clinicians, and 79% rated themselves as “much improved” or “very much improved.” Of those clients who were considered improved at post‐ treatment, 83% were still considered improved at follow‐up. Thus, preliminary e­vidence suggests that the effects of CBT for HD are durable. We therefore suggest that CBT for HD is very promising. It should be noted, however, that our protocol differs somewhat from that used in several other studies (Muroff et al., 2012; Muroff et al., 2009; Steketee et al., 2010; Tolin et al., 2007). We have attempted to reduce or eliminate what we perceive to be some of the limitations of prior CBT models of treatment for HD. Specifically, we have minimized elements that past participants found confusing, such as complicated psychoeducation modules, and elements for which the evidence of efficacy seems questionable, such as lengthy formal challenging of cognitive distortions. We have incorporated newer techniques that have demonstrated efficacy for other psychiatric disorders (including impulse control disorders such as compulsive buying) and show promise in HD as well. These newer strategies include: ●●

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Cognitive distancing, which involves mentally changing one’s personal connection to, or psychological distance from, a stimulus (e.g., thinking of an item as if it belonged to someone else). Cognitive distancing may be a more effective tactic than the more traditional cognitive reinterpretation for reducing negative affect (Ochsner, Silvers, & Buhle, 2012). Emotional acceptance, rather than direct efforts to reduce unpleasant emotions. Emotional acceptance appears to be a more effective emotion regulation strategy than emotional suppression (Asnaani, Sawyer, Aderka, & Hofmann, 2013; Hofmann, Heering, Sawyer, & Asnaani, 2009). Compared to emotion reduction strategies, acceptance‐based CBT seems to have greater impact on distractive and ruminative thoughts (Jain et  al., 2007), and acceptance‐based strategies appear promising in the treatment of conditions such as generalized anxiety disorder (Hayes‐Skelton, Roemer, & Orsillo, 2013) and chronic pain (Thorsell et al., 2011; Vowles et al., 2007). Stimulus control. Recognizing the importance of excessive acquisition in HD, we have adapted stimulus control strategies from treatment of compulsive buying and other problems of self‐regulation. Stimulus control has been used independently and as part of multi‐component behavioral interventions for such diverse self‐ regulatory problems as obesity (Hall & Hall, 1982; Stuart, 1971) and health mainte­ nance (Mayer & Frederiksen, 1986; Meyers, Thackwray, Johnson, & Schleser, 1983). Contingency management, which refers to the systematic administration of rewards for task completion. The inclusion of contingency management has been demonstrated to improve treatment attendance and drug abstinence

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide among substance‐using outpatients (Ledgerwood, Arfken, Petry, & Alessi, 2014; Petry & Carroll, 2013; Petry et  al., 2005). Our protocol includes therapist‐ a­dministered rewards, but also encourages the use of self‐control strategies (Kanfer, 1971), in which clients track their progress and self‐administer p­redetermined rewards. In one open trial of group CBT that incorporated prize‐ based contingency management, participants’ scores on the SI‐R decreased by 32%, which is more than what has been documented in prior clinical trials (Worden, Bowe, & Tolin, 2016).

What Does the Group Look Like? The Basic Setup The class is designed as a group treatment to be provided in 16 weekly sessions, with each session lasting 90 minutes. In our clinic, we have found that group treatment tends to have several benefits over individual CBT for HD. First, the treatment tends to “flow” much more effectively than individual treatment for HD. In individual treatment, clients tend to struggle with sustaining attention on the clutter problem, likely due to high rates of co‐occurring problems, attentional difficulties, and diffi­ culties prioritizing. The group compensates for this by having a class‐like structure, along with clear socialization to the very specific treatment focus of HD. We also find that the group is destigmatizing. We often find that clients enter treatment with a high degree of apparent defensiveness, and often make statements early on in group reflecting that they feel stigmatized and misunderstood. In informal polls of our groups who have been treated using this protocol, they have consistently reported that the support and feedback from group members has been one of the most beneficial and liked parts of the treatment. We often find that as group leaders, group members are unlikely to “take it from us” when we provide feedback or sug­ gestions about clutter, but that they appear much more receptive to similar sugges­ tions from fellow group members. Finally, group members help in holding each other accountable. The group reward‐based system is designed to help group m­embers encourage each other to change. We have found that having two group leaders for groups of 5–8 individuals is ideal. Due to the complex nature of the population, we highly recommend that at least one of the leaders has experience and specialized training in the treatment of individuals with HD. While supervised experience in the treatment of HD is highly recommended, we have found that the level of education of the treating professional has not reliably predicted outcomes for participants in the group. There is also research to indicate that non‐professionally run support groups result in outcomes similar to those conducted by trained clinicians (Frost, Pekareva‐Kochergina, & Maxner, 2011). In our clinic we have typically had one psychologist along with one student conducting the group, and we have found that this works well. Therefore, we invite individuals with all credentials to use the manual. However, the manual will



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likely work best for those with at least a basic understanding of cognitive‐behavioral treatment concepts, as the treatment is essentially cognitive‐behavioral in nature.

The Class‐Like Atmosphere While the treatment is referred to as a “group treatment,” readers may find the group to be more class‐like in orientation than like a traditional psychological treatment group. The group is quite structured, follows a specific curriculum, and tends to de‐emphasize (but certainly not omit) interpersonal processes common to many group therapies. Due to several factors likely to be present in this population, such as relatively high levels of disorganization, tangentiality, personality pathology, and therapeutic reactance, we have found that a highly structured group prioritizing teaching of skills has been most beneficial. We therefore refer to the group as a “class” rather than as a “group” and make participants aware in advance of the didactic, focused nature of the group. The group is held in a room with a large writing surface (e.g., whiteboard) that all participants can see clearly. Group leaders may also wish to have name tags for the first several group sessions. Participants are given a notable amount of homework to complete between each session. The homework consists of worksheets to facilitate learning of group skills, and assignment of time spent sorting and discarding. Group leaders are encouraged to collect the completed worksheets each week and review them. In leading groups at our clinic, we often review the worksheets, write comments on them, and hand them back in subsequent sessions. We find that the worksheets provide information to the clinicians about how participants are picking up on group skills and where they may be experiencing difficulty in understanding or implementation. The In/ Out Logs (on which participants log all items coming in and out of their home) can also provide information about progress in sorting and discarding. Ideally, over time clients should be able to practice more restraint, resulting in less items in the “in” portion of the log, and should also become more efficient in decision‐making, and thus, more items should be showing on the “out” portion of the log over time. In the group contract, participants are also discouraged from socializing together outside of the group while the group is running. While the group is a good source of social support for most participants, we have found that disagreements and con­ flicts can arise when participants socialize outside of the group, and these issues tend to interfere with treatment or dominate group discussions. Therefore we encourage participants to wait until after group completion to have formal outside contact with group members. We have found that upon group completion, group participants often design their own support groups and continue informal get‐ togethers to maintain social supports derived from the group. However, we have also learned that social support and group cohesion are important parts of the treatment group. Therefore, we encourage clinicians to allow some time (e.g., 15 minutes before and after the group) for the participants to socialize before and after the session, if space permits.

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

The Clinician Manual and Client Workbook The manual includes a chapter focusing on specific skills for each of the first 12  sessions; sessions 13–16 involve repetition and practiced application of skills learned in the first 12 sessions as well as some skills training regarding relapse pre­ vention. The modules in this manual are meant to be delivered sequentially. Each module covers skills to address one of the four “bad guys” (adapted from Tolin, Frost, & Steketee, 2014) in this order: problems with decision‐making/problem solving, intense emotions, unhelpful thinking, and motivation. Although most treatment manuals begin with addressing problems with motivation, we elected to address concerns with motivation in the fourth module as we have often found that motivation tends to be high at the beginning of treatment and declines over time. Each participant should be supplied with or personally obtain the accompanying client workbook, which will be used throughout the course of treatment. Treatment will progress through this workbook, using text from the workbook and worksheets completed in session.

Sorting and Discarding As noted previously, we practice sorting and discarding in each session. Participants are asked to bring a bag or box of their possessions to each class. The clinicians keep two large empty boxes or bins handy in the group room: one labeled “recycle/donate,” one labeled “trash.” It is important that the bins be easily accessible for participants to make quick sorting and discarding decisions. Many participants will wish to recycle the discarded item. If that is the case and recycling is available at the treatment facility, participants should be encouraged to leave the possession at the clinic for recycling to maximize the amount of possessions leaving the home. If time and resources allow, group leaders can take these items to local donation centers. Some clients will also request that a paper item be shredded first. Again, we often do this for group mem­ bers (in bulk) as we find that it facilitates quick decision‐making and reduces post‐ decision rumination and churning. Obviously, it may not be possible for some sites/ providers to take donation items to donation centers or to put paperwork in a shred­ der; in which case, participants can be held responsible for doing these activities on their own. However, we encourage discarding in session when possible as we find that this greatly reduces chances that the item will re‐enter the home. Clients are often encouraged (but not pressured) to make decisions about posses­ sions “on the spot” to reduce the time spent decision‐making and in churning behav­ iors. Clients also often have excessive or ritualized behaviors surrounding discarding, for example, feeling that every single piece of paper needs to be shredded, or that specific items need to be recycled in highly specific ways or places. The process of making a decision in session requires them to simplify this decision process and c­reates a behavioral experiment that helps test and challenge these rigid rules for discarding.



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The Virtual Store The group uses several in‐session nonacquiring exercises to facilitate in vivo p­ractice of nonacquiring skills. In order to do so, we encourage setting up a “virtual store” of free items that individuals in the group can identify as desired items. Group leaders can solicit donations from colleagues for items (such as books, tapes/DVDs, decorative objects, etc.) that are in new or good condition and are no longer desired/ needed. We have found that having a range of 10–20 items has been sufficient. Another option that has been helpful is to take “field trips” to a nearby store if one is located closely and resources are available to do so.

Taking Pictures In the course of treatment participants are asked to take photos of their homes. Participants will often have cameras on their phones or other cameras that they are willing to use to take photos of their homes. When participants absolutely do not have access to a camera, we ask that they do periodic Clutter Image Ratings (see below) to gauge overall clutter levels.

Reward System The treatment protocol emphasizes the use of contingency management. Group rewards are administered, and participants are encouraged to implement their own system of self‐reward for completion of goals. In session, participants are asked to keep logs of their goals, and both goals and specific homework assign­ ments are reviewed each week, asking participants whether they have achieved the goals. Completion of weekly discarding goals is reviewed at each session. As men­ tioned in session 2, when group members have achieved an established group goal, we reward all group members (in our case, with a free movie ticket or end‐ of‐class party). The potential for these rewards occurs twice during the group (once at session 8 and once at session 16). Small, non‐material rewards can be solicited as a voluntary donation from community businesses. In our groups, we have used a reward of movie tickets for the session 8 reward, and an end‐of‐group pizza party for the session 16 reward. The purpose of the group goal is not only to serve as behavioral reinforcers, but to unite group members in working toward a goal, and to facilitate group members encouraging each other to complete therapy tasks. It is understood that rewards or resources to obtain rewards may be hard to come by in community practices. In these cases, group facilitators are encouraged to solicit small donations from local services or agencies in order to provide the  group rewards. We consider the rewards an integral part of the treatment protocol.

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

Who Is This Group Designed For? This program is designed for individuals who have been diagnosed with HD as defined in the DSM‐5 (American Psychiatric Association, 2013). Use of a semi‐ structured diagnostic measure, such as the Diagnostic Interview for Anxiety, Mood, and OCD and Related Neuropsychiatric Disorders (DIAMOND; Tolin et al., 2017) or the Structured Interview for Hoarding Disorder (SIHD; Nordsletten et al., 2013) is highly recommended in order to diagnose HD. It is highly recommended that a thorough pre‐treatment evaluation be conducted to help differentiate cases of HD from other diagnoses in which hoarding behaviors may be present, such as OCD, ADHD, dementia, severe depression, psychosis, mania, or brain injury. The treatment manual is not indicated for hoarding related to these disorders as it has not been studied with these populations. In addition, this manual has not been examined with individuals with primary animal hoarding. Animal hoarding is a generally understudied phenomenon, likely in part due to the low rates of voluntary treatment seeking in animal hoarding populations. Although little is known about animal hoarding, existing knowledge suggests that it may be a subtype characterized by enhanced risk accompanied by reduced insight and motivation for treatment (Hoarding of Animals Research Consortium, 2002). However, it remains unclear how effective CBT is for animal hoarding, and to our knowledge, this has not been formally examined. As standard practice, we recommend carefully reviewing the limits of confidenti­ ality with clients with hoarding disorder, as one would with all therapy clients before beginning an assessment. Although most people are aware of the limits of confiden­ tiality as it applies to suicidality, homicidality, and child or elder abuse/neglect, most do not anticipate that hoarding can lead to mandated reporting. However, as described previously, hoarding disorder can often result in health and safety haz­ ards, such as risks for falling, fire, and sanitation concerns that could be a cause for mandated reporting of potential child/elder neglect. Information about such poten­ tial hazards is often identified during assessment of hoarding disorder. Individuals with HD as a group tend to report high rates of comorbid physical and mental health conditions (Frost, Steketee, et  al., 2011; Tolin, Frost, Steketee, Gray, et al., 2008). Therefore, we have noticed that co‐occurring mental health diag­ noses are the norm rather than the exception for participants in our groups. We infrequently exclude potential members of the group based on these co‐occurring issues, and participants are excluded only if there is a strong suggestion that they may be extremely disruptive to the group (e.g., manipulative, aggressive, or domi­ neering) or if they need a higher level of care or have a more primary issue (e.g., active substance abuse, psychosis, suicidality) or other issues that would make group therapy inappropriate (e.g., severe cognitive impairment due to dementia, stroke, or brain injury). We typically allow participants to attend therapy for other non‐hoarding‐ related issues (e.g., generalized anxiety disorder, post­traumatic stress disorder, major depressive disorder) while they are taking part in the group.



Implementing Group CBT for Hoarding Disorder

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Participants also often experience medical conditions that impact treatment; for example, those that limit physical mobility or stamina, which may create a barrier to decluttering. It is helpful for group leaders to be aware of these comorbid conditions (both mental health and physical), and assist with problem solving any barriers to treatment (e.g., referral to another mental health or medical provider, enlisting the help of an able‐bodied friend or relative for decluttering). The participants with whom this program has been researched were largely p­articipants who had voluntarily sought treatment for HD. They tended to voice moderate to high motivation for change, although ambivalence was always p­resent. Therefore, the groups with which this program was developed may not be representative of all populations with HD, particularly those who are not self‐ motivated for treatment. We recommend against conducting this protocol with individuals who report an absence of motivation to change hoarding behaviors. While some degree of ambivalence is likely normative, the treatment requires that participants self‐i­nitiate discarding, requiring time and effort each day. If potential participants feel they will be unlikely to adhere to this requirement, we discourage them from attending the group until they feel they can devote enough time and energy to the program to be successful. Motivational interviewing or values‐based work may be more indicated for some of these individuals to aid in problem rec­ ognition and possibly to enhance existing motivation.

Use of the Manual Throughout this manual, sample therapist scripts are written in italics. The scripts are meant to be suggestive of possible language the therapist can use when describing the group content; however, the therapist is encouraged to use and adapt language as he/she feels necessary. Each session begins with a review of the homework assigned at the end of the previous week’s session. Importance of homework should be emphasized and com­ pletion should be considered mandatory. When participants are having trouble completing assigned homework, therapists should problem solve with the participant to encourage improved completion of homework. Clients will often have executive functioning problems that interfere with homework completion, such as difficulty remembering assignments and/or with planning and initiating their completion. Helping participants problem solve these issues and using structured reminder tools, such as writing down homework at the end of each session, can help facilitate homework completion. As mentioned above, the group format is more class‐like than group treatments for most other disorders, and tends to place less emphasis on “group process” than some other programs. We have found that a structured, highly organized group atmosphere tends to better facilitate participants staying on task and accomplishing tasks designed for that session. Due to participants often having executive functioning deficits such

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

as tangential speech/circumstantiality, disorganization, and difficulty focusing, the amount of time that participants speak within the group may seem quite low relative to other treatment groups, particularly within the first third of the group in which the modules are oriented toward teaching of skills. Within the last two thirds of the group, the group begins to transition more toward direct participant participation and in‐session application of skills. It is important to socialize the group appropri­ ately to this shift in format, emphasizing that group sharing is relatively low at the beginning of the group in order to facilitate movement through the group modules and focus on skill acquisition. Group therapists have the challenge of balancing the focused, relatively directive approach with a high degree of encouragement, praise, and patience. Due to a high possibility for defensiveness, resistance, or overvalued ideation, the therapeutic style should be marked by a collaborative, empirical approach. This approach is common to cognitive‐behavioral therapies and involves using a “let’s test it out” approach to examine cognitions and behaviors that may be maladaptive. Prior to leading the group, group leaders should feel confident in their ability to be empathic and patient with this population, seeking additional training or supervision if necessary.

Troubleshooting Common Problems There are several issues that may arise in the course of the class that prevent effective implementation of the treatment. Below are listed some of the most common p­roblems encountered and suggestions for addressing these issues.

Inadequate Attendance It is common for members of the Declutter Class to have many barriers to attending treatment, such as health problems, transportation difficulties, fluctuating motiva­ tion, and scheduling conflicts. While one to two missed sessions are common and expected, some participants may have persistent difficulties attending treatment. Therefore, we emphasize regular treatment attendance in our treatment contract (see session 1 materials). The contract outlines how participants are expected to attend treatment each session, and if the class member does not attend for three or more weeks, the class leaders may meet with him or her to problem solve attendance issues. If attendance issues are not able to be problem solved or it is apparent that the individual is simply not ready, willing, or able to complete treatment at this point in time, the individual may be encouraged to discontinue the group. The attendance rule is held to quite strictly as we have found that when it is not held to, regular attendance becomes a substantial issue. Thus, group leaders are encouraged to address poor attendance early in the treatment, as soon as it appears to be a problem.



Implementing Group CBT for Hoarding Disorder

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Inadequate Homework Completion Similar to issues with attendance, inadequate homework completion may be a result of issues such as flagging motivation, time management, lack of resources, or mental health/physical health comorbidities. Therefore an expectation for regular home­ work completion is mentioned in the treatment contract alongside expectations for treatment attendance. Participants are expected to complete homework regularly and several behavioral motivators are integrated into the treatment protocol to attempt to reinforce homework completion. We recommend that group leaders implement a policy similar to that for attendance, in which a group member has a brief individual meeting with a group leader to problem solve barriers to homework completion. However, consistent non‐completion of homework usually results in the client being withdrawn from the group.

Physical Disability Occasionally participants will report physical disability, or will be otherwise unable to move items from the home. With routine weekly discarding practice, we recom­ mend that participants focus their attention on objects that they are able to move (e.g., paperwork, mail, clothing, knick‐knacks). Typically there is sufficient non‐ heavy material to work on throughout the course of the group. If participants truly wish to remove heavy items and are unable to do so, they can be coached in how to elicit support from family, friends, fellow church members, or other volunteers. We have found that when these individuals are instructed to touch and remove only the items that the participant has made a decision on, this can progress quite smoothly and remove large items from the home relatively quickly. Participants in our groups historically have relied quite heavily on free, local pick‐up donation services that will come and pick up most donation items. Other group members with financial ability have elected to hire professional organizers who assist them in organization and removal of items from the home, or professional junk removal services. If participants have persistent physical disability that substantially interferes with mobility, group leaders should assess the appropriateness of completing the group at this time. Group members are unlikely to benefit maximally from the group if they are unable to attend regularly, comply with discarding homework assignments, and bring items to group to practice with. It may be appropriate to encourage group members to treat or address physical disability, or recruit appropriate assistance, prior to participation in the group.

Difficulty Applying Skills During In‐Session Practices In‐session practice of discarding and resisting acquiring is one of the most impor­ tant elements of this treatment and we suggest that nearly every one should include some element of in‐session discarding. The ultimate goal of the group is to improve

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

efficiency at discarding and reduce acquiring. Without this, participants will make little progress in their hoarding. The importance of actual discarding should be emphasized to the participants and reviewed before in‐session discarding practice. Although it is not the role of the group leaders to coerce participants to discard, or to instruct participants to discard any specific object, group leaders should make clear that the purpose of the in‐session discarding exercises is to practice discarding as many objects as possible. Participants who discard few items in session or who fail to discard at all can be given honest feedback about their apparent low rate of dis­ carding, and can be reminded to use previously learned skills that seem relevant (e.g., distress tolerance techniques). We have found that other group members will often notice when a fellow member is having trouble discarding and will ask helpful challenging questions. Group members can also have the group help the individual work through his or her items; often valuable feedback and challenging questions come up during this process. Similarly, with in‐session practice with the “virtual store,” participants often ask if they are truly able to keep items from the store. They often do desire to acquire items from the virtual store and may not have full skills to be able to resist the acquisition. In this case participants can be reminded that the goal of the exercise is to practice applying their skills to resist acquiring, and therefore taking objects home from the “virtual store” should ideally be avoided. Participants can be asked to practice applying relevant skills until the desire to acquire the item is reduced. If participants insist on acquiring the item, they can be asked to delay their decision (as the items for the virtual store will be used again in future sessions).

Tangential or Circumstantial Speech One of the most significant potential barriers to effectively running the Declutter Class can be maintaining a focus on the task at hand. Hoarding disorder tends to be marked by overly inclusive verbal styles that can manifest as rambling speech pat­ terns, off‐topic comments or discussions, interrupting, and sharing of excessive or irrelevant details. Participants also often have difficulty “wrapping up” comments and may not create many opportunities for the group or group leaders to intervene strategically. In addition, participants may have reduced awareness of nonverbal cues from group members and class that may signal disinterest or excessive v­erbosity. These problems with speech content often lead to (a) a minority of participants dominating the group discussions, with little chance for other participants to share, (b) group leaders experiencing great difficulty in maintaining a focus on a topic and rerouting talkative participants, and (c) participants feeling unheard or invalidated when they are cut off. In order to address these difficulties with speech patterns, the manual makes use of a small sign with a clock symbol. Class leaders can photocopy this sign on a sheet of paper to use in group. Both the therapist manual and the client manual orient p­articipants to use of the clock sign. The clock sign is used as a way of nonverbally



Implementing Group CBT for Hoarding Disorder

29

signaling that the participant should “wrap up” his or her comments so that the class leaders can proceed. The clock sign can be used at any point during the group when a participant has difficulty with circumstantial or tangential speech, or for clients who tend to dominate the group discussion. It is important to appropriately socialize clients to this sign in the first session, reinforcing that the sign is not meant to be punitive but rather is to help with organizing the group, ensuring fairness, and ensuring that all skills are imparted. We have found that if participants are appropriately socialized to the clock sign, it is an extremely helpful tool in ensuring that treatment progresses smoothly, and participants respond well to it. We find that when using the clock signs we are able to cover more content in treatment, participants are encouraged to practice being concise and clear, and there are fewer complaints from participants about other group members dominating the group interaction. Finally, if a group participant requires excessive or repeated use of the clock sign, or if he or she consistently fails to respond to the clock sign, class leaders may wish to speak to the group partici­ pant individually in order to encourage him or her to allow other group members a chance to share.

Information Acquisition Difficulties In running the group, we have found that simpler is better. Because individuals with HD may have executive functioning impairments, they may have difficulty identi­ fying and recalling relevant details. When skills are taught, they tend to be over‐ inclusive in attempting to get each “morsel” of information possible. However, this “information hoarding” tends to lead to participants losing the forest for the trees – being so preoccupied with following and obtaining all information that they often fail to process it, integrate it, and apply the model to their personal experience. In addition, they likely have difficulties attending to and organizing incoming information. Therefore, the materials in the manual should be delivered at a very basic level (we aim for a 5th to 8th grade reading vocabulary) and at a relatively slow pace. Repetition of skill practice is present throughout the manual. We have found that participants respond well to this style, regardless of their level of education.

Therapeutic Reactance Individuals with HD tend to show a high rate of therapeutic reactance, often subtly or overtly resisting suggestions made by group leaders and members. This response is understandable in the context of the lives of individuals with hoarding; they have often been criticized by family members or others who do not understand why they are unable to “just get rid of things.” It is easy for a defensive stance to develop in which the participant is more in the mode of defending his or her behaviors rather than considering change. Therefore it is crucial that the therapist take a

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

nonconfrontational stance throughout the course of the group, emphasizing that all decisions are up to the participant. The group leaders should never force or pressure a participant to discard or part with an object if he or she does not want to; such pressure can lead to a substantial backfire in which the participant not only struggles to keep the item, but often develops a resentful, mistrusting attitude incompatible with positive change. We encourage strong use of the cognitive‐ behavioral Socratic method in all exercises, treating participants with respect and allowing them to make their own decisions about possessions. We have found that working with people with hoarding disorder often requires more conscious effort from the therapist to remain empathic, supportive, and nonjudgmental than other types of clients. It is important for the participants to experience the therapist as understanding that they have excessive clutter not simply because they do not care about the clutter or that they have not tried to address it. By the time most participants enter treatment, they have already spent a significant amount of time over many years attempting to declutter without much success. Showing understanding of how frustrating this experience has been can help reduce the therapeutic reactance. It is also important for the group leaders to remain neutral, supportive, and patient during in‐session decluttering and non­acquiring class. This can be difficult as participants often choose to keep most items they bring to session for discarding practice. We have found the task of encouraging the participants to discard/not acquire while maintaining a nonjudgmental stance to be challenging but essential.

Relapse After completing the declutter group, almost all of our participants continue to have significant clutter in their home. This appears to be the case even among the participants who showed the most progress in their ability to declutter and resist acquiring. Thus, during the initial session of the group, group participants are fore­ warned of this likelihood, and to have reasonable expectations about their progress in the group. The goal of the group is to learn skills to declutter more effectively, and to resist acquiring. But due to the extent of clutter in the home, participants should plan on continuing to dedicate time and energy into decluttering even after completing the 16  weeks’ group. In the last few sessions, relapse prevention is reviewed. We have also found that some group participants return to our clinic after completing the group, reporting that their decluttering progress slowed after completing the group, or that some of the clutter returned in their home. A significant portion of group participants request repeating the declutter group, continuing their work with an individual therapist, or requesting a support group. We have offered all of these options (individual therapy, repeating the class, support group) for maintenance therapy, and have found a structured, skills‐based and time‐limited group to be most successful at helping participants continue to make progress with their clutter.



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Measuring Outcomes We recommend regular symptom monitoring using self‐report questionnaires. Some of the most commonly used self‐report questionnaires for individuals with HD are outlined below. We recommend administering at least one of these outcome measures at a minimum of pre‐treatment, mid‐treatment (week 8), and post‐ treatment. However, some sites may wish to administer a brief outcome measure at the start of each session.

Saving Inventory‐Revised (SI‐R) (Frost et al., 2004) The SI‐R is a commonly used 23‐item measure of hoarding severity. The measure yields a total score, as well as a score on three subscales: (1) clutter, (2) saving, and (3) acquiring. The SI‐R demonstrates excellent psychometric properties (internal consistency ranging from .84–.98 and test‐retest reliability ranging from .86–.94) (Fontenelle et al., 2010; Frost, Rosenfield, Steketee, & Tolin, 2013; Frost et al., 2004; Wootton et  al., 2015). A cut score of 41 represents clinically significant hoarding symptoms on this measure (Tolin, Meunier, Frost, & Steketee, 2011).

Clutter Image Rating (CIR) Scale (Frost, Steketee, Tolin, & Renaud, 2008) The CIR is a pictorial scale of three main rooms (bedroom, living room, kitchen), in increasing order of clutter severity, with a total of nine photographs for each room. Participants are asked to indicate which picture best represents the level of clutter in the rooms of their home. They are asked to select a rating for their bedroom, living room, kitchen/dining room, hallway, basement, attic, car, and any other rooms in their home. The CIR has demonstrated good internal consistency, test‐retest, and inter‐observer reliabilities, as well as convergent reliability with other measures of hoarding severity (Dozier & Ayers, 2015; Frost et al., 2008).

Clinical Global Impression (CGI; Guy, 1976) and CGI Self‐Report (Hannan & Tolin, 2007) The CGI is a widely used, brief assessment of problem severity. The CGI consists of two questions, one that assesses severity (CGI‐Severity) and one that can be used to assess improvement with treatment (CGI‐Improvement). The CGI‐Severity requires clinicians to rate the past‐week severity of the participant’s presenting problem on a 1–7 Likert scale, with 1 reflecting “No problem,” and 7 reflecting “Extreme problem.” The CGI‐Improvement also is similar but asks the clinician to rate the participant

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

from 1, “very much improved,” to 7, “very much worse.” The interview version is designed to factor in all sources of available information including clinical observa­ tion, participant report, and collateral report if available. We also have routinely used a self‐report version of the CGI (Hannan & Tolin, 2007), although interrater examination of the self‐report version (DiMauro, Tolin, Frost, & Steketee, 2013) suggested that individuals with HD may rate themselves slightly higher than ratings given to them by independent raters.

The Activities of Daily Living for Hoarding (ADL‐H) (Frost, Hristova, Steketee, & Tolin, 2013) The ADL‐H is a 29‐question self‐report measure to assess the functional impact of clutter. It is designed to assess the impact of clutter on one’s ability to complete basic daily activities (e.g., moving through the home, paying bills, and laundering clothing). It also queries for other risk factors such as pest infestation, or inoperable utilities. Recent research on the ADL‐H suggests that the first 12 items of the original 29‐item scale show superior psychometric properties, with strong internal consistency, test‐retest reliability, and convergent and discriminant validity (Frost, Hristova, et al., 2013).

Part II

Treatment Manual

Chapter 1

Welcome to the Class

1. Welcome to the Declutter Class (15 minutes) Sorting and Discarding Bringing Clutter from Home to Group Staying on Schedule Photos Class Task: Introduce Yourself! 2. Class Rules and Guidelines (10 minutes) Treatment Contract Class Confidentiality Contract 3. What is Hoarding Disorder? (20 minutes) 4. What Will I Learn in This Class? (20 minutes) Learn More About What Contributes to You Having Clutter Learn Evidence‐Based Skills to Reduce the Clutter in Your Home Learn How to Apply the Skills on a Consistent Basis 5. How Well Does the Declutter Class Work? (10 minutes) 6. Homework (5 minutes)

38 38 39 40 40 41 42 44 45 46 47 47 48 48 48 49

Overview The first session of the declutter class focuses on providing participants with an orientation to the class. Class rules and confidentiality are reviewed. Participants are oriented to the expectation that they bring items with them each time they come to the group, so that they can practice decluttering skills in session with their own items. CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

At the beginning of this session group therapists should introduce themselves and spend a bit of time getting to know the participants. Each participant is asked to sign a treatment contract that outlines the group rules. We recommend that group leaders collect the signed forms and make a p­hotocopy for their records. Signed forms can then be returned to participants so that all parties have a copy. In the confidentiality agreement, participants are also asked to respect the confidentiality of other group members and not to share information from session outside of the class. Participants may express some reservations about some of the group components, such as sharing photos of the home. We have found that it is good to take some time in this first session to address participants’ concerns and to reiterate the rationale for each of these requirements. Participants usually identify and understand the concepts of skill practice and accountability, and recognize that while they may be mildly to moderately uncomfortable, these components are likely to be c­atalysts for change. Participants are also socialized to some of the expectations of the group, including weekly homework, bringing objects to sort and discard in session, and sharing photos of one’s home. Participants are initially oriented to the group structure and the manual layout. Participants are given some basic psychoeducation about terms and concepts that are commonly referred to in the group, including “churning” (i.e., the process of simply moving objects from one location to another without discarding) and the “OHIO” (only‐handle‐it‐once) method. Participants are encouraged to use a three‐ receptacle method of discarding throughout the course of the group. The three‐receptacle method involves using receptacles to sort the final location of objects, e.g., trash, donate, and keep. Participants are encouraged to use no more than 3–4 receptacles as decision‐making complicates substantially with each additional potential end point for an object. This three‐receptacle method should also be practiced throughout the course of the group when sorting and discarding are conducted in session. In this session participants are also provided with psychoeducation about the diagnostic criteria for HD, and information on how hoarding may differ from collecting and nonclinical clutter/disorganization. Participants are given some brief information about the effectiveness of group CBT for HD. The importance of daily practice and homework completion is introduced. During introductions, group members can be encouraged to introduce themselves and say a bit about why they are attending the group at present. This is designed to facilitate connection between members of the group and to aid in learning of names. Again, it is encouraged that name tags or other identifiers be used in the first 1–3 sessions of the group to facilitate interaction between group members. Participants are asked to speak a bit about why they are motivated for treatment, both to normalize hoarding behaviors and related consequences within the group, and to enhance recognition of individual motivators for change. Verbalizing these motivators also allows other group members to be aware of others’ treatment goals to enhance accountability. The session also includes a brief review of some of the many problems that HD can create, and participants are encouraged to identify any consequences that are relevant to them that they would like to change.



Welcome to the Class

37

The session ends with assigning homework to be completed prior to the next session. As part of the homework, participants are reminded to bring items from home to the next session, to review materials from the session, and to take photos of all of the main areas of their home to send to group leaders or to bring to class. Participants are also assigned a worksheet entitled “What Has Hoarding Taken From Me?” as homework. On this form they are asked to identify some ways in which hoarding has impacted their lives negatively.

Empirical Support and Rationale In this initial session, it is important to ensure that all group members understand the treatment contract and feel prepared to adhere to it. If a participant misses this initial group, we typically schedule an independent (brief) session with them in order to go over these rules and ensure understanding and commitment. While the group structure may seem rule‐heavy and somewhat strict, we have found that the group runs much more efficiently when expectations are outlined, and rules are clear and implemented reliably. Anecdotally, we have found that participants appear to have better outcomes when structure is emphasized and adhered to. This is consistent with one small study by Muroff et al. (2009), who found that in a small sample of individuals completing CBT for HD, a small group (n = 8) that had a more formalized protocol with clear rules and structure improved significantly more than previous groups (n = 24) that were less structured. We feel that this is likely due to the executive functioning deficits and disorganization that are central to this population. When deadlines and schedules are adhered to, it can improve the “flow” of the group dramatically. It can often be tempting to avoid enforcing the rules, as they can seem strict at times. However, we have found that when participants are well socialized to the rules up front, and the rules are implemented with compassion, participants have responded well to the rules and structure. One may notice that there is a lack of thorough presentation of a cognitive‐ behavioral “model” of hoarding etiology or development. Participants may become confused by complicated discussions of the multiple factors that play a role in the maintenance and development of hoarding (as mentioned above, this model can be quite complex!). Participants may not be likely to remember components of these models after treatment (Ayers et al., 2012). Therefore, a full case conceptualization model is not laid out up front but rather woven into the individual chapters as each “bad guy” is discussed. The manual specifically limits formal discussion of the various factors that may cause hoarding behaviors. Participants will likely have questions about these issues, and often wonder how developmental factors such as trauma may have influenced or caused their hoarding behaviors. Obviously, these questions can be addressed, but we recommend staying away from lengthy/ complicated discussions about the developmental “model” of hoarding. This is not to diminish the impact of these factors, but to simplify relevant content for participants, and to encourage a focus on the here‐and‐now.

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

1.  Welcome to the Declutter Class Welcome to the Declutter Class! Group leaders should introduce themselves to the group, and provide contact information. Remind class members that the class lasts 16 weeks, and each session is designed to last 90 minutes. All participants should be provided with a group workbook. This is the group workbook, which we will use throughout the course of the group. Please keep your workbook in a safe place, as you will need it during each group. Please bring the workbook with you to each of the sessions. Today we group leaders will spend a lot of time talking, but hopefully we will also have some time to get to know each other. Today we will talk about what you can expect to learn in the group, and will discuss some general rules and guidelines for the group. Point out to participants the class tasks icon in their workbooks, as shown here. During the group we will be teaching you lots of new information and skills. We will also do lots of tasks together. When you see this picture it means that we will do a group task. These tasks will vary, but they are an important part of the group. Inform participants that the workbook uses a fictional case example, Rita, to further illustrate group techniques and skills. These participant story sections will be marked by an image of the participant, Rita, as shown here. The graphic of Rita in your workbook indicates that Rita will explain how she used the skills to help her hoarding symptoms. Rita and her story are a good way to see how the skills from the group can be applied.

Sorting and Discarding Throughout the course of this group we will suggest using a “three‐box” method of sorting through your possessions. Discuss the receptacle method with group members. Group members are encouraged to use three receptacles (boxes, bags, bins, etc.) for sorting. Participants typically have three boxes or bins: one for items to keep, one for items to donate, and one for trash items. Emphasize how there should be no “deal with it later” box, and that the goal of the group is to get participants in the habit of making decisions, not delaying decisions.



Welcome to the Class

39

Introduce the concept of “churning.” Many people with HD will have made attempts to clean up the clutter. However, those efforts frequently involve just moving things from pile to pile. This “churning” behavior may feel like cleaning up, but it’s not. In this group, we will emphasize making decisions and taking action. In  that spirit, introduce the concept of “OHIO:” “Only handle it once.” That is, whenever possible, items should only be handled once before a decision is made and action taken. In addition, participants should carefully choose their boxes; for example, having a box full of items “to give to daughter‐in‐law” is not a helpful box if the daughter‐ in‐law has requested not to receive items, and having a “sell” box is not all that helpful if the individual overestimates the value of his or her possessions. We tend to discourage participants from trying to sell most items, as for most people in the group the amount of planning and organization that is necessary to sell the item often outweighs the monetary value of the item. The goal of this group is to help you to reduce your clutter. Our experience shows us that people in the group do best when they practice sorting and discarding using three boxes (or bins or bags): a. Keep b. Trash c. Donate/Recycle We will be using this system throughout the group, so we encourage you to imme­ diately set up this system in the area you wish to work on. You may wish to label your receptacles so you remember which is which. You might find this p­ractice difficult, but we will work on ways to help you manage feelings of distress that come up. At this point in the group, group leaders show participants the receptacles that they have marked as “trash” and “donate/recycle.” Here are the bins that we will be using throughout the course of the class. You will notice that one is marked “donate/recycle” and one is marked “trash.” If you elect to put your item in the donate/recycle bin, we will donate or recycle it for you. Sometimes participants will want to know whether discarded paper materials will be shredded/recycled. In our groups we have a large bin for confidential material shredding that already exists in the clinic and we volunteer to place paper materials with identifying info in the shredding bin for participants.

Bringing Clutter from Home to Group In order for you to complete various group assignments we will ask you to bring in a small bag or box of your belongings from home each week, starting in week 3. You will not be required to discard anything until you feel ready, but it will help us

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

to learn about your symptoms and demonstrate the skills that will be helpful for reducing your clutter. It might be tempting to pre‐sort your belongings before class, leaving the “good stuff ” at home and only bringing in things that would be easy to discard. For the sake of this practice, we don’t want you to pre‐sort what you bring in. Just take several belongings from one area of your home, regardless of your thoughts about keeping or discarding them. Address any questions or problems the participants have with the idea of bringing items to session. Emphasize how participants should quickly grab items from a location (e.g., sweep arm across a table, sweeping all items into a bin to bring to session), without pre‐screening items. Inform participants that the goal of having them bring items in is to practice skills in session, and therefore they should not bring in items they have already decided they are going to discard. Remind them that they will not be forced to throw anything away. Participants should be encouraged to bring many items, typically a box or bag of at least 10 items. Remind them that the degree to which these items are used in session will vary, but that they are expected to have many items to work with in session should the therapists ask them to practice.

Staying on Schedule Show group members the clock sign (a copy for use can be found in Appendix A). You will notice that we have a sign with a clock on it. We will use this to help keep class members on track. We have found from our past groups that many class members have important stories to tell, but there often just isn’t enough time to get through all of them. We want to make sure that we stay on track and get through all the materials to help you reduce your clut­ ter. We will use the stop sign as a reminder for you to finish up with what you are saying quickly and as a signal that we need to move on. When we use the clock sign, it doesn’t mean that we’re not interested in what you have to say! It just means that we need to make sure everyone gets a chance to talk and that we have enough time to cover the material for the class. Please respect your f­ellow group members by not interrupting, and by allowing everyone a chance to contribute.

Photos Inform class members that they will be asked to take photos of their homes throughout the course of the class and normalize that this process can be uncomfortable for some class members. We ask you to take photos of your clutter now, at the start of treatment, and as you work through treatment. The photos help us to be able to monitor your progress and



Welcome to the Class

41

give you feedback, since we are unable to visit your home. The photos also help you keep track of your progress, and help you be accountable to the group. In talking to past groups, we have found that they often state that “accountability” is one of the factors that helps them make progress in the group. It is a lot like a weight loss group: you would most likely weigh yourself in front of the group to show your progress and to show the group where you are, so that they can give you feedback and support you. We know that this aspect of the class might also be difficult for you. You might feel embarrassed showing pictures of your home, or you might worry that your pictures won’t show enough progress over time. We understand that it can be hard, but in our opinion, taking and showing pictures is very important. It helps to break the wall of secrecy and shame that so often surrounds hoarding, and helps you and us get a good understanding of how well the program is working for you. The photos also help you see how far you’ve come. It is easy to forget how much progress you have made in the group and focus only on what is left to be done. In past groups, when participants have reviewed their “before” and “after” photos at the end of class, they have often been blown away by the difference, which was much greater than they thought! There are several ways that you can share your photos with the group. If you have a camera on your phone you can use that, and you can either send the photo to us via email, or bring the photo to session on your phone, or print it out. As with all information in the group, the photos that you show us/send us are completely c­onfidential and are not shared outside of the group. If you do not have access to a digital camera you may need to purchase a disposable camera to take hard‐copy photos. When taking photos, we would like one photo for every main area of your home. So this usually works best if you simply stand in a doorway and take a photo of that room. We want to see all the rooms of your home, regardless of whether they are currently cluttered or not. We want to see the cluttered rooms to talk about your goals in these areas and track progress over time, and we want to see the non‐cluttered areas to make sure that they stay this way and you do not engage in  churning  –  simply moving objects from one room to another without much going out. Does anyone have any questions about this? We will ask that this week you take photos of every room in your home, so that we can get a sense of where you are starting from. We will share all of your photos at the beginning of the next group. CLASS TASK: Introduce Yourself! To get started let’s start with introductions. Please tell us briefly: ●● ●●

Your first name. Why reducing your clutter is important to you right now.

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

Group leaders should also provide class members with contact information for their preferred method(s) of contact. Participants have a place to write down this information on page 3 of their workbooks.

2.  Class Rules and Guidelines You will notice that there are a lot of rules and structure to the group. If you have been in a therapy group before, you may find this group to be much different. We will be teaching you many skills to help address your clutter problem, and we have a lot to cover in a short time. We find that this group works best when we have clear rules and guidelines that everyone in the group follows. On the next few pages you will find a treatment contract and a class confidentiality contract. Please read through these contracts and sign the bottom of the form if you agree. Because we know from having completed several groups for many years that these rules are very important to the success of the class, we take the treatment contract and class confidentiality quite seriously. Unfortunately, if you do not agree to the treatment contract we are unable to have you in our class. We will take a copy of the signed contract so that we know that you agree to the rules, and you will have a copy of these rules in your workbook to refer to if you have questions in the future. It is recommended that the group read the forms aloud in order to better process the rules of the group and address questions that arise. If desired, group leaders can ask group members to take turns reading individual rules, and answering questions about rules as they arise. Reinforce how the group rules are not designed to be authoritative but rather to provide structure, organization, fairness, and respect to group members. Participants will often ask why they are discouraged from dwelling on past events (treatment contract item 6). We inform them that historically, our group members have tended to overly focus on past life difficulties that may have contributed to development of the clutter problem, but may not be workable or relevant now. We remind them that we do not necessarily need to know the reason a problem started, or the cause of it, to be able to treat it. We therefore tend to focus on factors that are maintaining the problem in the present. Group members may wish to point out that “the things that may have started your problem may not be the same things that keep it going in the present.” In reviewing rule 9, reinforce how it can be difficult to resist obtaining items from other group members especially when group members begin to bring in items to be discarded. For many group members, it is difficult to watch others discard items even if the items are not personal possessions. The group therapists also have some rules that they will follow. Our rules are that we: ●● ●●

Will not touch any of your possessions without your permission. Will not throw away any of your possessions without your permission.



Welcome to the Class ●● ●● ●● ●●

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Will allow you to make all the decisions about your discarding. Will be creative and flexible in the treatment process. Will allow everyone the chance to speak and learn in the class. Will convey nonjudgmental empathy and compassion, and will strive to understand your situation as accurately as possible.

Next, group leaders should review the treatment contract and class confidentiality contract (on pages 5 and 6 of the participant workbook). In regards to item 3 of the confidentiality contract, inform participants that while it is OK to talk about group skills or the general theme of the group sessions outside the group, the contract requires that personal information about group p­articipants be kept private.

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

Treatment Contract 1. Willingness to discard.  The purpose of this class is to help me to reduce my clutter and improve my quality of life. For this reason, I am willing to discard items in my home. I will be able to control what I keep and discard, but I am open to discarding at least some of the items in my home. 2. Being on time.  I understand that if I am 15 minutes or more late to the class (according to the clock in the classroom) I will not be able to attend class that week. If I am less than 15 minutes late the class will not stop to review what I have missed but I may join the class for that week. 3. Bringing in clutter from home.  I agree to bring in some of the clutter from my home to every class (starting in week 3). This will help me apply and p­ractice the skills from class. This is an extremely important part of the class. I understand that if I do not bring items each week I may be withdrawn from the class. 4. Maintaining regular attendance.  I understand that if I miss 3 sessions or am late by 15 minutes or more for 3 sessions I may be asked to leave the class. This is because it is distracting for other class members. If I do miss a class, I understand that I am responsible for contacting the class leaders to find out  the homework assignment. Homework must still be completed for missed classes. 5. Completing assigned home exercises each week.  I agree to turn in all assigned homework worksheets at each class. If I miss this goal, I understand that I will be asked to meet privately with the class leaders to problem solve any difficulties. If I miss this goal more than 3 times I may be withdrawn from the class. 6. Focusing on making changes to my current life and not dwelling on past events.  During the class, I will only bring up past events if it is for the purpose of making changes to my current situation. 7. Letting others have their turn to speak.  I will not interrupt others or divert a topic of discussion. I understand that the class leaders will use the clock sign to signal me to finish up what I am saying quickly before moving on to the next topic. 8. Ceasing all social conversation with other class members by the start of the class. 9. Refraining from giving belongings to other class members or acquiring materials from other class members unless instructed by the class leaders as part of demonstration of skills. Signature: ___________________________

Date: _____________



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Class Confidentiality Contract This is a contract for confidentiality among the members of this class. 1. Each member of the class agrees to keep personal information discussed in the class private. 2. Any information shared by a class member about himself or herself should be considered private information. This information should not be shared with anyone outside of the class. 3. Due to potential conflicts, we do not recommend contact between class m­embers outside of the class. ●● ●●

I agree to respect the right of others to follow this recommendation. I agree to not share contact information while at the class.

Name: ____________________________________________________________ Signature: _________________________________________________________ Date: _____________________________________________________________

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

3.  What is Hoarding Disorder? Inform participants that HD is marked by the following problems: 1. Difficulty throwing things away because of a perceived need to save things. 2. Experiencing excessive distress when trying to throw things away. 3. Having so much clutter that one is unable to use rooms and objects in the home for their intended use. Also discuss with participants that individuals with hoarding disorder often have a problem of excessive acquiring. That is, they buy or pick up more items than they need, and bring them into the home, adding to the clutter. Excessive acquiring is not currently one of the diagnostic criteria for hoarding disorder, but we have found it to be present in most cases. Review with participants some common consequences related to hoarding/­ clutter, such as those listed below. Many people with hoarding disorder report that the clutter in their home can lead to many problems, including: ●●

●●

●●

●●

●●

●● ●●

Unsanitary and unsafe living conditions ◦◦ Mold, water/roof leaks, structural decay, pest infestation, animal feces, trip/ fall hazards, fire hazards Difficulties getting contractors or emergency workers into the home ◦◦ Doorways may be blocked, or passages narrow, inhibiting movement of repair personnel or emergency personnel in the case of an emergency Difficulties with family members ◦◦ Family members disapproving of clutter or acquiring habits Reduced social contact ◦◦ Arguments and discord with family or friends ◦◦ Refusing to allow people into the home, such as repair persons, family, or friends Problems with the legal system ◦◦ Eviction, complaints ◦◦ Social services agencies to oversee protection of children or elderly Dissatisfaction with the functioning of the home Losing/being unable to find items that are important

Ask group members to indicate whether they have experienced any of these hoarding‐related impairments, or other impairments not listed here.



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4.  What Will I Learn in This Class? Next, we will talk about what you will learn in this group. In this group we will help you to: 1. Learn more about what contributes to you having clutter. 2. Learn evidence‐based skills to reduce the clutter in your home. 3. Learn how to apply the skills on a consistent basis.

1.  Learn More About What Contributes to You Having Clutter Guide participants to the illustration in their workbook. We have found that these four “bad guys” tend to work together to create hoarding problems. Keep in mind that all of you likely vary in how much each of these factors contributes to your clutter problem. For example, some of you may have diffi­ culties in one or two of these areas and not the others; some of you may have moderate difficulties in some and high in others; or some of you may have strong difficulties in all the areas. Not to worry: the goal of the group is to help you under­ stand which of these areas is most problematic for you, and to target strategies at those areas.

Decision-making and problem solving

Intense emotions

Unhelpful thinking

Acquiring and difficulty discarding

Motivation

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

2.  Learn Evidence‐Based Skills to Reduce the Clutter in Your Home From session 3 through 10 we will be teaching you skills to reduce the clutter in your home. We call these skills “evidence‐based” because we know from previous research that they work! The skills are not easy to do, though, and require lots of repetition and perseverance. Just like learning any new skill, it takes time! We are confident, however, that if you work on these skills a little bit each day you will make improve­ ments in your clutter. While you may find that some of these factors drive your hoarding behavior more than others, we find that learning skills in all of these four areas is helpful regardless of the primary cause of your clutter problem. Therefore, as we work through the strategies to target these factors, we ask that you give them your best  effort and try all of them thoroughly, regardless of how much you think they  might apply to you. You may find some things do not work for you and that’s  OK, we just ask that you really try everything thoroughly before you decide  you don’t like it or don’t want to use it. Usually that means trying it for at least a month or two.

3.  Learn How to Apply the Skills on a Consistent Basis This is the most important part of the group. From session 11 onwards we will be putting all the skills together and making these skills your new habits. This takes lots of practice and repetition. After lots of practice with these skills we expect that you will make much improvement in reducing the clutter in your home.

5.  How Well Does the Declutter Class Work? Discuss with participants that it is important to have realistic expectations for progress within the group. Emphasize that while substantial reductions in clutter are expected during the course of the group, much progress in decluttering occurs after the group has been completed. We use the techniques that we show you because past group members have found them to be very helpful. Also, past research that we have conducted suggests that most people who complete the group feel much better and have substantially less clutter at the end of the group, improvements in quality of life, improved safety within the home, less acquiring, and increased ability to let go of possessions when necessary. However, it is important to have realistic goals; you likely still will have some clut­ ter and some related difficulties at the end of the treatment program. You likely did



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not accumulate all of your objects overnight, and therefore it often takes a long time to declutter as well. It may take months to years to declutter to the point that it is not distressing or interfering with your life. However, you should be feeling better, less cluttered, and more confident in your skills as you go through the group, so please let us know if you are finding that is not the case! The important thing is that you learn the skills and how to apply them so that you continue to improve even after the group has ended.

6. Homework Reinforce to participants the importance of regular homework completion. Doing homework is not always pleasant. It’s time consuming and can be difficult, both emotionally and physically. We understand that your life may already be quite busy, and that you may not want to do things that feel bad. But we cannot emphasize enough how critical this part of the class is. This is because we have found from our previous classes that people who do their homework consistently each week get the best outcomes. For example, one recent research study found that 80% of those who did their homework ­regularly responded to treatment versus only 20% of those who did not do their homework regularly. In other words: If you do your homework consistently, you will probably have a very good outcome of this class. If you do not do your homework consistently, you will probably not have a very good outcome of this class. For this reason we will give you homework every session. We want you to get the most out of the class so we want you to do your homework every day. As mentioned in the treatment contract we discussed earlier, if you do not do all your homework consistently we may meet with you individually to discuss what may be getting in the way. Outline the homework tasks for week 1, as follows: 1. 2. 3. 4. 5.

Reread information from week 1 (including Rita’s story). Take “before” photos of ALL main areas of your home. Complete the “What Has Hoarding Taken From Me?” worksheet. Other: ______________________________________________________ Other: ______________________________________________________

You will see your homework for this week listed on page 11 of your workbooks. We recommend spending at least 1 hour a day working through your homework, which may include reading back through your worksheet or completing specific tasks. Remember that the more you do the homework, the more likely you are to

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

improve! You will hear us remind you of this often during the course of the  group  –  because it is very important! You can decide how much you put into  this and how much you get out of it. We have found that individuals who do not do the homework are unlikely to improve substantially during the course of the group.



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Sample Answers to Common Questions Question: I’m going on vacation/having surgery/etc.; what if I have to miss some sessions? Answer: We understand that emergencies happen, and usually a couple or even a few missed sessions is not a substantial problem. Obviously we recommend that you attend as many sessions as possible to get the most benefit from the treatment, and we hope that you will attend all the sessions! As specified in the treatment contract, however, if you miss more than three sessions, we will meet with you individually to discuss what has been getting in the way and possibly to help you problem solve some of the barriers to completing treatment successfully. We may also discuss with you whether completion of the group is in your best interests right now. Sometimes we find that group members have other issues that may take priority, and that’s OK  –  in which case we will simply encourage you to reattend the declutter class when you are able to give it your full attention. We tend to discourage participants from continuing with the group if they have missed four sessions or more as this is simply not enough attendance to get the full benefit of the group. We would rather have you take this class at the right time and succeed than take it at the wrong time and be disappointed. Question: What if something comes up (e.g., a serious illness, family emergency, etc.) that stops me from doing the weekly homework assignments? Will I be thrown out of the group? Answer: We understand that issues come up that make it challenging to complete the homework. We also understand that the group homework can be time consuming. However, as we know that the homework is so important to your success in this group, we ask that you put your best effort into it, even if you are having additional life stress or difficulty. We often find that times that we are stressed, busy, and fatigued are the best times to practice skills from the group, as these are the times that we are most likely to fall back on old habits! As mentioned in the treatment contract, if you are repeatedly unable to complete the group homework, one of the clinicians may meet with you individually to discuss your progress in the group. He or she may help you problem solve some of the barriers that have gotten in the way of completing homework. The clinician may also discuss with you whether it is appropriate to continue with the declutter class. As always, we want to make sure the group is a priority in your life  –  and if it is not, that is OK – but we will ask you to refrain from participating now and return at a time when you can put your best effort in. If you are simply having difficulty completing the assignments because you are having trouble understanding them or have q­uestions, please contact the group leaders and/or discuss your concerns/questions in the group!

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

Question: Spending half an hour or more a day on homework sounds like a lot! I have a lot of things on my plate and I am not sure I can spend that much time on the assignments! Answer: We agree that the homework is a lot of work to do, and sometimes it can be hard to manage time and resources in order to get the therapy homework done. If you are unsure that you will be able to complete the homework demands of the group, please come speak to us after the group. We can then talk with you about whether now is a good time to complete the group. We occasionally find that participants have many life demands (e.g., family stress, medical issues, financial issues) and that the group work may be too much of an additional burden or that working on the hoarding problem is just not at the top of the p­riority list. If that is the case, we may simply ask that you reconsider completing the group at this time. Question: What if there is inclement weather? Will the group still be held? Answer: Depending on the likelihood of inclement weather, group leaders may wish to set an inclement weather policy at the start of the group. To make cancellation information easily locatable by participants, we have used cancellation information of local universities or community colleges, telling participants that we are also closed if the university has canceled classes/closed for the day/evening. This way, participants can usually look at the school’s website, call the school, or watch the news to determine if the group will be held. If such a facility is not nearby, group leaders may wish to obtain contact information for group participants and warn them to ensure that they can be contacted on days that inclement weather cancellation is possible. While lower attendance can be expected during inclement weather, we find that having a hard and fast rule for cancellation of the session is necessary to reduce confusion and anxiety. It is also often helpful to obtain alternative contact information from the group members if they need to be contacted in case of an emergency cancellation. We typically try to obtain more than one phone number if available, and ask participants’ consent to send emails. We often find that clutter and difficulty discarding may extend to voice mailboxes as well, and that we are often unable to leave messages for participants due to “voice mailbox full” messages. This can lead to participants not receiving messages and driving a long distance in inclement weather, just to find that there is no group being held! Therefore we recommend against a policy of simply calling participants when last‐minute cancellations are necessary. Question: How is hoarding different from just collecting things? Answer: We love to open this question to the group, and find that the group is often able to answer this question through discussion. We emphasize the following:



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Collecting

Hoarding/Problematic Clutter

Items that most people would agree has monetary or sentimental value Items do not impair one from using rooms of the home or items in the home in the way that they were intended Not distressing Items are usually organized and cared for

Others tend to see the items as having little to no value Items impair use of the home, furniture, or appliances in the way that they were intended (e.g., the stove is not usable because it is covered in items; a room is not enterable) Others or the hoarding individual themselves are often distressed by aspects of the clutter Items are usually disorganized and neglected

Question: Do I have to bring in items? Every session? Answer: Yes! You will get the most benefit from the treatment if you bring in your own items to practice the skills with. As we mentioned, we will not make you discard any possessions, and we will not make decisions for you, but we will encourage you to use techniques learned in the class as you make decisions about your possessions. As mentioned in the treatment contact, we view completion of homework as essential to your success in the class; bringing in items is another piece of the h­omework. The most important part of this treatment is practicing the skills you learn while attempting to sort and discard your own possessions. Question: I have many a­ntiques/collectibles that are worth money. I’m not going to just give these away. Answer: Of course you may have some items in your home that are legitimately worth money and that you may consider selling. We don’t expect you to give away everything. We just want you to be careful to ensure that you are not spending so much time and effort on selling any item that it outweighs the amount of money that you receive in return! We have often seen individuals put much time and effort into selling an item – finding an appropriate place to sell it, researching the prices, p­osting it/making an ad or listing, and/or meeting with potential buyers. Once you add up such time, it often is just not worth it. We generally take the philosophy of “don’t sell it,” as we so rarely find that it is worth the effort. However, we will talk in a later class about limits to set if you truly want to sell items; for example, setting a time limit for how long you are willing to have the item be “for sale” before you give up.

Chapter 2

Why Do I Have So Much Stuff?

1. Homework Review (20 minutes) 2. Rewards (20 minutes) Individual Rewards Class Task: Brainstorm Rewards Class Rewards 3. Meet the “Bad Guys” (20 minutes) Decision‐Making and Problem Solving Intense Emotions Unhelpful Thinking Waxing and Waning Motivation Class Task: Identifying Your “Bad Guys” 4. Setting Goals (20 minutes) Class Task: Setting SMART Goals 5. Homework (10 minutes) In/Out Logs

57 58 58 59 59 60 61 62 62 63 64 66 67 68 68

Overview The session begins with a review of homework completed since the last session. All participants are then asked to share the “before” photos they took of their home. A portion of this session is dedicated to sharing photos that each participant took of his or her home. Often this may require a computer or a projector, if available, to share CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.



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digital photos. If a projector or computer is not available, participants can be asked to show the photos on their device. We have had participants share photos on their cameras, phones, or tablet computers, or simply share developed or printed photos. To ensure that participants did not simply take photos of “problem areas” or clear areas, ask participants to take photos of all areas of the home in order to assess churning throughout the course of the group (i.e., while a room may appear to have been cleared at post‐treatment, it is possible that objects have simply been shifted to another area of the home). During the photo sharing, participants should be encouraged to describe areas that they would like to improve upon. Group leaders should give genuine feedback about the severity of the clutter and areas that may need to be targeted as a priority. Obvious safety risks should be addressed first (e.g., a blocked entrance or papers piled near a stove). After safety risks are addressed, participants are asked to select an area or two that they will focus their efforts on. Ideally, this should be an area or room that, once decluttered, will result in a notable increase in functioning. For example, decluttering a kitchen or living room tends to have more impact than storage areas or guest rooms that are not frequently used. In this session participants are encouraged to begin to use rewards for accomplishing personal discarding goals. They are asked to begin to create their own reward systems, and are informed about the group reward system that the class uses. Group participants are introduced to the reward systems that are emphasized across the course of the group. There are two reward systems: one that emphasizes regular self‐initiated rewards for accomplishing personal goals, and a second group reward that the entire group works toward. This second reward is earned when the group completes a satisfactory amount of discarding homework. We find that participants tend to underutilize self‐driven reward systems as a motivator for behavioral goals. Participants often set high goals in the absence of rewards, expect change rapidly, and then feel discouraged when they are unable to complete these goals at a fast pace. Reward systems therefore encourage breaking larger goals down into more achievable goals and giving oneself a reward to provide a short‐term incentive for taking steps toward a long‐term goal. Participants are then informed about the four “bad guys” that create the framework of the class didactics. They are educated about each of the “bad guys” and how they may play a role in difficulties decluttering. Participants are asked to do a brief self‐assessment to think about the degree to which each of the “bad guys” might be in play for them. The session ends with a discussion of how to create SMART goals. Participants will be asked to create a SMART goal at the end of each session from this session forward.

Rationale Having homework review as the initial exercise in each session reiterates the importance of regular homework completion, and helps add accountability for homework completion. It also allows group leaders to gauge the group’s understanding of

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previously learned content, and to briefly problem solve any issues that may be b­arriers to homework completion. The first group‐based goal is met when 75% of SMART goals are achieved for 6 weeks or more; the second is met when the same target is achieved after an additional 6 weeks. Group leaders are free to change the reward as necessary, depending on resources and what may motivate that particular group. The group‐based goal is designed to enhance encouragement and accountability among group members. In  conducting this group within our clinic, we have not found that the group‐based goal has led to participants feeling too pressured or ostracized by the group. Participants are then introduced to the four “bad guys” of hoarding disorder. In developing this treatment, we sought to identify the main problems that maintain hoarding disorder and target these issues with simplified content. We found that the themes of strong emotions, negative cognitions, difficulty decision‐­ making and problem solving, and waxing and waning motivation were recurring issues that seemed to characterize the core pathology of HD. However, we acknowledge that participants may vary in the degree to which each of these “bad guys” is present for them. Therefore, the manual contains brief education about how all of these e­ lements may contribute to hoarding, and then in later sessions encourages participants to self‐assess how much each “bad guy” may interfere for them. With the introduction of each “bad guy”, it is important to give several examples. For instance, with the intense emotions “bad guy”, do not assume that participants will be able to identify, describe, and label emotions. The manual offers several examples and then asks participants to consider if these examples apply to them, or if group members can offer additional examples. Group leaders can use this opportunity to help participants practice identifying and labeling their experience. Participants are taught how to set short‐term (i.e., weekly) goals that are well operationalized and relevant. We have received feedback from prior groups that setting of these goals each week was one of the most helpful aspects of the group. Setting goals gives participants practice in creating goals that are nonsubjective and measurable. In negotiating these goals with the clinicians, they learn what is feasible in the course of a week, yet are encouraged to challenge themselves. Finally, participants are shown how to use the In/Out Logs and are informed that they are expected to complete these logs for the rest of the class. The In/Out Logs are a crucial part of treatment and serve several functions. First, they help participants become more aware of items that are going in and out of the home. We find that participants often do not pay attention to many items they collect and simply bring items such as paperwork, receipts, pens/pencils, gifts, extra groceries, etc., into the home on autopilot. We often find that participants will return In/Out Logs with nothing in the “in” column and we will then make comments such as “What about mail? Receipts? Paperwork?” It is nearly impossible to go a day without acquiring something, even if one does not leave the home! Encourage participants to be honest and aware with their logs.



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The logs also help the clinicians to be aware of where participants may be struggling. For some participants the logs may indicate much difficulty with excessive acquisition, for others, with decision‐making. For example, if a participant reports that he or she is spending several hours each week sorting and discarding, but few items are listed in the “out” column, feedback can be given to this person about the discrepancy and possible barriers to effective decision‐making can be addressed. Finally, the logs also help with tracking progress across the course of the group. Ideally, participants should show increased amounts going out each week on the logs, within the same or less amount of time. The goal of the treatment is  to help participants make more efficient discarding decisions; therefore p­articipants should ideally improve in their rate of discarding across the course of the group.

1.  Homework Review As we mentioned in the last class, homework is a very important part of treatment. Research shows that if you do the homework you’re very likely to get a lot out of the program, and if you don’t do the homework, you’re very unlikely to get a lot out of the program. So we want to stress again that doing homework is extremely important. For this reason, we will spend time each week talking about your homework.

CLASS TASK: Homework Review Clinicians should ask everyone to take out their homework review form to review whether assigned homework from session 1 was completed. This is also a good opportunity to discuss any problems or questions that class members had regarding the homework. Go around the room, quickly having each member of the group answer whether they completed the assignments below. Encourage participants to keep their answer brief, or in yes/no format, but group members should be enthusiastically praised for homework completed. We will now go around the class and ask whether each person completed their homework tasks. The homework tasks from last week are outlined below. 1. 2. 3. 4. 5.

Reread information from week 1 (including Rita’s story). Take “before” photos of ALL main areas of your home. Complete the “What Has Hoarding Taken From Me?” worksheet. Other: ______________________________________________________ Other: ______________________________________________________

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On your “What Has Hoarding Taken From Me?” worksheets that you were assigned to complete this week as homework, did any of you think of any additional motivators for working on your problem right now? We discussed this a bit last week, but we would like to hear any additional reasons you have for working on decluttering right now. Please turn in your “What Has Hoarding Taken From Me?” worksheets now. Have all of you either brought with you or sent us “before” photos of your home? If not, please bring them next time. We will follow up with you then. For those of you who have them today, let’s spend some time now sharing your photos with the group. Please tell us about the rooms of your home and what you would like to change in those rooms.

2. Rewards Individual Rewards We believe that rewards are an important part of helping people to maintain motivation in treatment. Each week we will review your goals to see if you are meeting them. We encourage you to reward yourself for meeting your goals! It can be difficult to keep up decluttering behaviors. Decluttering can be emotional, time consuming, and/or boring. Sometimes it can be hard to see progress. Therefore, by rewarding yourself you can help keep yourself motivated. At the end of your workbook, you will find a sheet to record your weekly goals and your self‐reward for completing this goal – it is called the Reward Monitoring Sheet. Each week as part of the homework review we will discuss as a group whether you met your homework/discarding goal. Each time you meet your goal you will place a check on the reward chart. This is an easy way to keep track of the homework that you have completed. Now, you might be thinking that this seems a little silly or even childish. After all, a lot of people use reward charts like this for their children, or for students in school. But we want to emphasize that we don’t think of rewards as silly or childish at all. Whenever someone has a personal goal – whether it’s to quit smoking, to lose weight, or to declutter their homes – they are much more likely to stick with the program when they can give themselves small rewards along the way. That’s true for kids, adults, even your class leaders. We all need encouragement when we’re doing something that’s hard. When you obtain a check we want you to reward yourself with a pleasant thing that you don’t normally do. This may be something like: ●● ●● ●● ●● ●●

Going to a movie Going on a day trip somewhere special Having a nice dinner Watching your favorite TV show Visiting a friend



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CLASS TASK: Brainstorm Rewards As a class let’s come up with some pleasant things that you might like to do. If a group member mentions something that you think would interest you, write it on your worksheets on page 17. If group members list material items or unhealthy behaviors (e.g., excessive eating, spending, substance use) as rewards, encourage them to c­onsider more healthy pleasant activities as rewards. It is often helpful to write down all responses on a dry‐erase board or similar so that the group can see all responses. Solicit both small rewards for small tasks or steps and larger rewards for achieving bigger goals. Participants often struggle with this task, and often mention that they give themselves these rewards anyway. The group leader may want to discuss how intrinsically rewarding behaviors that the group members engage in regularly (e.g., watching TV, seeing friends, calling a family member, reading a book) can be arranged so that they are contingent upon completion of a task. You may find that it is difficult to think of ways to reward yourself. We often find that people indulge themselves in small ways, but this is not the same thing as rewarding yourself for completing a challenging task! For example, when people allow themselves some of the rewards listed on the board without “earning” them, they tend to not enjoy them as much, and tend to be less motivated to do the difficult tasks. For instance, watching television all day, thinking to yourself, “I should be decluttering,” and feeling guilty can be quite different from a guilt‐free reward of your favorite TV show after a productive decluttering session. So these rewards will only be helpful to you if they are entirely dependent on your decluttering work – if you do the work, you get the reward, but if you don’t do the work, you don’t get the reward.

Class Rewards In addition to the individual reward system, each group member will also contribute to a group reward. In order for the group to get a reward point, 75% of the group need to have completed their SMART goals (we will talk more about SMART goals later today). When there are 6 points, the entire class will be provided with: ______________________________________________________________ ______________________________________________________________ Once the first reward is received the reward will then reset and you will work toward a second reward. You will need another 6 points to reach this reward. The second reward will be: ______________________________________________________________ ______________________________________________________________

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We have found from our past groups that most group members enjoy these rewards and we have found that working as a group toward rewards helps to keep motivation high. For us, the first reward is a free movie ticket and the second reward is an end‐of‐ class party, which typically includes eating pizza (check with class members for dietary restrictions and preferences) and providing participants with certificates of group completion. Clinicians may want to use alternative non‐material rewards, depending on the availability of resources. Small non‐material rewards (e.g., movie tickets, pizza at the end of treatment) can also be solicited from local agencies willing to make a charitable donation. Now let’s learn more about why clutter is a problem for you.

3.  Meet the “Bad Guys” As we mentioned briefly in the last class, we know from past research that p­eople with hoarding disorder tend to have problems in one or more of the f­ollowing areas: 1. 2. 3. 4.

Decision‐making and problem solving Intense emotions Unhelpful thinking Waxing and waning motivation

Difficulties in these four areas lead to difficulties in discarding. This is shown in the diagram on page 18 of your workbook.

Decision-making and problem solving

Intense emotions

Unhelpful thinking

Acquiring and difficulty discarding

Motivation



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Everyone is different and the extent to which these issues are significant for each group member will vary. It is important to identify which of the above issues is a problem for you. This way you will know what to focus most on in the treatment. To help you identify your own symptoms we have provided some further information below and we will help you to figure out how each of these aspects of clutter is relevant for you over the coming classes. Reinforce to the class that nearly all participants in the group struggle with all four of these dimensions, although the extent to which they can be problematic can vary. Also remind participants that these dimensions are not independent – they often interact! For example, unhelpful thinking can lead to negative emotions, which can lead to low motivation, and so on.

Decision‐Making and Problem Solving There is a lot of research to show that people with hoarding disorder tend to have some difficulties in the areas of: ●● ●● ●● ●●

Problem solving Decision‐making Organizing Maintaining attention and focus

Disorganization and difficulties with problem solving and decision‐making often lead to both acquiring and difficulty discarding. For example, with regard to acquiring: ●●

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●●

People leave the house without a plan about what to buy (which results in buying other unneeded items). People focus on the positive aspects of the object without considering other r­elevant factors (e.g., focusing on the sale price of an item and ignoring that they don’t need the item at all). People buy something that they already have but can’t find because of the clutter.

We have seen in our past experience with people with hoarding disorder that when they try to discard, their problems with disorganization and difficulties with  problem solving and decision‐making often get in the way. Often people get distracted by other things and tend to just shuffle through items rather than discarding items. They often do things like: ●● ●● ●●

Have difficulties making decisions about what item to start with. Tell stories about the item rather than making decisions about where the item belongs. Tend to get distracted by other things in the box, rather than focusing on the item in their hand.

62 ●● ●● ●●

●●

CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide Tend to become involved in other people’s belongings instead of their own. Jump from one section to another, never making any progress in one area of discarding. Move items from pile to pile without actually removing them from the home (i.e., “churning”). Spend excessive amounts of time making decisions about possessions.

An important part of the class is to teach you skills to become better at solving p­roblems, making decisions, and organizing things.

Intense Emotions Emotions are a normal part of life. However, all emotions can become problematic when we let them influence our behavior in a way that is not helpful to us. Individuals with hoarding disorder tend to collect belongings because it makes some kind of emotional distress less severe. Similarly, people with hoarding disorder avoid throwing things away because they know it will cause some kind of bad feeling or emotion – so they avoid throwing things away to avoid the bad feeling. Individuals with hoarding disorder tend to collect things to reduce feelings of: ●● ●● ●● ●● ●● ●●

Anxiety Sadness Anger Loneliness Grief Guilt

People with hoarding disorder also tend to have difficulty discarding because of these same intense emotions. While it may seem like we are all familiar with these emotions, we often do not know when we are experiencing these feelings, or we may not be good at identifying our emotions. Group participants often say, “If I throw this away, I would just feel bad!” They are often unsure of how to describe the feeling, and fear what it will be like. A big part of this class is learning skills to help you identify your emotions better, and cope with intense emotions in more adaptive ways.

Unhelpful Thinking Unhelpful thinking is one of the four big things that may get in the way of decluttering. Unhelpful thinking consists of those negative thoughts we have when we try to discard something or when we try to resist acquiring something.



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Those negative thoughts can really lead us to feeling bad. We have known for a long time that the way we think about things determines how we feel about them. For example, imagine that a family member offered to help you with clearing your home. You may think about this in a number of different ways. If you thought: “She’s always judging me.” You might feel: Angry, irritated, sad If you thought: “Maybe she won’t come around anymore if I don’t clean up the house.” You might feel: Anxious If you thought: “I’ll never be able to get through all this stuff.” You might feel: Sad, frustrated If you thought: “What a great help that might be. I could get through things much faster with some help.” You might feel: Hopeful, excited, happy So even in the same situation a person can have different thoughts about it which leads to a different emotional response. That’s because the way we think about the situation, not the situation itself, determines how we feel about it. The good news is that we can practice thinking in ways that lead us to feeling better. The group leader may wish to briefly discuss with group members how changing one’s thinking style does not simply mean thinking more positively, and that thinking overly positively can be detrimental as well. Emphasize how when we are anxious or in a depressed mood we often “see things through negative glasses,” and that the idea of practicing new thinking is to begin to think more realistically, without jumping to conclusions or exaggerating. A big part of this class is learning skills to help you reduce the unhelpful thoughts that might get in the way.

Waxing and Waning Motivation People with hoarding disorder tend to have trouble maintaining motivation to sort and discard their belongings. Often we see that motivation goes up and down over the 16 sessions of the group. However, we have found that motivation tends to be lowest around mid‐way through the group through the end of the group. This may be because class members have done so much hard work already, and they may be feeling fatigued or discouraged. Therefore the modules designed to enhance motivation are incorporated later on in treatment. While most participants who enter our groups do so voluntarily and verbalize a high degree of motivation for treatment, it is recognized that decluttering classes at

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other treatment settings may include participants who have a significant amount of external motivators or coercion for treatment (e.g., ultimatums of family members, eviction threats). Therefore it is certainly likely that some participants may also be of lower motivation at the outset of treatment. In these cases, class leaders may wish to briefly solicit and discuss the participant’s personal reasons for change right now, validating that externally imposed goals can often serve as effective motivators as well. While some participants in the group may be highly ambivalent about treatment (this may actually be the norm rather than the exception), it is assumed that all participants in the class are beginning treatment with at least a moderate amount of motivation to decrease clutter and/or acquisition. People with hoarding disorder tend to have trouble maintaining motivation to sort and discard their belongings. Often we see that motivation goes up and down over the 16 sessions of the class. Therefore, another important part of this class is to help you to improve your motivation for sorting and discarding. Now you have met all the “bad guys”. In the coming weeks, we will begin to recognize these “bad guys” more and more, and use tools to stop them from bullying us around. We hope that you have already learned more about why you have a lot of clutter in your home. We will cover the following topics over the remaining class lessons.

Week 3

Making Decisions and Solving Problems: Part 1

Week 4

Making Decisions and Solving Problems: Part 2

Week 5

Intense Emotions: Part 1

Week 6

Intense Emotions: Part 2

Week 7

Unhelpful Thinking: Part 1

Week 8

Unhelpful Thinking: Part 2

Week 9

Waxing and Waning Motivation: Part 1

Week 10

Waxing and Waning Motivation: Part 2

Week 11

Putting It All Together: Part 1

Week 12

Putting It All Together: Part 2

Week 13

Putting It All Together: Part 3

Week 14

Putting It All Together: Part 4

Week 15

Staying Clutter Free in the Future: Part 1

Week 16

Staying Clutter Free in the Future: Part 2

CLASS TASK: Identifying Your “Bad Guys” In this class task we would like you to start to understand how much each of the “bad guys” impacts your own hoarding behavior. Rate how much you think each of these “bad guys” is impacting your acquiring and difficulty discarding below.



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Decision‐making and problem solving Acquiring: How much do you think problems with decision‐making and problem solving are getting in the way and are affecting your acquiring? How much do you notice that you are unable to weigh up the pros and cons and think through your decision when you want to acquire an item? 0

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0 = Not a problem for me 10 = A very big problem for me Discarding: How much do you think that problems with making decisions and problem solving are getting in the way of your discarding? How much do you notice that you want to sift through your belongings rather than focus on one particular item and make a decision about it? How much do you notice your mind wandering, rather than making a decision about the item? Are you changing your mind back and forth about whether or not you should keep the object? 0

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0 = Not a problem for me 10 = A very big problem for me Intense emotions Acquiring: What kinds of emotions are you feeling when you acquire something? Interested? Excited? What kinds of emotions do you think you will experience if you don’t obtain this object? Guilty? Sad? Bored? How much are these intense emotions contributing to your acquiring behavior? 0

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0 = Not a problem for me 10 = A very big problem for me Discarding: What kinds of emotions are you feeling when you are discarding? What emotions do you think you will feel after you discard an object? Sadness? Grief? Anger? Frustration? Anxiety? Guilt? How much are these emotions getting in the way of you being able to discard as much as you would like to? 0

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0 = Not a problem for me 10 = A very big problem for me Unhelpful thinking Acquiring: When you are faced with a situation where you want to acquire, what is going through your mind? How much are you experiencing unhelpful thoughts? Are

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you thinking that you might have a good use for the item? Are you thinking that you shouldn’t pass up such a great deal? 0

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0 = Not a problem for me 10 = A very big problem for me Discarding: When you are discarding, what is going through your mind? How much are you experiencing unhelpful thoughts? Are you thinking the item will be useful? Or that you’re being wasteful? Or that you could give the item to a friend? 0

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0 = Not a problem for me 10 = A very big problem for me Waxing and waning motivation Acquiring: How much do you think low motivation is getting in the way of you resisting acquiring? In other words, are you feeling like you don’t want to work on your clutter problem right now? 0 1 2 3 4 5 6 7 8 9 10 0 = Not a problem for me 10 = A very big problem for me Discarding: How much do you think low motivation is getting in the way of you discarding? In other words, are you feeling unmotivated to work on your discarding right now? Or are you thinking that maybe your clutter isn’t such a big problem after all? 0

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0 = Not a problem for me 10 = A very big problem for me We will rerate the “bad guys” after we have practiced skills to work on each of them. Now, let’s begin to work on your program for change! The first important part of making change is to set goals. Let’s learn more about this now.

4.  Setting Goals In trying to achieve any big task, it is important to have goals! Setting personal goals and working toward them is a huge part of reducing your clutter. Part of what we will practice doing today is to set some improvement goals for you. However, simply setting a goal for ourselves is not enough – we often set goals



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that are too broad or unrealistic. Therefore, in the group we will practice setting goals that are what we call SMART goals: S M A R T

Specific Measurable Attainable Relevant Time limited

For example, a goal of “Get the entire house uncluttered and spotless by the end of the group” is not attainable. A goal of “Get the house uncluttered enough to make me happy” is not specific. Here are some examples of SMART goals: ●● ●● ●●

Discard five inches of paperwork this week. Take two bags of clothing to goodwill every week. Throw away five magazines each day.

A helpful tip to keep in mind is that you should be at least 80% sure that you can reach your goal…if not, you may have designed a goal that is too difficult! Ideally, we want your goal to be challenging but doable.

CLASS TASK: Setting SMART Goals Take a moment now to think about your long‐term SMART goals. What do you want to achieve in the course of this group? Take a minute to write down some long‐term goals in the blanks on page 25 of your workbooks. Each week you will be asked to set a short‐term SMART goal as part of your homework. These goals should follow the SMART formula and should involve some quantity of discarding. These SMART goals can work toward the longer‐term goals you wrote above. This goal should be focused on decreasing the clutter in your home. Remember that completion of this goal will lead to both personal rewards and group rewards. We recommend spending at least 30 minutes per day working on your discarding; however, more time is generally better. Ask class members to write a personal goal for the week on their homework page (page 26) of their workbooks. Ask class members to voluntarily share their personal goals for the week. Lead the group in a discussion on whether the goals are SMART goals. If they are not SMART goals, have the group aid the participant(s) in developing a goal that is specific, measurable, attainable, relevant, and time limited. Participants can also be asked about their intended rewards for completion of their weekly SMART goals.

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5. Homework Outline to participants the homework for the week: 1. 2. 3. 4. 5. 6.

Reread information from week 2 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring items from home to class next week. Other: _________________________________________________________ Remember that people who do the most homework tend to have the best outcomes, and you get what you put into the program. As a reminder, we recommend spending at least 1 hour a day working through your homework; part of this will be the 30 minutes each day you spend sorting and discarding. Does everyone feel pretty confident they will be able to do the homework?

Group leaders should help participants problem solve any difficulties they anticipate in completing the homework this week.

In/Out Logs Describe to group members how to use the In/Out Logs. Inform them that they need to list all items that are brought into or out of their possession. On the In/Out Logs, please write all things that come into and out of your possession. We will have you complete these records throughout the course of the group. Some people have reported to us that they have found it most helpful to carry the logs with them, or leave them on a table or in another prominent area, so that they remember to do them. Please do not write down an item until it has actually left your possession! If it is in a pile to be discarded it does not count until it actually leaves your home. If you have other people in your home you do not need to be concerned with what they are acquiring or discarding, unless you make decisions for them (e.g., small children). Oftentimes, we will receive In/Out Logs that have nothing in the “In” column. While we definitely want your acquiring to be at a minimum, having consistently blank acquire columns is impossible! You gather many things in the course of a day: receipts, paperwork, mail, groceries, and other objects. There should never be a truly blank acquire column – or at least very rarely! We will use the In/Out Logs for many purposes. This helps us get a sense of the progress that you are making outside the group. We also find that it is helpful in increasing awareness of what items you are acquiring and discarding. In addition, it helps us get a sense of your efficiency in making decisions and moving objects out of your home. We often find that people are spending excessive time in these activities. We also hope to see that you are engaging in the 30 minutes per day of sorting and discarding.



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Sample Answers to Common Questions Question: Why would I reward myself for completing decluttering tasks? I feel like it’s something I should be doing anyway. OR: Having less clutter is reward enough; that’s all I need as far as rewards go. Answer: We love rewards for hard work and we encourage you to use them. It is not only a way of helping to maintain motivation, it is also a way of treating yourself kindly! Also, we find that people tend to feel less depressed when they have activities that give them a sense of achievement. While we totally agree that decluttering can be a reward in and of itself, sometimes it can be hard to see progress even when you are working hard. As we mentioned in the previous session, substantial reductions in clutter can take a long time to achieve, and often take regular work to get there. Therefore we would like you to reward yourself along the way! However, in order for a reward to help you most effectively, you should only give it to yourself after you have achieved the task you set out to achieve. It does not have to be a big task, nor a big reward. It is also most helpful if you give it to yourself right after you complete the task you set out to do. Question: What if I’m not motivated at all for treatment/to work on reducing clutter right now? In fact, the only reason I’m here is because [my family made me come, my landlord threatened to evict me, etc.]. I don’t even think my clutter is a problem. Answer: Ideally, this is an issue that would have been addressed prior to the p­articipant entering the decluttering class as we recommend only including those participants in the class who have at least moderate motivation to change. Often, participants will initially voice motivation for treatment. However, when these individuals are confronted with the demands of the group and the motivation and progress of other group members, they may become either passively or overtly resistant to treatment recommendations. This can be evidenced in many forms, such as noncompletion of homework, repeated expressions of skepticism or dislike of treatment techniques, or excessive defensiveness during the session (e.g., excessively defending why they are keeping objects). This is certainly not to say that these issues (e.g., homework noncompletion or defensiveness) necessarily signal a lack of motivation for treatment, but we have found that these issues can be vehicles by which participants may demonstrate that they are unwilling to use treatment techniques at this point in time. Throughout the treatment, if the readiness, willingness, or ability of a participant to benefit from the treatment is in question, class leaders are encouraged to have a brief meeting with that individual to discuss what has been observed and to decide if the participant feels that he or she will benefit from the group. Because the class moves rapidly, requires much work, and requires supporting other individuals in the process of discarding, if participants are truly unmotivated for treatment and are simply taking part in the class to forestall action against them or their property, we discourage them from attending the group at this point in time. As with most

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behaviors, trying to convince an unwilling person to change is a losing battle, even when the consequences appear acute and severe to outsiders (e.g., eviction, removal of at‐risk children). Participants such as this may be provided with general psychotherapy referrals or case management referrals that may be better able to process insight and/or motivation concerns. Question: I work all day/have many obligations/have a busy week. What if I can’t find an hour a day to do my homework? Answer: We understand that you are very busy people and that finding time to do the homework can be difficult. However, we can almost always find time for things that are priorities for us. It is important to ask yourself, “Is decluttering a priority for me right now?” If it is, then it deserves some of your time, at least half an hour per day. We encourage you to use scheduling of decluttering activities and treatment homework, as this tends to help people do these tasks more easily. Making them a habit can be really helpful, for example, doing the activities at the same time each day. This way you are unlikely to forget the activity and are likely to “factor in” time to complete the tasks. We often hear comments such as “Life got in the way!” We know that this tends to happen and that demands can sneak up on us. For this reason, we encourage you to reduce distractions as much as possible – turn off your phone, TV, or other distractors. When things are important to us, we find time for them. Imagine if a loved one was hurt and ended up in the hospital. My guess is that you would find time to see them, possibly dropping everything! You made time for what was important. Most likely, you also attend doctor, dentist, or other appointments, despite a busy life. How are you able to do this? You schedule it and make it a priority. Decluttering tasks can be managed the same way. Make “an appointment” with decluttering – literally. Pencil it in your schedule, and treat it as time dedicated to your priority, decluttering. While we recommend at least half an hour a day, especially because behaviors are more likely to become a “habit” when they are repeated frequently, some participants simply cannot manage this. Some of you may wish to complete decluttering sessions in massed sessions, like for several hours on a weekend. If you find that this is more effective for you, go ahead! However, if you set out to do this and it is not helpful, please try scheduling more regular sessions.

Chapter 3

Making Decisions and Solving Problems Part 1

1. Homework Review (15 minutes) 2. Making Decisions and Solving Problems (10 minutes) 3. Making Decisions and Minimizing Distractions (20 minutes) Guidelines for Discarding Class Task: Making Your Own Guidelines Scheduling the Time to Work on Discarding Class Task: Identifying the Best Time for Discarding and Planning Your Day 4. Making Decisions and Improving Organization (20 minutes) How Much is Too Much? Class Task: Identifying if I Have Too Much Stuff Where Do Things Belong? Class Task: Make Your Own Categories 5. Putting Skills Together to Discard Better (10 minutes) Follow the Flowchart for Discarding Class Task: Using the Flowchart to Help with Discarding 6. Homework (15 minutes)

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Overview The session begins with a review of homework and an assessment of whether a point has been earned toward the group reward. The group then reviews the 10 “guidelines for discarding,” such as using the OHIO (Only Handle it Once) method, and CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.

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getting items out of the house as soon as possible. Participants are asked to create their own guidelines for sorting and discarding, to help minimize the amount of time spent making decisions and emotional distress related to decision‐making. The group discusses “how much is too much,” taking common categories of clutter, such as books, shoes, or dishes, and discussing how many of these items are reasonable to own. The group also discusses common locations for categories of items, and p­articipants are asked to create a “map” of these categories of items in their home, so that they are able to find items when needed. Participants are then encouraged to schedule daily time to sort and discard. They are instructed in how to do so and practice doing so in session with a weekly calendar in the participant workbook (or using their own calendars). Finally, the group ends with practice discarding, categorizing, and organizing, using a flow chart to facilitate application of skills. As participants sort through objects brought to session, if they keep an item they are requested to identify where the item belongs in their home, and whether there is space in the intended location to accommodate this item. As usual, both sessions end with a review of homework assigned, and by the setting of weekly SMART goals.

Minimizing Distractions In the Guidelines for Discarding section, participants are given some information that relates to how to discard effectively. Several of these rules focus on managing attentional issues specific to HD. Participants are encouraged to focus on decluttering one area at a time, and to use the OHIO method to minimize churning. At the beginning of the group, participants often report that they are shifting from room to room, becoming distracted by other possessions or tasks. The idea of focusing efforts on one area is designed to help participants limit distractions, along with being able to see progress more readily, thereby increasing the reinforcement value of decluttering. To further minimize distraction, participants are encouraged to schedule times for sorting and discarding, using a written calendar or planner. They are encouraged to begin sorting and discarding at least 30 minutes per day, or the equivalent (e.g., several hours on a weekend). Sorting and discarding each day is encouraged whenever possible, to get participants in the habit of setting aside time for discarding. This scheduled time is viewed as “an appointment” with discarding, and therefore participants are encouraged to minimize all other distractions, possibly by turning off their phone or television. Participants are encouraged to schedule discarding at a time when they are likely to be most focused – typically not late at night or first thing in the morning. Scheduling daily times for discarding tends to be one of the tasks that group members find the most difficult to implement regularly. There is often much resistance to the suggestion of scheduling, with participants stating that they “don’t live by a schedule,” or that other unpredictable demands interfere with



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adhering to the schedule. In the former case, we remind participants part of the problem may be exactly that: they are not living their lives on a schedule, and therefore procrastinating, not prioritizing, and/or not making sufficient time to sort and discard. They are encouraged, as with all group activities, to try scheduling for a while before deciding that it is not helpful. The latter group is again encouraged to treat the selected discarding time as a non‐negotiable appointment. Remind them that they are usually capable of keeping up with other responsibilities, such as doctor’s appointments. They can treat their selected time for discarding as an appointment too – sometimes this means telling friends and family that they are not available, or asking family members for privacy during this time.

Increasing Efficient Categorizing of Possessions In this session, participants are given a list of possible ways to categorize belongings, and are asked to practice identifying a limited number of categories for their possessions. They are also asked to name the intended home for a particular category of possessions, for example, where a class of items, such as kitchen utensils, should belong. Participants in our groups have often self‐reported difficulty with knowing where possessions should be placed, and how to categorize them. Participants are also asked to practice in‐session discarding using their categorization system to identify a final home for each object they decide to keep. Practicing this skill with personal possessions brought from home is emphasized as individuals with HD tend to display categorization difficulties mainly in the context of personal possessions (Wincze et al., 2007). Initial discarding exercises are also likely to foster a sense of self‐efficacy when done well. Therefore, in the initial exercises in which participants are asked to discard items, participants should be encouraged for any progress discarding, regardless of whether they find the items they chose to discard easy or difficult to discard. As the group proceeds, participants should be asked to bring in various types of items to ensure they are generalizing their skills. They should also be encouraged to bring in items that they consider more difficult to discard as the group continues.

1.  Homework Review CLASS TASK: Homework Review Use the list below to review with participants whether they have completed the assigned homework for last week and check whether at least 75% of the group have completed their SMART goal for the week.

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The homework tasks from last week were: 1. 2. 3. 4. 5. 6.

Reread information from week 2 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring items from home to class next week. Other: ______________________________________________________

In addition to reviewing the assignments listed above, review with participants their individual SMART goal that was set at the end of last week, asking whether this goal was completed. If not, when resetting SMART goals at the end of today’s session, group leaders may want to briefly problem solve completion of the goal.

Did at least 75% of the group complete their personal SMART goal this week?

❑ YES   ❑ NO

Review with participants how many points they have earned toward the group reward. Again, the group is awarded a point each time 75% or more of the homework is completed.

2.  Making Decisions and Solving Problems There are a number of ways that difficulties with decision‐making and problem solving can lead to problems discarding. We will talk about a few of them in this class – and you may find that some relate to you more than others. Some of the things that can get in the way when trying to discard include the following: ●● ●● ●● ●● ●●

Not knowing how much stuff is too much stuff to keep Not being able to find the time to discard Not knowing where things go Not having a system for discarding Not knowing how to solve problems that come up when discarding

In this class we will learn skills to address each of these obstacles. We know that not all of these issues will apply to all people in the group, but we ask you to give each of these skills a try before focusing on the ones that are most relevant for you.



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3.  Making Decisions and Minimizing Distractions To help you learn how to minimize distractions we will introduce two specific skills: ●● ●●

Guidelines for discarding Scheduling time for discarding

Let’s begin with the guidelines for discarding. These start on page 32 of your workbooks.

Guidelines for Discarding Often people with hoarding disorder tell us that they are not exactly sure how to go about discarding. For this reason we developed 10 rules or guidelines to help you with your sorting and discarding. These guidelines will help you to get the most out of your sorting and discarding sessions. 1. Take regular photos so that you can see your progress.  Often people forget what their home first looked like before they started the class, so they forget or don’t see the good work they are doing. A lot of people have mentioned in our past classes that it has been helpful for them to take photos of each room as they work through the class so that they can look back through the photos and see all the positive changes that they have made. 2. OHIO – Only Handle It Once.  When you are working your way through your belongings it is important that once you have made a decision on something, you stick to it. Also, if you pick something up, you make a decision about it immediately – you can’t put it back down and say, “I’ll deal with this later.” For example, if something goes in the recycling, then it stays in the recycling. Or if you pick up an important magazine, then you make a decision about the important magazine immediately. Using the OHIO rule (Only Handle It Once) will help you get through the greatest amount of your belongings as possible and help you to learn how to make decisions about things more effectively. 3. Get it out of the house.  Often when people decide to donate or recycle an  item they will forget to take it to the final location (e.g., a charity or the recycling depot). An important rule for effective discarding is to remove these items from your home as soon as possible. It may be helpful to schedule some time through the week to drop off your donation or recycling items. The nice thing about using boxes, rather than piles, is that the box has a built‐in signal. When no more will fit in the box, stop and move the box to where it goes.

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4. Work on the same area.  When people are working on their sorting and discarding, they often move between different areas of their house – for example working in the kitchen one day then the garage the next day, then the patio the day after that. Rather than spending 30 minutes each day on a different area of your house, we recommend that you focus on the one area until that is clear. This will allow you to see the progress that you are making and will help to boost motivation. 5. Choose a highly visible area.  When you are choosing the area to work on it is important that you choose a highly visible area in your home (such as a main room or hallway) rather than choosing an area of your home that you will rarely see (like inside a closet). Working on these sorts of areas will help  you to see your progress, and again, this will provide you with extra motivation. 6. Don’t churn.  When you have picked the area that you are going to work on it is important that you spend the full 30 minutes actually working on sorting and discarding items in your home rather than just picking things up and putting them down on a different pile to decide later what to do with them. We call this “churning.” We want you to pick up the first thing you see and make a decision about it quickly. 7. Throw it away (especially if it is damaged).  People with hoarding disorder frequently say that they prefer to donate items than to throw them in the trash. Often donating items makes people feel less intense emotions than throwing them away. However, donating means that you have an extra step when you are discarding (going to goodwill or the second‐hand store) and can be an extra hurdle that you don’t need. For this reason it is often preferable to throw items in the trash rather than trying to donate them. If your item is damaged in any way – stained, has holes in it, or is not working properly – then it is best just to throw it away rather than trying to give it to someone else or donate it. Many donation sites also do not accept or will discard nonworking or damaged items, so save yourself the time and effort. 8. Be your own cheerleader and reward yourself for good work.  Often people with hoarding disorder are their own worst critic. As we talked about before, thinking unhelpful thoughts leads to negative emotions. We want you to be your own cheerleader – be as kind to yourself as you would to someone else in the same situation. Would you tell someone else in the group that there is no point, so stop trying? No – so don’t do it to yourself! Make sure you give yourself the kind of encouragement that you would give to another group member. We have also talked a lot about using rewards in the declutter class. When you are discarding it is important that you reward yourself and give yourself a  pat on the back when you are doing a lot of discarding. We know it is difficult!



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9. Schedule discarding sessions.  It is important that you schedule time into your day to practice sorting and discarding. If you do not schedule this time into your day, you may find that all the other things you need to do in the day get done, but you have not practiced your sorting and discarding. Scheduling the time allows you to make sure everything gets done. We will learn more about scheduling later in this class. 10. The 12‐month rule.  A lot of people have found it helpful to have a 12‐month rule. This means that if you haven’t used the item in the past 12 months, get rid of it.

CLASS TASK: Making Your Own Guidelines These are the 10 guidelines that we have found to be most helpful for other people with hoarding disorder. Everyone is different, though, and you may have some other rules that are relevant for you. On page 34 of your workbook, please list any additional rules you can think of that might help you know what to discard and when. We will then share some of them with the group – because you may find that other people have the need for the same rule. Some examples of rules that participants have used in the past include: ●● ●● ●●

Discard three items before getting any new item Discard the old one before I get a new one Get rid of it if it no longer fits me

Remember that just because you can use something doesn’t mean that that’s a good reason to keep it. For example, could I use 300 pens, or 300 coffee mugs? Certainly! I could use a different one each day. However, that doesn’t mean that I need 300 pens or coffee mugs, or that I have space for such things. Just a few will suffice! One phrase we often find can be quite dangerous is “stock up:” often when you want to “stock up,” it can be a sign that you might be tempted to excessively acquire. Another potentially dangerous phrase we will be on the lookout for is “just in case.” Therefore, keeping something simply because it is “usable” is not a helpful rationale. Rather than looking at whether it can be used, think about whether you WILL use it in the near future, and whether it is among your top possessions. Remember that as part of this group you will be required to part with objects that you want to keep – there is no way around it. You cannot save everything for the future and have a decluttered home – these things are quite incompatible. Therefore we want to practice making sure that you prioritize keeping only the objects that are most valuable to you that you are confident you will use in the near future. One way to approach this is to think about where you want your ideal home to be. Imagine your ideally decluttered home for a moment. How decluttered is it? How

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much of your possessions would you have to remove from your home to get it to that point? A third? Half? If you would need to reduce your items by half, keep in mind that each possession you keep should be in the top 50% of all of your possessions. If you need to reduce your items by two thirds in order to have an ideally cleared home, then keep in mind that all possessions you keep should be in the top third of your possessions. Therefore simply wanting an item or thinking it may be useful is not a reason to keep it – it must be among your top possessions.

Scheduling the Time to Work on Discarding We know from our past classes that people who spend the most time on sorting and discarding are the people who tend to be doing the best at the end of the class. But we also realize that people are busy and may not know where to schedule time in their busy day to work on their discarding. As part of your homework you have been asked to work on discarding for 30 minutes per day (or 3.5 hours a week). Many of you may like to work on discarding for more than that and that’s great, but we recommend 30 minutes per day at a minimum. You may also find it helpful to set a number of items to discard in each sorting and discarding session – this will make it less likely for you to just churn during sorting and discarding. In order to figure out the best time to discard we recommend that you: 1. Find the best time for you.  Some people like to work on their discarding first thing in the morning to get it out of the way. However, other people say that they like to do their discarding at another time of the day. We recommend that you think about the things you do regularly through the day (such as watching your favorite night‐time show) and agree that you will do that only after you have completed your discarding homework. 2. Pick a time of the day when there are minimal distractions.  It’s best to work on your sorting and discarding when you won’t be distracted by other people. For example, a time of day when your children or spouse are not home would be preferable. Remember that you have the power to reduce distractions by turning off the phone ringer, the television, etc. You also can add things that will help keep you motivated or relaxed, such as your favorite music. 3. Break down your scheduled discarding sessions to multiple, shorter sessions, if the thought of sorting and discarding for 30 minutes is too overwhelming.  We recommend that you dedicate at least 30 minutes daily, preferably an hour, to sorting and discarding in order for your treatment to be successful. If this seems impossible, schedule three (or more) 10‐minute sessions each day. You  also can use this strategy on days when you are feeling ­overwhelmed or unmotivated to sort/discard for 30 minutes in one sitting. You may want to set a timer for 10 minutes and sort/discard until the timer goes off. Over time, you can gradually increase your sorting/discarding time with this strategy.



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4. Pencil it in.  Use a calendar or daily planner in order to help you schedule the best time for discarding for you. Once you schedule in a time, stick to it. Don’t put it off. An important way to find time to work on discarding is to schedule your day so that you make sure you have factored your discarding around your other commitments. We will talk more about this later, but in order for you to make the most out of the class, sorting and discarding need to be your main priority. As we have talked about before, using small rewards can give you an important boost in motivation.

CLASS TASK: Identifying the Best Time for Discarding and Planning Your Day Let’s practice making a plan and finding the best time to practice. To do this, ask yourself the following questions, writing down your answers on page 40 of your workbooks. 1. What is the time of the day when you are most motivated? ________________ 2. What time of the day do you have least distractions? ____________________ 3. What works for you? One 30‐minute block or three 10‐minute sessions? __________ Now, use this information to schedule sorting and discarding sessions in your daily planner. If you do not have a planner, you can use the calendar we have made for you on page 38. Use your planner or the calendar to schedule your day for tomorrow so that you are able to fit in all your commitments, including your sorting and discarding. If you need an idea of what this should look like, there is a completed example for you on page 36. We recommend that you schedule your day, particularly your discarding time, in advance. On page 36 of the participant workbook is a completed calendar/activity chart with each hour of the day scheduled out. Participants are also provided with a blank copy of this chart on page 38 (there is an example on page 80 of this manual). We often find that there can be a great deal of resistance to scheduling times for sorting and discarding, and therefore we like to solicit feedback from group participants with questions such as: How do you feel about the prospect of scheduling time for sorting and discarding? How confident do you feel you can follow the schedule? What barriers might come up? How will you deal with these when they arise? How can you minimize these barriers? As with all group skills, we encourage participants to try the skill thoroughly before deciding it does not work for them. We remind them that there is often much reluctance to schedule, but that we ask group members to do it because we know it is helpful.

Monday 5 am–6 am 6 am–7 am 7 am–8 am 8 am–9 am 9 am–10 am 10 am–11 am 11 am–12 pm 12 pm–1 pm 1 pm–2 pm 2 pm–3 pm 3 pm–4 pm 4 pm–5 pm 5 pm–6 pm 6 pm–7 pm 7 pm–8 pm 8 pm–9 pm 9 pm–10 pm 10 pm–11 pm 11 pm–12 am 12 am–1 am 1 am–2 am 2 am–3 am

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday



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4.  Making Decisions and Improving Organization How Much is Too Much? People in our past classes have often indicated that they are not sure how much is too much to keep of certain items. For instance, how many old newspapers should someone keep? How many years of receipts should someone hold on to? How many sweaters should someone own? How many tote bags should someone have? How many couches should someone have in their house? While understanding how much is too much is based on many factors (such as how much space and money someone has), coming up with some general rules can also be helpful.

CLASS TASK: Identifying if I Have Too Much Stuff The first thing to do is to list the things that you often have too much of in your home. Be specific here (i.e., instead of “furniture” indicate the type of furniture – “sofa,” “bed,” “chairs,” etc.). Then as a group we will decide how much is too much of that item. Please take a moment now to write down the categories of items that are problematic for you. Once group members have inventoried categories that are relevant for them, solicit the group for some common categories. Then go around the room asking each participant to briefly state how much they think is appropriate to have. Remind participants NOT to answer how many they actually have, but rather how many they think are appropriate or needed. To save time and discourage negative judgments, encourage participants to answer briefly, providing just a number (and not a rationale for the number). Example: Items

How much is reasonable?

Newspaper

3 papers

Item: 1. 2. 3. 4. 5. 6.

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 7.  8.  9. 10.

Once the group has taken a few minutes to complete the table in their workbooks, go around the room having each group member share at least one category they wrote down. For each category, survey everyone in the group as to what they think a reasonable amount of that type of item would be. Remind participants periodically that you are not asking how much of that item they have, but rather what they think a reasonable amount would be to own at any one time. We often include group leaders in this survey as well, and encourage group leaders and participants to be honest with opinions. We like to put the survey results in table format on the board so that participants can see the collected information. An example is given below. Christina

Scott

Liz

Gretchen

Blaise

William

Newspapers

5

2

1

3

2

2

Pairs of shoes

6

10

50

20

35

10

50

40

500

35

50

60

Dish sets

3

1

2

1

1

1

Plastic grocery bags

5

10

50

0

10

0

Books

After completing the table, review with participants some of the conclusions made from the gathered data. Is there an average or general consensus about how much is too much? If no, what is the range? Are there outliers?

Where Do Things Belong? Often when things have been in the wrong place for a long time people forget where things actually go. It is important that all items in your home have a place so that you can find them and know where to put them when you have made more progress with clearing your home. Some common categories and locations for possessions are outlined below. Categories

Where it belongs

Mail and miscellaneous paper

File cabinets, drawers in office

Magazines

Shelves

Photos

Drawers, boxes, photo albums

Newspapers

Recycle box



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Categories

Where it belongs

Clothing

Drawers in bedroom, closets, laundry basket

Coats

Closets, clothes rack in bedroom

Boots and shoes

Closets, shoe rack in bedroom

Books

Bookshelves

Audio and videotapes

Shelves, drawers

Souvenirs and knick‐knacks

Display cabinets, drawers

Decorative items

On display

Office supplies

Desk drawer, shelf, top of desk in office area

Games

Shelves, cabinets

Hardware

Basement, garage, kitchen drawer

Furniture

Placed in appropriate room

Empty containers

Cupboards, basement, garage

Food

Refrigerator, cupboard, pantry

Kitchen utensils

Drawers, containers in kitchen

Pots, pans, and dishes

Cupboards, on hooks in kitchen

Linens

Dining room/bathroom cabinet, linen closet

Toiletries

Bathroom shelves, cabinets or drawers

Cleaning products

Kitchen, bath or laundry cabinet

Cleaning tools (e.g., broom, mop)

Closet, garage or basement

Garden and yard tools

Garage, basement

Recreation equipment

Garage, basement, attic, closet

Paint and equipment

Garage, basement

Pet food and equipment

Closet, cupboard

Handicrafts

Cabinet, shelf, basement

CLASS TASK: Make Your Own Categories If you have a lot of belongings that don’t fall into these categories then you will need to come up with some of your own. Discuss as a group the stuff that you have and where in your home  belongs.

Categories

Where it belongs

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Categories

Where it belongs

5.  Putting Skills Together to Discard Better Follow the Flowchart for Discarding It can also be useful to follow a flowchart to help you see what you need to do with your belongings. This flowchart provides the basics on how to discard. Over the coming weeks you will learn more skills to help you discard. Step 1: Select an item from your belongings to work on Step 2: Make a decision about whether to discard the item or not ●●

●●

If you choose to discard the item, then you need to figure out which box it belongs in (trash, recycle, or donation). Well done for making this decision. If you choose to keep the item, you need to figure out where it belongs (use the categories worksheet from this class to help you decide). You then need to move it to the appropriate location in your home. If space is available, place the item where it belongs. If it isn’t, then you need to make a choice about whether you keep the item or not.

Use the flowchart to help you make decisions about this. Select item Make decision Have I used it in the past 12 months? • Is it worn or damaged? • Do I have too many of these? • Do I have room for it? • Do I want it more then I want a clear house? •

Discard

Keep

• Trash (place in trash) • Recycle (place in recycle) • Donate (put in donation pile)

Where does it belong? (Use categories worksheet)

Is there space available?

Yes

No



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CLASS TASK: Using the Flowchart to Help with Discarding As a group spend some time working through the discarding flowchart, using the possessions you brought from home. Participants should practice sorting through their possessions from home, using the flowchart to guide them in making decisions. Group leaders can observe and encourage participants to think out loud to ensure that participants are using the chart in a productive way and naming appropriate locations for possessions that are kept.

6. Homework Outline the homework for this week: 1. 2. 3. 4. 5. 6.

Reread information from week 3 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day (or equivalent). Complete weekly SMART goal. Bring items from home to class next week. Other: ______________________________________________________

Have each participant share their SMART goal for the week with class to ensure that the group agrees that the goal meets the SMART guidelines. Participants can write their weekly SMART goal and anticipated reward on page 45 of their participant workbooks.

Chapter 4

Making Decisions and Solving Problems Part 2

1. Homework Review (10 minutes) 2. Making Decisions: Acquiring (20 minutes) Understanding High‐Risk Situations Class Task: Identifying High-Risk Situations Understanding Healthy vs. Unhealthy Acquiring Class Task: Identifying Common Unhealthy Reasons for Acquiring Guidelines for Acquiring 3. Solving Problems (20 minutes) Class Task: Identifying Problems That Maintain My Clutter Problem Learning How to Solve Problems Class Task: Practice Problem Solving 4. Discarding Practice (20 minutes) 5. “Bad Guy” Re‐evaluation (10 minutes) 6. Homework (10 minutes)

87 88 88 89 90 91 91 92 93 93 95 96 96 97

Overview In Chapter  4, participants are educated about common high‐risk triggers for acquiring, such as sales, mood states, or certain stores. Participants are asked to inventory their own personal high‐risk situations in order to increase awareness of acquiring in these situations. Participants are encouraged to avoid high‐risk settings when possible. Participants are then instructed about common “healthy” and “unhealthy” reasons for acquiring. CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.



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Participants then review the 10 “guidelines to reduce excessive acquiring,” similar to the guidelines for discarding in Chapter 3. Participants are asked to create their own rules for nonacquiring and to write their most important rules on a reminder card which they are instructed to carry with them at all times, if possible. Participants are led through a model of problem solving. They are first asked to practice identifying problems, brainstorm solutions, then evaluate pros, cons, and results of inventoried solutions. Participants are asked to practice the problem‐solving model in session with a problem they perceive to be a barrier to decluttering or reducing acquiring. Similar to Chapter 3, Chapter 4 contains practice with in‐session discarding using the discard or keep flowchart. Participants are asked to identify a final home for all objects that are kept.

1.  Homework Review CLASS TASK: Homework Review Use the list below to review with participants whether they have completed the assigned homework for last week. 1. 2. 3. 4. 5. 6.

Reread information from week 3 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day (or equivalent). Complete weekly SMART goal. Bring items from home to class next week. Other: ________________________________________________________

In addition to reviewing the assignments listed above, review with participants their individual SMART goal that was set at the end of last week, asking whether this goal was completed. If not, when resetting SMART goals at the end of today’s session, group leaders may want to briefly problem solve completion of the goal. Review with participants how many points they have earned toward the group reward. Again, the group is awarded a point each time 75% or more of the group completes their SMART goal. Did at least 75% of the group complete their personal SMART goal this week?

❑ YES   ❑ NO

Have all participants turn in their In/Out Logs from last week. Now let’s learn more about how problems with being focused can cause you to acquire.

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2.  Making Decisions: Acquiring Many people with hoarding disorder tend to have difficulty with skills like ­organization, problem solving, and decision‐making. There are many ways that problems with these skills can contribute to acquiring. In this lesson we will learn some practical skills to help you improve your ability to resist acquiring. The first thing we will learn about is how to recognize high‐risk situations for acquiring.

Understanding High‐Risk Situations When people are trying to reduce any unhelpful behavior (such as acquiring or reducing smoking or drinking), one of the most helpful initial steps is to avoid high‐ risk situations. High‐risk situations can be both internal (an emotional state like feeling sad) or external (people/places/things). Some of the more common internal high‐risk triggers include emotion states or moods like: ●● ●● ●● ●● ●●

Feeling lonely Feeling sad Feeling worried Feeling happy Feeling bored

Some of the more common external high‐risk triggers include the following. People ●● Shopping with a particular person ●● Seeing a person who often likes to give you gifts or things to take home ●● Family members who also have problems with hoarding disorder Places ●● Dollar stores ●● Supermarkets ●● Thrift stores/second‐hand stores ●● Tag sales/garage sales ●● Art/craft stores ●● Internet shopping ●● TV shopping channel/catalogs



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Situations Sales ●● Gifts from others ●●

Things ●● Newspapers ●● Art/craft supplies ●● Books ●● Food ●● Clothing ●● Carrying a credit card ●● Carrying more cash than you need ●● Browsing in any store without a clear plan or budget ●● Free items

CLASS TASK: Identifying High-Risk Situations Ask class members to think about things they tend to acquire. Ask the following questions, having participants list their responses in their workbooks on pages 51–52. What are some of the high‐risk emotions that lead to acquiring? What are some of the high‐risk stores/places where you tend to acquire? What are some of the high‐risk items that are difficult to walk away from? Once participants have identified their common triggers: Can you share some of your biggest triggers with the group? The first step in reducing acquiring is stimulus control. Just as individuals with  substance use disorders are encouraged to avoid high‐risk triggers to using (e.g., avoid going to bars, liquor stores, hanging out with others who use substances), group participants are encouraged to develop a plan to avoid their triggers to acquiring. The next step is to begin to avoid these triggers. If you avoid locations you might acquire in the first place, you avoid what could possibly be a lengthy or uncomfortable discarding decision later. Are you willing to begin to avoid some of these situations? What is your plan for avoiding them? For example, can you drive a different way home? Can you ask others to not give you things? Can you cancel your paper subscription so that you are not tempted by coupons and sales? Ask participants to share their personal plans for avoiding their primary triggers, having the group aid with suggestions when necessary. Encourage participants to

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start these plans today. It may be helpful for participants to identify alternative activities/behaviors to their triggers. For example, if a participant identifies going to tag sales on Saturday mornings as a major trigger to acquiring, the participant should identify an alternative activity for Saturday mornings (e.g., go for a hike, go to breakfast with a friend).

Understanding Healthy vs. Unhealthy Acquiring Group leaders may wish to remind participants that individuals with clutter problems tend to have much difficulty making decisions. Having concrete rules for acquiring (e.g., knowing what to acquire, when, and how much) can make the decision process much simpler and less agonizing. However, participants may not know what “typical” or healthy rules for acquiring are. Therefore, it is good to review some examples of normative reasons for acquiring such as the ones below. An important part of overcoming acquiring is to understand the reasons for it and  to distinguish “healthy” from “unhealthy” buying and acquiring. Typical healthy and unhealthy reasons for buying or acquiring various items are outlined below. Healthy reasons I have run out of the product at home. ●● I have an immediate need for the item (i.e., it will be used in the next day or week at the latest). ●● It will be used to feed me and my family (again, typically within a week). ●● To replace something that is worn out or broken. ●● I had planned to buy it before going to the store (it was on my shopping list). ●●

Unhealthy reasons ●● Because I am feeling one of the intense emotions and I want it to go away. ●● Because it’s on sale. ●● Because it’s free. ●● Because it’s visually attractive. ●● To please or impress other people. ●● I could use it later (i.e., not “I need it,” or “I will use it in the near future”). ●● I’ll regret not getting it later. Participants will often be engaging in excessive amounts of shopping, engaging in shopping on a daily or near‐daily basis. Shopping frequency is often discernible from In/Out Logs that are turned in each week. If this is a common problem in the group, group leaders may also wish to use the group to brainstorm ways of reducing shopping trips while keeping acquiring to a minimum.



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CLASS TASK: Identifying Common Unhealthy Reasons for Acquiring Have group members browse items from the virtual store, selecting an item they are tempted to acquire. If they are unable to find an item they are tempted by, have them think of a recent item that they were unable to resist acquiring. List your reasons for acquiring this item on page 53 of your workbooks. Are they healthy or unhealthy reasons? Discuss your thoughts with the group. To address the difficulties in decision making and problem solving that lead to acquiring, we will teach you some practical tips that you can use to help you resist acquiring when you leave your home. The first thing to do is to remember the 10 rules for not acquiring, which we will talk about in just a moment. It might be helpful to put these rules somewhere visible so that you are always reminded of them. The next thing to think about is whether you can begin to avoid some of these situations. How? Can you, for example, remove yourself from mailing lists, cancel subscriptions, or drive a different way home? Tell someone to stop giving you things? If positive emotions are a trigger for you, can you get these positive emotions in other ways? Now let’s learn about some simple rules that you can follow to help you to reduce your acquiring.

Guidelines for Acquiring In order to help you to reduce your acquiring we have come up with 10 simple guidelines. A lot of people from our previous classes have said that sticking to these guidelines or rules really helped them to significantly reduce or eliminate their acquiring. 10 rules to reduce excessive acquiring 1. Ditch the credit card.  At an absolute minimum, you should leave your credit card at home when you go shopping. Ideally, we recommend that you cut up the credit card, give it to a trusted friend, or call the bank to freeze it. 2. Avoid high‐risk areas/people/things.  Avoid the places/people/things that would normally mean you would acquire items when at all possible. Shop infrequently and only to get what you need. Never browse, and don’t enter stores just to kill time or to see what’s there. 3. Only acquire for “healthy” reasons.  Only acquire items for the healthy reasons that we talked about – never for “unhealthy” reasons. 4. Have a budget.  Make a budget (i.e., make a list of the things you need based on the healthy r­easons for acquiring) and only take the cash you need to buy

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those items when entering high‐risk areas. Do not carry any more cash than you need for the items you plan to buy. 5. Use a list.  Always use a shopping list when you leave the house and don’t acquire anything that isn’t on the list. 6. Don’t use a shopping cart.  Don’t use shopping carts unless at the grocery store (to reduce your tendency to buy extra things). 7. Use the closest entrance/exit.  Use the entrance/exit nearest to the store or department that you need to buy an item from (so that you don’t have to walk past other items that you would normally want to acquire). 8. 24‐hour rule.  If you see something you want, but it isn’t on your list, you must wait 24 hours to buy it – this will give you an opportunity to think about whether you really need it. 9. Ride the wave of your emotions.  Instead of buying to reduce unhelpful emotions, let emotions decline on their own. All emotions, even the strongest ones, will decrease with time, but only if you let them pass without trying to fight them off. 10. Cancel subscriptions.  Cancel subscriptions to newspapers and magazines and other materials that come to your home on a regular basis. At this point, group leaders can pass out the laminated reminder card that lists these rules for nonacquiring. On the back of this card is a space for participants to write their own rules for nonacquiring. Encourage them to do so, and to make these rules very concrete to limit the amount of decision‐making that needs to  be done for each one. Participants should be able to look at their rules for ­discarding and know whether an item should be obtained or not. Some sample rules are: ●● ●● ●●

Only purchase if I get rid of the old one first Only purchase if I will use it in the next week Only obtain if I do not already have one

3.  Solving Problems We often see that people with hoarding disorder have difficulty solving many problems in their lives. Some common problems that relate to acquiring include: ●● ●● ●●

●●

Acquiring things as gifts from friends and family Difficulties refusing pamphlets or free things Acquiring things because they might come in handy one day or might be worth money someday Acquiring things because you or someone else might be able to use it someday



Making Decisions and Solving Problems: Part 2 ●● ●● ●● ●● ●●

●●

●●

●●

93

Acquiring things that are not in the budget Acquiring things that there is no room for Getting excessive mail Acquiring things just because they are on sale or appear to be a good deal Obtaining more object(s) in order to solve a bigger problem, e.g., “I can’t sort these papers until I have files and a file cabinet.” Acquiring things to be generous to others, or showing love by purchasing or acquiring for others Acquiring excessive information/paperwork because you may read/use it someday Acquiring more of an object because you can’t find it in your home

Some common problems that can arise for people with hoarding disorder that relate to discarding include: ●●

●● ●● ●● ●● ●● ●● ●●

A lot of my belongings were given to me by a family member who has now passed I want to have a garage sale but I don’t know how/haven’t gotten around to it I want to donate items rather than throw them away I don’t know how to ask people for help with my discarding How can I move desired clothes to my closet when it’s already full? How can I get my fridge fixed when the kitchen is cluttered? My family members have problems with clutter too I have a physical disability, poverty, or some other obstacle that makes me unable to discard

CLASS TASK: Identifying Problems That Maintain My Clutter Problem On page 55 of the participant workbooks, ask group members to list some of the problems (mentioned above or other) that c­ontribute to their difficulties with acquiring.

Learning How to Solve Problems Effective problem solving is an important skill for everyone to learn. When we can solve problems we feel less overwhelmed by them. Learning effective problem solving is a skill like anything else and it will take time to practice. The examples that we talk  about in this class will be specific to decluttering  –  but you can use these

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problem‐s­olving skills for any problem that occurs in your life (both related and unrelated to clutter). There are three important steps in learning how to problem solve: ●● ●● ●●

Step 1: Name the problem Step 2: Brainstorm solutions and consider the pros and cons of each solution Step 3: Select preferred solution(s)

We talked about some of the common problems that contribute to acquiring earlier in this class. Now we are going to practice using the three steps of problem solving to overcome these problems. Let’s practice with a common example first. One of the most common problems that relates to acquiring is when people give you gifts or free items because they know you like that kind of thing. Sometimes our family members also have problems with hoarding disorder and they give us items when they are trying to clear their own homes. Let’s practice problem solving using this example. Step 1: Name the problem We want to try to be as specific as we can when we identify the problem and define it in behavioral terms (your behavior). For instance, “I have too much stuff ” is not specific enough, whereas “I take too many items from other people” is more specific. Example problem: I take too many items from other people Step 2: Brainstorm solutions and consider the pros and cons of each solution At this step we want to try to come up with as many possible solutions to the problem as we can. They don’t have to be good solutions or even realistic ones at this stage – we just want to come up with a list of options. You may also like to ask trusted friends, family members, or your class leaders about other possibilities. 1. Stop talking to the person that is giving me the stuff ●● Pros: I won’t acquire as much stuff ●● Cons: I will be reducing my social circle even further 2. Tell them that the stuff is causing a problem for me and ask them politely to stop giving me items ●● Pros: It may stop the giving, and we can maintain our friendship ●● Cons: They will know I have a problem with clutter or may be hurt that I asked them to stop 3. Yell at them and tell them they are trying to sabotage my efforts ●● Pros: I won’t get any more stuff ●● Cons: They may no longer want to talk to me and I will reduce my social circle even further 4. Throw all the stuff in the trash can after they give it to me ●● Pros: I can get rid of it quickly ●● Cons: It is hard for me to throw anything in the trash



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5. Give the stuff to someone else ●● Pros: I will get rid of the thing ●● Cons: It is time consuming to figure out who to give it to and I may just be contributing to someone else’s problem – plus I have plenty of my own stuff to get rid of 6. Donate the stuff ●● Pros: I get rid of the item ●● Cons: It is time consuming and I have other important things to spend my time on like getting rid of my own stuff Step 3: Select preferred solution(s) From the list of solutions, and after considering the pros and cons of each, it is important to choose the best option. This may not be the perfect option, but it is the option with the least amount of cons. In some cases, you may be able to select more than one solution to try. In this example the preferred solution may be the second one: Tell them that the stuff is causing a problem for me and ask them politely to stop giving me items In order to find out if the problem solving worked you will first need to figure out how the outcome can be evaluated. In this example a good outcome might be the number of items that are acquired from other people within a 1‐month period. You will also need to figure out the steps required to implement your preferred option. In this example, if the person chose the second option they may like to role play the conversation with a trusted friend or family member before putting the solution into action. The final thing to do is to take action and then evaluate the result. At the end of the month (or week, or whatever timeframe you have set for yourself) you will need to evaluate the outcome. Has the problem been resolved? If the problem has been resolved, that’s great. But if it hasn’t, you may need to go back to Step 3 and add some more options or pick another solution.

CLASS TASK: Practice Problem Solving Choose one of the problems that contribute to acquiring that you wrote down on page 53 in your participant workbooks. Work on using the problem‐solving worksheet on page 58, which will walk you through the problem‐solving technique we just discussed. If group members are having difficulty coming up with examples, ask the group to suggest potential problems for them to practice the problem‐solving model with. Alternatively, if group leaders are aware of specific problems that may contribute to acquiring or discarding difficulties for a participant, they can ask the participant to consider working on that problem.

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4.  Discarding Practice The remaining time in the class is spent on in‐session discarding. Let’s take time now to practice some in‐session discarding with the items that you brought from home. You can practice using the skills you have already learned. You can use the discarding flowchart to help you remember how to do this. A copy of this flowchart is reprinted on page 59 of your workbooks. Select item Make decision Have I used it in the past 12 months? • Is it worn or damaged? • Do I have too many of these? • Do I have room for it? • Do I want it more then I want a clear house? •

Discard

Keep

• Trash (place in trash) • Recycle (place in recycle) • Donate (put in donation pile)

Where does it belong? (Use categories worksheet)

Is there space available?

Yes

No

5.  “Bad Guy” Re‐evaluation CLASS TASK: “Bad Guy” Re-evaluation Over the past two weeks we have talked about the decision making and problem solving “bad guy”, which interferes with our ability to solve problems and make decisions. Take some time to evaluate how much you think this “bad guy” is contributing to your acquiring behavior and difficulty discarding. On page 60 of your workbooks, you will see some scales, one for acquiring and one for discarding. On these scales, rate how much you think the decision making and problem solving “bad guy” has been hindering you over the past couple weeks. Rate on the scale of 0 (not a problem for me) to 10 (a very big problem for me). Acquiring: How much do you think problems with decision‐making and problem solving are getting in the way and are affecting your acquiring? How much do you



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notice that you are unable to weigh up the pros and cons and think through your decision when you are wanting to acquire an item? 0

1

2

3

4

5

6

7

8

9

10

0 = Not a problem for me 10 = A very big problem for me Discarding: How much do you think that problems with making decisions and problem solving are getting in the way of your discarding? How much do you notice that you want to sift through your belongings rather than focus on one particular item and make a decision about it? How much do you notice your mind wandering, rather than making a decision about the item? Are you changing your mind back and forth about whether or not you should keep the object? 0

1

2

3

4

5

6

7

8

9

10

0 = Not a problem for me 10 = A very big problem for me Now that you have rerated how much this “bad guy” continues to interfere for you, let’s check in. Did you find that this “bad guy” is bothering you less than when you started treatment? If no, have you been diligently practicing the skills from the past couple weeks (problem solving and making decisions)? What skills do you think you need to continue to practice?

6. Homework Remember that people who do the most homework do the best at the end of the class. We recommend spending at least 1 hour a day working through your homework. Remember that you should be practicing at least 30 minutes of discarding every day. Outline the homework for this week. 1. 2. 3. 4. 5. 6.

Reread information from week 4 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring items from home to class next week. Practice the problem‐solving worksheet with a different problem related to your clutter. 7. Other: ________________________________________________________ Have each participant report on the SMART goal they are setting for themselves that week, ensuring that the goal follows the SMART guidelines. Ask each participant what they intend to reward themselves with for completion of the goal. They can be encouraged to write down their goals and intended rewards on page 61 of their participant workbooks.

Chapter 5

Intense Emotions Part 1

1. Homework Review (15 minutes) 2. About Intense Emotions (30 minutes) Class Task: Class Discussion About Intense Emotions Class Task: Identifying the Intense Emotions That Lead to Clutter 3. Tackling Intense Emotions That Lead to Acquiring (30 minutes) Class Task: Identifying Negative Beliefs About Emotions 4. Homework (15 minutes)

99 100 101 102 104 105 106

Overview The intense emotion section begins with a focus on having participants practice identifying emotions that they experience while discarding and acquiring. Participants are given some brief psychoeducation about typical emotions that arise when discarding or acquiring. Participants are shown how catastrophic appraisals of emotional experience (e.g., “I can’t tolerate this,” “I will go crazy if I keep doing this”) may worsen negative emotions. Group members are encouraged to select and p­ractice positive self‐statements to use in lieu of these negative appraisals. This first chapter of the intense emotions section focuses on increasing awareness of emotional experience when discarding or acquiring. Participants may have low awareness of emotional variables that influence their decision‐making, or may have difficulty identifying specific emotions. They may report a vague sense of upset, or a fear of becoming upset, without being aware of nuances in emotional and cognitive experience. Identifying specific emotional experience can aid in identifying triggers, CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.



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implementing appropriate stimulus control, and beginning to practice distress t­olerance skills when necessary. Participants are encouraged to decatastrophize emotional experience by acknowledging that strong emotions are a normal human response that does not always need to be avoided. Negative emotions that arise while discarding are normalized and participants are encouraged to acknowledge and accept these emotions. In line with many acceptance‐based protocols (e.g., Hayes et  al., 1996), participants are encouraged to reduce resistance toward negative emotions. In this first chapter regarding strong emotions, participants are encouraged to “drop the struggle” cognitively by beginning to think of emotions as something that can be tolerated.

1.  Homework Review CLASS TASK: Homework Review As in former sessions, ask group participants to take out their homework review forms. Check in with group members as to  whether they have achieved their personal reward and the group reward for this week. The homework from last week was: 1. 2. 3. 4. 5. 6.

Reread information from week 4 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring items from home to class next week. Practice the problem‐solving worksheet with a different problem related to your clutter. 7. Other: ________________________________________________________ Also check in with the group to see how many participants completed their SMART goals. Did at least 75% of the group complete their personal SMART goal this week?

❑ YES   ❑ NO

Notify the group how many points they have achieved thus far toward the group reward (out of 4 potential points). Remind them that when the group has achieved 6 points they will receive a group reward. Have all participants turn in their homework from the last week.

100 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

2.  About Intense Emotions This section begins on page 64 of the participant workbook, if participants would like to follow along. Emotions are a normal part of life. We all experience many different emotions from time to time. Emotions can get in your way when they lead to unhelpful behaviors, such as acquiring things that we don’t need or can’t afford. For example, a person may acquire due to feelings of loneliness and may have trouble discarding due to anxiety. Or a person may acquire in order to reduce feelings of sadness but have d­ifficulty discarding due to feelings of grief. Other times, we ­experience positive e­motions when acquiring or saving (not discarding), such as excitement, interest, and joy. Emotions can be complex. Sometimes we can feel two or three different kinds of emotions at the same time. It is often helpful to inform group participants that emotions tend to be characterized by one‐word descriptors (while thoughts tend to be reflected in phrases/sentences). Group participants may initially volunteer descriptions of emotions that may be better characterized as thoughts. Group leaders may need to reiterate the difference between emotions and thoughts several times throughout the following exercises. It may be helpful to provide participants with a visual distinction between thoughts and feelings by listing thoughts and feelings reported by participants on a white board in different columns. For example, if a participant states, “Well, I’m worried that I’ll need it later and regret throwing it away,” the therapist can write “Worried” under the emotions column, and “What if I need it later? What if I regret throwing it away?” under the thoughts column. In addition, group members may have much difficulty identifying their emotions. When group members struggle with noticing or labeling emotions, it can be helpful to open the discussion to the group. The group members can be helpful in asking questions to help identify the emotion. It can be very hard to identify how emotions play a role in keeping clutter going. We often find that the intense emotions “bad guy” is at play when we do the following (on pages 65–66 of participant workbooks): ●● ●●

●●

●●

●●

We start to declutter and experience a negative emotion and stop. We think about decluttering, experience a negative emotion, and never get started. We start to declutter a specific area, experience a negative emotion, and decide to switch to a different area, jumping from one area to another, never really accomplishing anything. We start to declutter, experience a negative emotion, and end up “churning” – just making more piles of things rather than letting go of anything. We make excuses about why we can’t declutter, without even being aware that we are avoiding because of an intense emotion.



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CLASS TASK: Class Discussion About Intense Emotions Do you think any of these behaviors play a role in your clutter? Are there other ways that intense emotions keep you from decluttering? Emotions can be complex. Sometimes we can feel two or three different kinds of emotions at the same time. Sometimes it can be hard to describe our emotions. The first step in tackling intense emotions that lead to acquiring is to learn how to identify our emotions. This can be more difficult than it sounds. But by understanding what kind of emotions we experience when acquiring, we have a better chance of preventing unnecessary acquiring. Let’s practice together. You may think that you know your emotions, and are quite familiar with them! However, sometimes emotions can feel similar and we can have a hard time ­differentiating what is what. Sometimes we aren’t even aware that we’re having them. Therefore, the first step in dealing with emotions is recognizing them. Anxiety Anxiety is sometimes called fear. When people are anxious they tend to feel scared about something bad happening. When you feel anxious, you might notice that your heart rate speeds up, or that your breathing becomes shallow, or that you feel sweaty or clammy. Sadness Sadness that is very intense can be called depression. When people feel sad or depressed they often describe feeling down and blue. They often also feel tired or fatigued and feel like they have no motivation to do anything. Anger When people feel angry they tend to feel like they have been wronged in some way or some injustice has occurred. When people are angry they tend to feel changes in their body – they may feel hot like their blood is boiling, they often describe feeling tenseness in their muscles and describe clenching their fists or teeth. Loneliness When people feel lonely they often feel like they have no one to talk to or turn to. Grief When people experience grief it is often because they have lost someone or something that was very important to them. A person may have died or a relationship may have ended for other reasons. Excitement People may feel excitement when they are looking forward to something.

102 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide Joy We experience joy when we are thinking about or doing something we enjoy. Joy is also called happiness or contentment.

CLASS TASK: Identifying the Intense Emotions That Lead to Clutter Group leaders can lay out several “virtual store” items on the table or in an accessible area of the room. You will notice that the group leaders have set several items out in the center of the table. Please take a moment now to select an item that you might like to acquire if it were free. Ask participants to peruse the items and choose an object that they would like to acquire. Allow 1–2 minutes for participants to choose an object. If participants do not find an object that they are tempted to acquire, they can choose one of their own belongings from their box and answer the questions as if they were reacquiring that item. If they are attracted to the virtual store items but cannot choose an item after 1–2 minutes, ask them to quickly select an object for the exercise, reminding them they can revisit the objects later. Once everyone has selected an object: Now take a moment to handle the object that you were tempted to acquire in some way. Think about what draws you to the object and what you might feel if you left it behind. Then on the first table on page 67 of your workbooks, circle all the emotions that you are experiencing. As I look at/touch this object, I am feeling (circle as many that apply): Fearful

Angry

Sad

Joyful

Guilty

Anxious

Annoyed

Empty

Excited

Ashamed

Nervous

Frustrated

Lonely

Interested

Regretful

Worried

Irritated

Blue

Curious

Bored

Scared

Irked

Down

Happy

Overwhelmed

Other:

Are there other emotions not listed on here? Add them in the empty space. Often participants will have a hard time identifying what emotions may be motivating them to acquire or save objects. They often report no cognitive or emotional reaction, when it is clear that there is a strong emotional response. In these situations the group can be asked to help participants identify what emotions might be at play. It can also help to inform participants about how many times the emotion is being avoided via acquiring, and to ask, “What would happen if you did not acquire?” Participants often



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focus on the “high” that comes from acquiring, see this activity as pleasurable, and do not focus on the negative emotions that may be present if they did not acquire. Now let’s try this exercise again with discarding. Please quickly take out an item from the group of objects that you brought from home. Please consider discarding this item now. If it is easy for you to discard, discard it and grab another item until you find one that leads to some emotions as you think about discarding it. As you are handling your selected object, use the second table on page 67 of your workbooks to circle the emotions that you are experiencing. After you have practiced discarding for a while use the third table (on page 68 of your workbook) to indicate the e­motions that you experience after you discard the item. As I look at/touch this object and think about letting it go, I am feeling (circle as many that apply): Fearful

Angry

Sad

Joyful

Guilty

Anxious

Annoyed

Empty

Excited

Ashamed

Nervous

Frustrated

Lonely

Interested

Regretful

Worried

Irritated

Blue

Curious

Bored

Scared

Irked

Down

Happy

Overwhelmed

Others:

After I have discarded the object I am feeling (circle as many that apply): Fearful

Angry

Sad

Joyful

Guilty

Anxious

Annoyed

Empty

Excited

Ashamed

Nervous

Frustrated

Lonely

Interested

Regretful

Worried

Irritated

Blue

Curious

Bored

Scared

Irked

Down

Happy

Overwhelmed

Others:

Encourage participants to write in any emotions that are not listed in the above table, but ensure that they are emotional descriptors that are not better conceptualized as thoughts. Remind participants that the emotions that may contribute to acquiring and difficulty discarding can vary with the circumstances, including the type of object, mood state, and setting. However, handling a single object and using it as a specific example can be helpful in illustrating some of the emotion management techniques that follow. Now that you have been able to identify some of these emotions, let’s learn about how to manage them in better ways.

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3.  Tackling Intense Emotions That Lead to Acquiring This section starts on page 68 of participant workbooks, if participants would like to follow along. As mentioned earlier, emotions are a normal part of being human. We are not suggesting that you try to get rid of your emotions, or that negative emotions are not unpleasant sometimes. Instead, we want to learn how to handle intense emotions (positive or negative) so that they lead to helpful behaviors, rather than unhelpful behaviors, such as unnecessary acquiring. Often, we get in the habit of saying that a negative emotion caused our behavior. You might say, for example, “I tried walking away from that item but I felt really anxious, so I had to go back and buy it.” But here’s an alternative way to think about it: Your emotions do not control your actions. You always have control over what you decide to do, no matter what your emotion is. Emotions are harmless and natural. So the beliefs about emotions are the problem, not the emotions themselves. Group leaders can draw the following diagram on the board, first illustrating that when we are anxious or upset we often see this pathway as:

Emotion

Action

e.g., “I felt sad and bored”

“Therefore, I went shopping.”

However, when we think this way, we are omitting a large portion of the picture, which is how we are thinking about our emotions. Edit the diagram so that it illustrates the addition of thoughts about emotions as a mediating variable:

Emotion

e.g., “I felt sad and bored”

Negative beliefs about emotions

“I can’t stand feeling that way”

Action

“Therefore, I went shopping”

An emotion, in and of itself, is not intolerable, awful, or horribly uncomfortable. It is only intolerable, awful, or horribly uncomfortable if we view it that way, and we



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do not have to view it that way! Many people do not. These tend to be people who are higher in something called distress tolerance. When we have higher distress t­olerance we are less likely to fear strong emotions, and do not need to try to make them go away. Yes, negative emotions can be somewhat unpleasant. However, you do not always need to try to avoid them. Oftentimes, we create more distress when we try to avoid negative emotions, reduce them, or make them go away. We also create more distress with the negative ways that we view our emotions: by viewing them as scary/ dangerous, intolerable, unending, and so on. What kinds of beliefs do you have about: ●● ●● ●● ●●

Fear? Sadness? Anger? Happiness?

Did you find yourself thinking that some of these emotions are bad, and others good? Do some of them seem threatening or dangerous? Does it seem like you’re not s­upposed to feel some of them – or at least not too much? Emotions are just feelings; no more and no less. They’re important, and worth  paying attention to. But they are not rules, and they don’t have to be in charge.

CLASS TASK: Identifying Negative Beliefs About Emotions Review the following list of emotion‐related thoughts with group members, asking them to check off the ones that may apply to them. ●● ●● ●● ●● ●● ●● ●●

I can’t throw this away, I’ll regret it forever. If I don’t buy this item, I’ll be upset for the rest of the day. I won’t be able to cope with the sadness if I throw this away. I have to buy something in order to make myself feel better. Experiencing any negative emotion is bad. It’s important to make negative emotions go away as quickly as possible. I’ll go crazy if I keep feeling this way.

Do these types of beliefs about emotions play a role in your acquiring? Do you have any other beliefs about emotions that might be contributing to your acquiring?

106 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide What will happen or what does it mean if you experience these intense emotions? (Will you be harmed? Faint? Be embarrassed? Go crazy? Die? Feel awful forever? Feel like something’s wrong with you?) Ask participants to write down any additional thoughts about emotions on page 69 of their workbooks. One way to handle emotions more effectively is to view them in a different way. Rather than viewing emotions as unacceptable, intolerable, or permanent, here are some alternative ways of thinking about our emotions. We call these “coping statements.” These are listed next on page 69 of your workbooks. ●● ●● ●● ●● ●● ●● ●● ●● ●●

●●

Emotions are normal and OK – even negative ones. Everyone experiences negative emotions from time to time. Emotions might not feel good, but they won’t hurt me. Even intense emotions don’t last forever. I don’t have to act on my emotions. I can act on what’s important to me. I CAN throw things away, even if I’m afraid that I’ll regret it later. If I don’t buy this item, I might feel upset, but I CAN cope. I’ll feel sad for a little while if I throw this away, not forever. I don’t have to buy something in order to feel better. The bad feeling will go away on its own, or I can do something else to cope with the bad feeling. All emotions will pass with time.

Ask participants if they can think of any additional statements that can help them cope with intense emotions related to acquiring. Participants can write down these additional coping thoughts on page 69 of the participant workbooks.

4. Homework Review with class participants the homework tasks for this week and emphasize the importance of completing the homework. 1. 2. 3. 4. 5. 6.

Reread information from week 5 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring items from home to class next week. Other: ________________________________________________________ Remember that people who do the most homework do the best at the end of the class. We recommend spending at least 1 hour a day working through your homework tasks. Remember that you should be practicing at least 30 minutes of discarding every day.



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Have each participant report on the SMART goal they are setting for themselves that week, ensuring that the goal follows the SMART guidelines. Ask each participant what they intend to reward themselves with for completion of the goal. They can be encouraged to write down their goals and intended rewards on page 70 of their participant workbook.

Chapter 6

Intense Emotions Part 2

1. Homework Review (15 minutes) 109 2. Tackling Intense Emotions That Get in the Way of Discarding (50 minutes) 109 Accepting Our Emotions and Being Our Own Boss 109 111 Class Task: Being Your Own Boss: Acquiring Class Task: Being Your Own Boss: Discarding 112 113 Recognizing When Emotions Are Taking Over 3. “Bad Guy” Re‐evaluation (15 minutes) 114 4. Homework (15 minutes) 115

Overview In this second chapter about intense emotions, participants are encouraged to act on values despite emotions. This is referred to as “being your own boss.” Participants are encouraged to use mindfulness/acceptance techniques to identify emotions and accompanying thoughts, to observe these emotions nonjudgmentally, and to act on important values despite emotions. Participants are then taught mindfulness‐based skills to accept and tolerate intense negative emotions that may arise when discarding. Participants are educated about how trying to avoid emotions often backfires and leads to longer‐lasting distress.

CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.



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1.  Homework Review CLASS TASK: Homework Review As with prior sessions, review the homework list, checking in with participants as to how many of them were able to complete the tasks. Review each participant’s goals for the past week, asking whether they were able to achieve the SMART goal that was set at the end of last week’s session. If the SMART goal task was not achieved, group leaders may wish to review the task with the group, asking if the goal was too high, or possibly problem solving other barriers to homework completion. Encourage participants to reward themselves for successful completion of their SMART goals. The homework tasks from last week were: 1. 2. 3. 4. 5. 6.

Reread information from week 5 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring items from home to class next week. Other: ________________________________________________________

Check to see if 75% of class participants completed their SMART goals this week and remind the class that this contributes to the group reward. Did at least 75% of the group complete their personal SMART goal this week?

❑ YES   ❑ NO

Have all participants turn in their In/Out Logs from the last week. Now let’s learn more about dealing with intense emotions.

2.  Tackling Intense Emotions That Get in the Way of Discarding This section begins on page 74 of participant workbooks, if they would like to follow along.

Accepting Our Emotions and Being Our Own Boss Last week we talked a lot about intense emotions and how these intense emotions affect our acquiring and discarding. We also talked about how our beliefs about

110 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide intense emotions can lead to different behaviors. In this chapter we want to talk more about other ways to respond to emotions. Rather than acting on our emotions by acquiring or avoiding discarding, we suggest accepting our emotions instead. Let’s learn more about what this means. Learning to accept emotions involves three steps. Step 1: Just observe The first step in accepting our emotions is to observe and describe what we are experiencing. We don’t want to make judgments about our emotions, thoughts, sensations, or the situation. We simply want to notice, observe, and describe. In other words, the goal is to become aware of our emotions without trying to change them or get rid of them. This is probably quite different than what we normally do when we experience intense emotions (positive or negative), so it’ll take some practice. Step 2: Know what’s important to you: Be Your Own Boss The next step in handling intense emotions is to act in a way that is consistent with your values and goals, rather than allowing your emotions to be your boss. It’s very natural to be tempted to act based on our emotions. For example, when we are sad, we may have the urge to isolate ourselves and stay in bed. When we are feeling anxious, we have the urge to avoid whatever it is that makes us feel anxious, including discarding. When we are excited about an object, we may have the urge to acquire it. But if we act on these urges, who’s the boss? You or your emotions? In the last session, we learned about accepting our emotions rather than trying to get rid of them. We can do this by observing our emotions rather than judging them. That is, rather than viewing our emotions as something we need to change, the goal of accepting our emotions is to be OK with our feelings, even negative ones. A big part of accepting our emotions is to act in ways that are consistent with our goals and values, even if that’s the opposite of what we feel like doing – what we also call “being your own boss.” Acting on your emotions, even if that’s against your goals and values, is when you are letting “emotions be your boss.” Below are some examples of these two types of bosses for someone who has a SMART goal that involves decluttering their bedroom. ●●

My goals and values: to declutter my bedroom so I can relax in my room and sleep comfortably on my bed. Situation

Emotions as boss

Me as boss

Thinking about decluttering my bedroom

Don’t know where to start so I never get started

Make a step‐by‐step list of how to tackle the bedroom, breaking it into easier chunks

Trying to d­iscard s­entimental objects

Stop decluttering for the day

Practice “observing” my emotions, think of other ways to remember fond memories, then return to decluttering



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Situation

Emotions as boss

Me as boss

Decluttering the top of my bed so I can sleep on it

Switch to d­ecluttering a d­ifferent room

Set a timer for 10 minutes to allow myself a break when I get too frustrated; then return to decluttering the bed

Decluttering a pile of clothes I haven’t worn in years

Can’t decide what to keep so I just end up keeping everything

Practice “observing” my emotions. Focus on my goals, rather than keeping clothes just because of my anxiety

We will review your values more when we talk about motivation in a subsequent chapter. However, for now, please write down 2–3 important values and goals that motivate your decluttering right now. Do this in the worksheet on page 75 of your workbook. We will do more of this later, but for now, keep in mind this “bigger picture” of what motivates you. Step 3: Ride the wave The final and possibly the most difficult step is to act in line with your goals rather than your emotions. This means doing what is important to you, even if that means you will feel a negative e­motion (e.g., sad, anxious, regretful). We call our strategy “riding the wave.” Imagine a surfer on top of a wave. The wave is very powerful, yet the surfer is able to travel on top of it, rather than falling into it and being tossed around. Dealing with uncomfortable emotions can be a bit like surfing. Your emotions are powerful, and they can easily toss you around if you let them. But you can ride on top of your emotions. The trick is to tolerate your emotions, rather than try to struggle against them. When you stop trying to control or avoid your feelings, you’ll find that you can dedicate more energy and time to acting in a way that is consistent with your values. Riding the wave means being brave and doing what you need to do to achieve your goals. Emotions are like waves – they go up and down. Just like a surfer, once you ride the wave, a period of calm is often the result. Often people try to stop their negative emotion by acquiring or avoiding discarding things. But if they tried to resist, they would learn that the bad feeling goes away. They never learn that they can ride the wave – that they don’t have to acquire or keep an item to make the bad feeling go away.

CLASS TASK: Being Your Own Boss: Acquiring Group leaders should now lay out items to create the virtual store. Let’s practice using this technique when tempted to acquire. Select an item from the center of the table that you are tempted to acquire.

112 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide As you hold the object, practice being aware of your emotions. Describe the object, memories, and ideas associated with the object. Do this as many times as you can while you practice being your own boss. At this point, participants can write down their thoughts and emotions on page 77 of the participant workbooks. Participants can be asked to voluntarily share their responses, so that group leaders can ensure that participants are effectively observing emotional experience without making judgment. Next, let’s practice being your own boss, rather than your emotions being your boss. Use the worksheet on page 77 of your workbooks. You will see that there are three columns, one in which you simply describe and observe your emotion. Do this now. There is also a detailed example from a fictional person on page 77, if you feel like you need an example to follow. My goals and values: _______________________________________________ Describe and Observe

Emotion

Emotions as boss

Me as boss

CLASS TASK: Being Your Own Boss: Discarding Now let’s try with discarding. Pick a random item from your box of belongings and consider discarding it. As you hold the object, practice being aware of your emotions. Describe the object, memories, and ideas associated with the object. What are you feeling and thinking as you think about discarding this object? Fill out the table on page 78 of your workbooks to practice being your own boss with regards to discarding. Once you have filled out a row, decide whether you would like to keep that item or not. If no, please place it in the appropriate bin. We will lay out the bins for d­iscarding now. Once participants have completed at least one row of the worksheet, ensure that they have considered discarding their item. Continue with in‐session discarding practice for 5–10 minutes.



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Recognizing When Emotions Are Taking Over One of the biggest challenges of “being your own boss” is knowing when you are in charge and when you are not. Sometimes this can be obvious – there might be times when you know you are avoiding discarding because of a negative emotion. But it’s probably just as likely that you avoid discarding without knowing it! How often does this happen? When emotions are being the boss, we often see it typically in avoidance. People tend to avoid things that lead to strong emotions, but this is not a helpful coping strategy. It just prolongs the problem! However, we are not always good at recognizing when  we are avoiding because of strong emotions. If you find yourself thinking some of the following, it might be a hint that strong emotions are getting in your way. Read through the following list with participants, asking them to check off any of the thoughts that may apply to them (on page 78 of the participant workbooks): ●● ●● ●●

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I don’t get around to discarding because I’m too busy; too much is going on. I don’t get around to discarding because my family gets in the way. I don’t discard because I don’t have the proper materials yet (e.g., boxes, file cabinet). I don’t discard because I’m too tired. Problems keep coming up that get in the way. I plan to do it after I get everything else done, and then it’s too late. I only discard the “lower hanging fruit” – meaning I discard only the easiest stuff, never making any real progress. I don’t have a good plan for how to do this yet, so I can’t start. I can’t do this right now because I’m not in the mood.

Have you ever heard someone come up with multiple reasons why they didn’t get around to doing something, even if they say it’s really important? That person is probably letting their emotions be the boss without knowing it. These are things to be aware of  –  not to feel guilty about. We all fall victim to these ways of emotional reasoning. Sometimes we do have realistic difficulties, that is, real barriers that come up that get in the way. However, a telltale sign of this potentially being an emotion problem is if these barriers keep coming up. Can you think of other examples when we might not recognize we’re avoiding discarding?

114 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide In order to know when your emotions are taking over, ask yourself these questions several times a day: ●●

●● ●●

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Am I making a bunch of excuses as to why I haven’t been discarding? Even if they seem like good reasons? Have I not discarded anything at all today? Have I not discarded what I need to discard in order to reach my SMART goal by the end of the week? Have I saved an object even after I’ve come to the conclusion that it’s probably best to let it go?

If you’ve answered yes to any of these questions, then: You are probably letting your emotions be your boss! Are there any other questions you can ask yourself to find out if you are a­voiding discarding? Or are there other signs that could alert you that you are  letting emotions be your boss? Please write these down on page 79 of your workbooks. Is anyone willing to share their responses with the group? Once you realize that you’ve been letting your emotions be your boss, you know what to do! Use the three steps we just learned in order to make sure that you are being your own boss.

3.  “Bad Guy” Re‐evaluation CLASS TASK: “Bad Guy” Re-evaluation Over the past two weeks we have talked about the intense e­motions “bad guy”. Take some time to evaluate how much you  think this “bad guy” is contributing to your acquiring behavior and difficulty discarding over the past couple weeks. On pages 79–80 of your workbooks you will see some scales to rerate how much you feel this “bad guy” is ­getting in the way for you. There is one for acquiring and one for discarding. Take a moment now to do those ratings. Rate from 0 (not a problem for me) to 10 (a very big problem for me). Acquiring: What kinds of emotions are you feeling when you acquire something? Interested? Excited? What kinds of emotions do you think you will experience if you don’t obtain this object? Guilty? Sad? Bored? How much are these intense emotions contributing to your acquiring behavior?



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0 = Not a problem for me 10 = A very big problem for me Now that you have rerated how much you feel the intense emotions “bad guy” is continuing to be a problem for you, consider whether this has improved since the start of treatment. If no, have you been practicing the skills from the previous two chapters diligently? What skills might you need to keep practicing?

4. Homework Review with participants the homework tasks for this week: 1. 2. 3. 4. 5. 6.

Reread information from week 6 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring items from home to class next week. Other: ________________________________________________________

Emphasize to class participants the importance of homework compliance. As with prior weeks, have each participant report on the SMART goal they are  setting for themselves that week, ensuring that the goal follows the SMART guidelines. Ask each participant what they intend to reward themselves with for completion of the goal. They can be encouraged to write down their goals and intended rewards on page 80 of their participant workbooks.

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Sample Answers to Common Questions Question: Are you saying I should just accept that I feel bad? That sounds r­idiculous! I am here because I feel bad and I want to reduce it or stop it. Answer: Well, kind of. We are suggesting that you begin to stop fighting so hard against negative emotions. Many times we try so hard to fight against negative emotions that we make ourselves feel worse! Can you think of any ways that you have done this? When we feel bad we often try to avoid the things that make us feel bad; we try to distract ourselves, we desperately try to find things to make us feel better, and sometimes we do really unhelpful things like buy excessively, eat excessively, or drink excessively, all in attempts to feel better and make the emotion go away. However, if we truly step back and look at it, what is so bad about that negative emotion? It is just an emotion after all, and emotions will not harm us. They may feel temporarily physically uncomfortable, and may be a bit distracting, but that is all they are. They will not do lasting damage; that is, unless you fight them. When you try too hard to get rid of them, you create most of the distress. There are two levels of distress. One layer is the emotion itself: Yes, feeling sad, angry, or irritated can be uncomfortable. However, it is not catastrophic, intolerable, or unending. It will go away if you don’t fight it. However, if you fight it, that is, if you try to avoid it or suppress it, it will keep resurfacing and lingering. So just sit back and let the emotion ride out on its own – ride the wave. Don’t add the second level of distress of hating the emotion. By doing so you add an unnecessary layer of feeling bad. We don’t want to remove your ability to have negative emotions, because you are meant to have them. It is part of the human experience, and negative emotions serve many good functions. They often help motivate us. So we don’t want to remove all of them, we just want to help you tolerate them better, and help you behave in ways that are more functional when you experience them. Much of the problem lies in how people respond to their emotions: with avoidance, fear, and hatred. If you respond with acceptance and behave in positive ways that reflect your true values, you will begin to see that emotions have very little influence over you. Question: Are you saying that emotions such as sadness and anger are not bad? Everyone agrees that those things are bad, and everyone in their right mind would avoid them. Answer: Yes, I think most people would agree that if we had a choice, most people probably would choose to experience these emotions infrequently. The emotions can be indeed uncomfortable and unpleasant at times. However, the message is that they are not catastrophic. They will not ruin your life, unless you let them. You can choose to behave despite them, and by doing so, people often find that they feel much better than when they fought against the emotion and let the emotion run their lives.



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Question: I want to act toward my values, but I feel like my emotions won’t let me. For example, I recently lost my job and I feel really down and depressed. How am I supposed to work on sorting and discarding at a time like that? Answer: Emotions are just emotions, they do not have to dictate your behavior. Despite whatever you are feeling, you always have the ability to choose how to behave despite that feeling. This is an important message, as we often feel that our emotions are truth. Remember that just because I think something does not make it true. For example, just because I think I’m worthless, it does not mean that I am. It is indeed harder to work on things like sorting and discarding at times when you are feeling depressed and potentially unmotivated. We will talk about m­otivational issues later in more detail. But for now, keep in mind that it is OK to have negative emotions, and you can act toward your values while you are having them. Now, we are not saying that right after you experience a loss, you should sit down and work on your sorting and discarding. Rather, we want you to carefully think about what your goals are and act toward them, rather than try to fight off feeling bad.

Chapter 7

Unhelpful Thinking Part 1

1. Homework Review (20 minutes) 2. How Thoughts Influence Emotions (25 minutes) Class Task: Identifying How Thoughts Lead to Emotions 3. Identifying Unhelpful Thoughts (30 minutes) Common Unhelpful Thoughts in People with Hoarding Disorder Class Task: Identifying Unhelpful Thoughts That Lead to Difficulty Discarding 4. Homework (15 minutes)

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Overview In the Identifying Unhelpful Thoughts section, participants are taught to identify how thoughts lead to emotions, and to use some basic cognitive techniques to challenge negative thoughts, such as looking for alternative ways of interpreting situations/cues. Participants will review common categories of unhelpful thoughts that are often present in individuals with hoarding disorder, such as beliefs about wastefulness, responsibility, or identity. Group members are then asked to practice identifying their own thoughts that may lead to increased distress and difficulty parting with items.

CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.



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1.  Homework Review CLASS TASK: Homework Review Go around the class asking each person to briefly report on whether they have achieved their personal SMART goal and reward. Group leaders should keep track of completed assignments and inform group members if they get a point this week toward the group reward. (Again, a point is awarded if 75% or more of class participants complete their SMART goal.) Homework tasks were: 1. 2. 3. 4. 5. 6.

Reread information from week 6 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring items from home to class next week. Other: ________________________________________________________

Check to see if 75% of class participants completed their SMART goals this week and remind the class that this contributes to the group reward. Did at least 75% of the group complete their personal SMART goal this week?

❑ YES   ❑ NO

Have all participants turn in their In/Out Logs from the last week.

2.  How Thoughts Influence Emotions We discussed previously that the way people think can lead to acquiring and d­ifficulties discarding. We will focus this week on the thoughts that contribute to acquiring and difficulty discarding. As we mentioned in the previous groups when we were talking about emotions, our thoughts strongly influence how we feel in any given situation. How we feel, then, really can influence our behavior! If I am feeling frustrated, sad, or angry, I am much less likely to do productive work on any problem, than if I am feeling upbeat, excited, and interested. We often think that events lead to emotions, such as “I didn’t grab that item when it was available,” therefore “I am now feeling lots of regret,” or “I threw out that envelope” so “now I feel bad.”

120 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide Draw the following diagram on the board: EVENT: I threw the item out.

EMOTION: I feel awful: guilty and sad.

However, it is not the event that made us feel bad, it was how we thought about it. Update the diagram to reflect the addition of cognitions: EVENT: I threw the item out.

UNHELPFUL THOUGHT:

EMOTION:

I am being wasteful, and wastefulness is bad.

I feel very guilty and sad.

As you can see from the diagram, the unhelpful thought led to our negative emotions. However, this is just one way to think in this situation. What are some other ways a person could think when they throw something out? How would they feel? We often find that when people are decluttering, negative thoughts lead to negative emotions, which can often lead to unhelpful behaviors (such as avoidance of decluttering). Therefore, we will work on how you think so that we can begin to alter how you feel and how you act. The first thing we need to do is to try to identify some of the problematic thoughts that come up for you. We will start with thoughts that lead to acquiring. These may be different for each of you. Let’s look at some examples of how the way someone thinks can affect their emotions and behaviors. This is shown in the table on page 84 of your workbooks. Imagine you are at the supermarket and you are waiting to be served. The cashier walks away before serving you. You may think about this in a number of different ways. If you thought…

You would probably feel…

“She probably needed to do something important and will be back in a minute.”

Okay

“How dare she walk away before serving me! Who does she think she is?”

Angry

“She probably didn’t serve me because she thinks I’m a loser.”

Sad

So even in the same situation a person can have different thoughts about it, which leads to a different emotional response. That’s because the way we think about the situation, not the situation itself, determines how we feel about it. In the next class task ask class participants to try to identify the feelings or e­motions that result from each of the thoughts.



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CLASS TASK: Identifying How Thoughts Lead to Emotions Let’s see if you can identify which emotions would be associated with the following examples. If you thought…

You would probably feel…

“Why bother trying? I’ll never be able to get through it all.” “If I throw this away I’ll lose something important.” “I have many of these items, I don’t need more than one.” “I’m really making some good progress on getting through this clutter.”

3.  Identifying Unhelpful Thoughts Now let’s talk about how to identify these thoughts in ourselves so that we can begin to practice changing them. One way we like to start this is to review a list of common unhelpful thoughts we often hear. These are listed on pages 85–87 of your workbooks.

Common Unhelpful Thoughts in People with Hoarding Disorder As you review the list with class members, ask them to check off thoughts that they identify with.

Responsibility beliefs It is my responsibility to make sure things get disposed of properly. ●● I have to make sure everything goes to a “good home.” ●● If someone else can use it, I’m responsible for hanging on to it. ●● I will disappoint someone if I get rid of it. ●●

Usefulness beliefs ●● I need to keep it or acquire it because I’ll be able to use it one day. ●● I will be able to fix it one day. ●● Someone will be able to use this eventually. ●● I have to get this for my friend/family member because he or she could really use it/ benefit from this information.

122 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide Identity beliefs ●● Without my possessions I would be nothing. ●● These things are part of who I am. ●● I need to acquire or hang on to these things so that I can be an artist/craftsperson/etc. ●● I’m clever if I can find a bargain. ●● A good parent/sister/brother/friend would keep this item  –  how can you throw away something from/made by someone you love? Attachment beliefs ●● I need to acquire or keep the objects because they serve as reminders of important times in my life. ●● My things feel like my friends. ●● I have to acquire or keep this object because I don’t want to make it sad. ●● I’ll miss the item too much. Valuation beliefs ●● I paid for it, so I can’t throw it away because that would be flushing money down the drain. ●● I can’t throw anything away that has value. ●● It’s mine, so it’s valuable. ●● If it’s on sale, it makes financial sense to buy it. ●● I should hang onto this item because it is worth money. ●● I don’t have much money; therefore, I need to save everything. Wastefulness beliefs ●● It’s wasteful to throw things away that can still be used. ●● Wasteful people are horrible. ●● I would be stupid to pass up a deal this great. ●● I would be wasting money if I didn’t purchase this now. Memory beliefs ●● I need to keep information close by, otherwise I will forget it. ●● I need to be able to see all of my things. ●● If I put this away, I’ll forget it. ●● I’ll forget the memories that are associated with the item. Anticipation of emotion beliefs ●● I can’t throw things away because I will be too sad. ●● I’m so stressed out; going shopping will make me feel better. ●● If I throw this away or pass this up, I’ll regret it forever. ●● If I become upset, I’ll never get over it. ●● This item is so beautiful, it will make me happy whenever I see it.



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Pessimism beliefs ●● There’s too much stuff – I’ll never be able to get rid of it all. ●● I’m not making as much progress as I’d like. Why bother at all? ●● I’ve already spent more than I planned; I might as well buy these extra things. ●● I won’t be able to control my spending this weekend. Let’s see what thoughts are relevant for you when discarding.

CLASS TASK: Identifying Unhelpful Thoughts That Lead to Difficulty Discarding To help us identify the unhelpful thoughts that occur when d­iscarding, please take out your belongings that you have brought from home. This exercise is to help us identify some of the beliefs that may come up for us when we are thinking about discarding. You do not have to choose an object that you are ready to discard; we just ask you to select an object so we can practice identifying thoughts. Sometimes it is easier to identify thoughts when we handle a real possession. Take out the item and think about discarding it. What sorts of things go through your mind? On page 87 of your workbooks, in the first set of blanks, jot down some of the thoughts that come to mind. Ask if anyone is voluntarily willing to share some of the responses they wrote. Ask them how these responses might influence how they feel, and how they behave. Does that thought make it easier or harder to discard? Are there alternative ways to view it? Are any of you willing to discard your item now? If so, please do so now. Now to practice with thoughts related to acquiring. Choose an item from the virtual store that you feel you would be tempted by if it were free. If absolutely nothing from the virtual store appeals to you, please think of something that you recently acquired. After each group member has chosen an item: As you handle the item, on page 87 of your workbooks, write down the thoughts that are drawing you to the object, and thoughts that come up when you think about leaving the item behind. Ask if there are any group members willing to share the thoughts that they experienced. Ensure that they listed both thoughts that drew them to the object, and any negative thoughts about consequences of leaving the item behind. Ask participants how these thoughts might influence emotions and behavior. Are there other ways of thinking about the object?

124 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide Now that you have practiced identifying your thoughts, you can begin to see how they might be problematic at times. On page 88, write down which beliefs you noticed yourself thinking the most. Once participants have written these, have each member of the group share at least one common belief they experienced, and have the group practice identifying which type of belief theme(s) from the list (on pages 85–87 of the workbook) these beliefs may reflect. To remind group leaders, the main belief themes are: ●● ●● ●● ●●

Responsibility Usefulness Identity Attachment

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Valuation Wastefulness Forgetfulness/ memory

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Anticipation of e­motion Pessimism/ discouragement

Great job! Now that you know that some of your thoughts might not be so helpful, we can begin to practice thinking in new ways. In the next session we will begin to practice thinking in more helpful ways as you declutter.

4. Homework Outline to participants the homework for the week. Your homework this week is: 1. 2. 3. 4. 5. 6. 7.

Reread information from week 7 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Bring items from home to class next week. Take photos of your progress for your mid‐treatment review. Complete weekly SMART goal. Other: ________________________________________________________

As with previous weeks, have participants set a personal SMART goal for the week. Now can be a good time to remind group members that in order to get “credit” for completion of a SMART goal, they actually have to complete the specific goals they laid out. That is, substitutions do not count, although we encourage class members to do other things beyond their SMART goal if they can. Also, a discarding goal does not count unless the items go out. For example, a SMART goal of discarding two large boxes of items has not been met if the items have simply been set aside to be discarded. The goal is met when the items are finally discarded/donated.



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Sample Answers to Common Questions Question: I just have lots of stuff (e.g., when my mother died she left me all of her stuff); I don’t really have a problem with acquiring too many things I don’t need. Answer: As with most of the modules that we cover in the group, the acquiring skills apply a lot to some people and a little to others. Sometimes people do not struggle as much with acquiring as with clutter that is already in the home. However, we often find that when we look more closely, we can find somewhere you might be excessively acquiring. We are often unaware of many things that we acquire, such as paperwork, junk mail, pamphlets, and other items. We often grab things on autopilot! In addition, while you may be purchasing things you think you need, you may not need them as much as it feels, or you may be able to get by with less of that item. In any case, the same skill set in reducing acquiring often applies to that of discarding: facing the “bad guys” of unhelpful thinking, intense emotions, decision making and problem solving, and low motivation; and therefore we encourage you to practice these skills regardless. However, we encourage you to really consider whether or not there are places you may be able to reduce your acquiring, even if it seems like it is low to begin with. Question: I find that my thinking is often accurate; that is, it seems like when I don’t purchase something, I always end up regretting it. Answer: It may indeed seem that way. Chances are you may be looking at things in a biased way. We tend to pay more attention to the times that we made the wrong decision than the right one. For example, I am likely to remember the one time I missed out on a great bargain, rather than the 20 times that I walked away from a deal and never thought about it again. The missed opportunity sticks out in my mind. However, that does not mean that it is a more likely outcome, although it can sure seem that way. Therefore, you may be overestimating a scary outcome, such as missing out on a great bargain. In addition, you may be overestimating how awful such an experience is. Most people find that even when they miss out on obtaining something they wanted (I can think of several times I have done this myself!), although they may regret it, they eventually forget about it with time or it becomes not such a big deal. This is how negative emotions work (any negative emotion): they tend to fade with time if you let them. If you are worried that you will feel anxious, or regretful, or sad, if you leave that item, you might – at first. Then chances are if you allow yourself to feel the emotion, it will pass with time. That is how your body is wired to work!

Chapter 8

Unhelpful Thinking Part 2

1. Homework Review (15 minutes) 2. Tackling Unhelpful Thoughts (50 minutes) Question the Thoughts Class Task: Practice Questioning Your Thoughts: Acquiring Class Task: Practice Questioning Your Thoughts: Discarding What Would You Say to a Friend? Class Task: How Would I Advise a Friend? 3. “Bad Guy” Re‐evaluation (10 minutes) 4. Homework (15 minutes)

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Overview In this second Unhelpful Thinking session, participants are asked to begin challenging and testing some of the problematic thoughts that they identified in the prior session. The session begins with a review of homework, as usual, along with some time devoted to sharing photos that participants have taken of their homes. The skills portion of the session focuses on direct cognitive challenging. This is primarily done through the use of prescripted “questions for discarding” and “questions for acquiring.” These questions are designed to have participants practice asking themselves questions about objects, to better diminish the degree to which negative cognitions and resulting emotions control decisions. Participants are also asked to practice identifying what they may say to a friend in a similar situation, in order to practice self‐compassion and more realistic patterns of thinking. CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.



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As in obsessive‐compulsive disorder (OCD), problematic thoughts in hoarding disorder may often reflect intolerance of uncertainty. Thoughts may be nonspecific, and angled toward an exaggerated aversion of misfortune and being unprepared for possible negative outcomes. Individuals with HD often fear making the wrong decision about an object, and may fear “something bad” resulting from such a wrong decision, but they may be unable to verbalize what such an outcome may be other than they will feel a strong desire or need for that object in the future. Therefore, as one may do with OCD or similar disorders, addressing the cognitive aspect of HD can involve pointing out to participants that they are likely overestimating the likelihood and severity of negative outcomes, including the strength of negative emotions when strong emotions are the feared outcome. Participants can then be encouraged to realistically evaluate the likelihood and severity of outcomes, but also to practice tolerating uncertainty. The session ends with a brief re‐evaluation of the unhelpful thoughts “bad guy”, asking each participant to rerate how much they think unhelpful thoughts may be impeding their progress in discarding and reducing acquiring.

1.  Homework Review CLASS TASK: Homework Review As in previous sessions, check in with each participant about whether they have achieved their weekly SMART goal (and reward!). Inform participants whether the group gets a point toward the group reward for this week. Be sure to collect the In/ Out Logs from each participant. The homework from last week was: 1. 2. 3. 4. 5. 6. 7.

Reread information from week 7 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Bring items from home to class next week. Take photos of your progress for your mid‐treatment review. Complete weekly SMART goal. Other: ________________________________________________________

Check to see if the class met their group target for this week: Did at least 75% of the group complete their personal SMART goal this week?

❑ YES   ❑ NO

128 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide Photos of progress Did everyone bring photos to share with the class? Spend some time reviewing group photos, having participants point out what they have accomplished and what they still need to work on. If participants did not bring photos, remind them to bring photos to the next session and repeat that this is an important part of class.

2.  Tackling Unhelpful Thoughts In the last chapter we talked a lot about identifying our unhelpful thoughts. We will continue to talk about how to tackle this “bad guy”. We will now talk about skills to tackle the unhelpful thinking “bad guy”. Different skills will work for different kinds of thoughts. We will teach you how to: ●● ●●

Question the thoughts Act as you would advise a friend

These skills can be used to target both acquiring and saving. The first skill we will teach you is to question your thoughts. Remember that the goal is to question your thoughts. Remember that just because you think something does not mean that it is true. And just because it feels true does not mean that it is. We often view things through “biased lenses”: When we are anxious or depressed, we often selectively pay attention to information that is n­egative. In order to feel less anxious and depressed, it is important to begin to practice looking at the whole picture before making conclusions. We do this by first being aware of our thoughts, then beginning to question them. Now that you have practiced being aware of some of your problematic thoughts (in the last session), let’s begin to question those thoughts. One of the best ways to do this is to use our list of questions on page 93 of your workbooks.

Question the Thoughts Many people have told us that the following questions are important to ask themselves when they are discarding: ●●

●● ●● ●●

In my ideal home, is there a place for this object? When I imagine my ideal home, where does this object go? If I don’t save this item or acquire this item, will anything bad happen to me? Is this item in good working order? Do I have a specific plan to use this item within the next 12 months?



Unhelpful Thinking: Part 2 ●●

●● ●● ●●

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Would someone without a problem with clutter keep or take this item into their home? Do I have more of these than I need? Would I be able to get the item (or information) again in the future? Does having this thing mean more to me than having a clear house?

Now let’s practice using these questions.

CLASS TASK: Practice Questioning Your Thoughts: Acquiring Class leaders should lay out the virtual store. As with previous times when we have used the virtual store, please identify at least one item that you would like to take home if it were free. Again, if there is absolutely nothing that attracts you, think of something that you recently acquired (but we definitely prefer you using something from the store). Please do that now. Once you have identified one item, please ask yourself the questions on page 93 of your workbook, circling yes or no. You will notice some boxes around some of the yes and no responses. If you answer the questions honestly and there are more “boxed” than “unboxed” responses circled, then it is likely that you do not need the item and that it is contributing to your problem with clutter.

CLASS TASK: Practice Questioning Your Thoughts: Discarding Now let’s practice asking ourselves questions when discarding. Identify one item from your belongings that you have brought to class today. Once you have identified one item please c­onsider discarding that object. As you consider discarding it, ask yourself the questions on page 93 of your workbook. You will find that these questions are slightly different as they are asking about discarding. Again, at the end of the exercise, encourage participants to share their responses on the form, if they are willing. If participants are willing to discard the item, encourage them to do so at that time. Do you have more boxed than unboxed responses? That likely means you do not need the item. If you are keeping it, why? Are you letting your emotions drive the bus? As with all exercises, reinforce that the goal of the exercise is not to pressure p­articipants to discard, but rather to get them to think of the object. Never pressure an individual to discard an item, but do encourage participants to use the discarding questions and to ask each other the questions.

130 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

What Would You Say to a Friend? One of the best ways to challenge negative thoughts is to ask yourself what you might say to a friend in a similar situation. In different situations we often respond to ourselves in a much more negative fashion than we do to other people we care about, such as friends and relatives. This ends with us being extremely negative with ourselves! For example, see how someone responds to themself more harshly than they do to a friend in the examples below.

Situation

What you say to yourself…

What you say to a friend…

Acquiring a pen from the bank

I’m so stupid for a­cquiring that.

Don’t beat yourself up – just try to stay on top of it next time.

Starting d­iscarding session

I’ll never get through all of this, so why bother?

It will take time, but you’ll get there. Just take it a bit at a time.

Seeing an item at a thrift store that you like

That is such a great deal, I should buy a few of them.

You have been doing a great job lately not acquiring things you don’t need. Are you sure you a­bsolutely need this?

Looking around cluttered home

I’m such a loser for l­etting things get this bad.

Things are not as you want them to be, but with some hard work you can have your house looking the way you want it to look.

Another important way to reduce your unhelpful thinking is to start responding to yourself as you would to a friend. Remember that the way that we think has a huge influence on how we feel and how we behave. Ask yourself what advice you would give to a friend in the same situation.

CLASS TASK: How Would I Advise a Friend? Identify a situation or situations related to discarding and unhelpful thought(s) that you have been having. Think about how you would respond to a friend in a similar situation. Is it the same as you respond to yourself or is it different? How can you be kinder to yourself and respond as you would to a friend? Fill out the table on page 95 of your workbooks, writing what you might say to yourself, and what you might say to a friend.



Unhelpful Thinking: Part 2 Situation

What you say to yourself…

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What you say to a friend…

Did any of you find that what you say to yourself was very different from what you might say to a friend? Can you begin to be kinder to yourself and practice coaching yourself as you would coach a good friend or loved one?

3.  “Bad Guy” Re‐evaluation CLASS TASK: “Bad Guy” Re-evaluation Over the past two weeks we have talked about the unhelpful thinking “bad guy”. Now take some time to evaluate again how much you think this “bad guy” is contributing to your acquiring behavior and difficulty discarding. On page 96 of your workbooks, you will see scales like the ones you used to originally rate how much the “bad guys” were interfering for you. Again rate how much you think the unhelpful thinking “bad guy” is interfering for you, from 0 (not a problem for me) to 10 (a very big problem for me), but consider how much it has been interfering for you over the past couple weeks. Acquiring: When you are faced with a situation where you want to acquire, what is going through your mind? How much are you experiencing unhelpful thoughts? Are you thinking that you might have a good use for the item? Are you thinking that you shouldn’t pass up such a great deal? 0

1

2

3

4

0 = Not a problem for me 10 = A very big problem for me

5

6

7

8

9

10

132 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide Discarding: When you are discarding, what is going through your mind? How much are you experiencing unhelpful thoughts? Are you thinking the item will be useful? Or that you’re being wasteful? Or that you could give the item to a friend? 0

1

2

3

4

5

6

7

8

9

10

0 = Not a problem for me 10 = A very big problem for me As always, now that you have rerated the unhelpful thoughts “bad guy”, consider whether you have improved on this since you entered treatment. If unhelpful thoughts are still a big problem for you, have you been practicing the skills from the previous two chapters? What might you need to practice more?

4. Homework Outline the homework for this week and remind participants about the importance of homework compliance. 1. 2. 3. 4. 5. 6.

Reread information from week 8 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Bring items from home to class next week. Complete weekly SMART goal. Other: _________________________________________________________

As in prior sessions, spend the remainder of the group having each participant briefly set a SMART goal to be checked in on at the beginning of the next session. Ensure that the goals are properly challenging. Unless a goal was not achieved last week, this week’s goal should be somewhat more challenging. If a goal was not achieved last week and the participant wants to retry the goal this week, discuss with him or her what will be different this time around such that the goal is more likely to be completed.

Chapter 9

Waxing and Waning Motivation Part 1

1. Homework Review (15 minutes) 134 2. Improving Motivation (30 minutes) 134 135 The Pros and Cons of Continuing Your Efforts Class Task: Identifying Pros and Cons of Continuing Your Efforts135 3. Acting on Your Top Goals and Values (30 minutes) 136 136 Focusing on Goals and Values Class Task: Identifying My Life Goals and Values 137 Class Task: Are My Life Goals Consistent with My Acquiring and Discarding Behaviors?138 4. Homework (15 minutes) 139

Overview In the Waxing and Waning Motivation section, participants are encouraged to revisit original motivators for treatment, and to again take stock of motivators for change. Class members are asked to create a pros and cons list for continuing to work on their clutter problem, like motivational interviewing (Miller & Rollnick, 2013). Class m­embers are then asked to inventory their top personal values and goals and to determine whether ongoing acquiring or saving behaviors are in line with these values. Participants are also encouraged to participate in an in‐session visualization exercise to attempt to visualize their decluttered home. In subsequent discarding exercises, if participants elect to keep an object, they can be asked if it belongs in this CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.

134 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide ideal home, and if so, where. Participants then practice discarding, applying motivational skills as necessary. They are asked whether keeping items would be in line with their primary values and goals. Participants are then encouraged to revisit the long‐term SMART goals they set at the beginning of the group, to assess whether they are making progress toward this goal or need to alter their approach. The module ends with a re‐evaluation of how much the waxing and waning motivation “bad guy” is continuing to interfere, and a discussion of how to continue to apply the goals.

1.  Homework Review CLASS TASK: Homework Review Review with participants the homework tasks from last week. 1. 2. 3. 4. 5. 6.

Reread information from week 8 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Bring items from home to class next week. Complete weekly SMART goal. Other: _____________________________________________________________

Go around the class checking with each participant as to whether they were able to complete their SMART goal for the week. Did at least 75% of the group complete their personal SMART goal this week?

❑ YES   ❑ NO

Group leaders may also want to check in as to whether participants are completing the expected 30 minutes per day of sorting and discarding (or time equivalent). Check in with participants as to whether they are beginning to find this process easier than at pre‐treatment, and whether they are increasing the efficiency of making decisions. Have all participants turn in their In/Out Logs from the last week.

2.  Improving Motivation The final “bad guy” that we will focus on in the Declutter Class is motivation. We often find that motivation tends to go up and down over the 16 weeks of the class. Often people start off very motivated, but then get less motivated over time. Your motivation will also go up and down after you finish the class.



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We want you to be able to use the skills that we discuss over the next two weeks to help improve your motivation, both during the class and after the class ends. We have a number of tasks to help you increase your motivation to reduce your acquiring and improve your discarding. The skills we will learn over the next two weeks include: ●● ●● ●●

Understanding the pros and cons of continuing your efforts Focusing on goals and values Using your imagination

Let’s get started.

The Pros and Cons of Continuing Your Efforts Often people say that there are both good and bad things about changing their behavior and an important way to increase your motivation is to consider the pros and cons of your current behavior. We can think about both the short‐ and long‐term pros and cons of change. Emphasize to participants that there are likely many good reasons for acquiring and saving behaviors, along with not so good ones. Emphasize that problems in decision‐ making are often exacerbated by the presence of many good and bad factors. We can weigh out pros and cons systematically to see if some of our reasons for change outweigh our reasons for staying the same. This can be a motivating thing to do, and can help us see what is most important to us.

CLASS TASK: Identifying Pros and Cons of Continuing Your Efforts Spend some time thinking about the good things and bad things about making changes to your behavior. Why should you continue to work on your discarding, despite it being quite difficult at times? Are there good reasons to not work on your decluttering or reducing your acquiring? On page 103 of your workbooks you will see a blank pros and cons grid. There are four areas so that you can inventory the pros and cons of continuing to change, both in the short and the long term. Please begin your inventory now. Once you have completed this we will discuss your findings with the group. Other group members might be able to identify some cons that you hadn’t considered before. Once participants have completed their personal inventory, it can be good to create a combined inventory on the board in front of the group, encouraging participants to add pros and cons to their own lists as necessary. Ensure that the group has considered relevant factors in many areas, such as social, financial, health/hygiene,

136 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide mood/mental health, and physical health. The inventory can take the format of the worksheet in the workbook, which mirrors the table here. SHORT TERM Advantages (Pros) of Continuing to Work on Decluttering

Disadvantages (Cons) of Continuing to Work on Decluttering

LONG TERM Advantages (Pros) of Continuing to Work on Decluttering

Disadvantages (Cons) of Continuing to Work on Decluttering

Emphasize to the group that the goal of this exercise is not to simply argue that change is necessary, but rather to have participants see if it is a priority for them right now. Group leaders may wish to mention that after weighing the pros and cons (either now or in the future), participants may realize that staying the same is better than changing. The pros and cons inventory is designed to help them make a decision about change and inventory‐relevant data, not to convince them that change is necessary, although most participants do find that the latter is the case. Now let’s talk about how focusing on our goals and values can help us reduce clutter.

3.  Acting on Your Top Goals and Values Focusing on Goals and Values We find that often people say that they value having a clear home. However, their actions do not support this because they continue to acquire items that contribute to the clutter in their home or they fail to make the behavioral changes required to clear



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the clutter in their home. An important part of overcoming clutter is to think about what your goals and values are for your life and whether your actions or behaviors are in line with these goals. In order to understand if your behaviors are in line with your goals and values, we need to find out exactly what is important to you. Knowing your most important values and keeping these things in mind can really help boost your motivation. These can be some tough questions to answer, but they are essential to think about so that you can tell if your behaviors are consistent with your goals and values. We can have goals in many aspects of our lives. It is important that you think about what you actually value, not what you think other people think you should value.

CLASS TASK: Identifying My Life Goals and Values Starting on page 104 of your workbooks, you will see a section to begin to identify what your important goals and values are. We have listed many of the main areas in which people tend to have substantial goals and values, such as in relationships, finances, and well‐being. Please take a moment now to use that space to inventory your personal life goals in those areas. On the worksheet, participants are asked to inventory their values/goals in the ­following areas, relative to decluttering. Relationships What’s important to you about your relationships? This can include romantic relationships, friends, and family. For example, do you want to be able to have people over to your home? Do you want to be able to spend less time on making discarding decisions and more time on friends and family? Personal well‐being What’s important to you when it comes to your personal well‐being? This can include things like your health (mental and physical), spirituality, learning and education, or hobbies. For example, do you want to reduce your risk of falling in the home? Do you want to have a quiet space to concentrate and relax? Career and finances What’s important to you in your career and financial future? For example, do you want to reduce your spending so that you can pay off important bills? Do you want to be able to better balance work and home life? We often have many goals and values that we are working on at any given point,  and sometimes it can be difficult to choose between them. Therefore it is important to be aware of which of your goals or values are most important to you.

138 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide Now that you have defined your values, we want to know which three values are the most important to you; please write these on page 105 of your workbooks.

CLASS TASK: Are My Life Goals Consistent with My Acquiring and Discarding Behaviors? Now that you have had a chance to consider your life goals and values, it is now important to start to practice considering these life goals when you are making choices that could affect your clutter. First, we will consider how your values fit in with acquiring behaviors. Please look at the items that the class leaders have in the virtual store. Take a moment to choose an item that you would like to acquire if it were free. Then work through the worksheet on page 107 of your workbooks to identify whether acquiring the item is consistent with your top life goals and values. There is an example of a completed form on pages 105–106 if you need some guidance. The worksheet asks participants to (a) identify an object they are tempted by, (b) relist their top three values, and (c) assess whether acquiring the item would be in line with their top values. After the group is done completing the form with one item, ask volunteers to share whether they felt that acquiring the item was or was not in line with their values. Group leaders should ensure that participants are not overlooking important ways that behaviors do or do not align with goals. For example, a participant may say, “My goal is to always be prepared, so to meet this goal I should save things just in case, right?” Or, “My goal is to be a good mother, and a good mother would save everything her child makes in school.” In these instances, participants may not readily see that their actions in service of their goals/values are actually hindering their progress toward that value/goal, or are in conflict with more important values. To challenge this, group leaders can ask if hoarding behaviors are truly guiding one toward a higher value. Often this can be done by restating the participant’s perspective with slight exaggeration of the statement to highlight the discrepancy between the behavior and the goal(s). Alternatively, clinicians can ask if the behavior is the best way, in the participant’s belief, to work toward the identified goal/value. To highlight how this can be done in session, some examples of misguided values are given below, with an example clinician prompt to highlight the contradiction in the value and the behavior. Example participant statement: “My value is to be a good mother. Therefore, I should keep all of my child’s projects, because a good mother would do that.” So to you, a way to define a good mother is by Example response: how many of her child’s crafts she keeps? If that is not true, are there better ways to be a good mother?



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Example participant statement: “My value is to be generous and to care for others. Therefore I should always grab things I think others can use.” Example response: So to you, being a generous, caring person means how many objects you acquire and save for other people? If that is not accurate, what is a better way to work toward being a generous, caring person? This also sounds like it leads you to acquiring and saving things, which sounds like it may contradict your other stated goal, decluttering your home. How can you work toward both of these? Example participant statement: “My goal is to be a happy person, and acquiring this object will make me happy. Therefore it is in line with my goals.” Being happy is a very broad value, so let’s Example response: break it down a bit. What will it take to make you happy – do you know? Do you think that acquiring or saving many objects is what will make you truly happy in the long run? If so, you may be in the wrong treatment group! But in all reality, I know you are here because you have stated that your acquiring/your clutter has made you extremely unhappy. What is a better way to work toward your value of ­happiness? What does that mean to you? Next, let’s do the same review of values, but this time with discarding. Please choose one item from your box of items from home. Consider discarding this object. On page 107 of your workbooks, please again list your values, and fill out the rest of the worksheet to assess whether discarding or keeping this item would be consistent with your goals and values. Please do this now. Group leaders can lay out the sort and discard bins. Again, once the worksheet is completed, have volunteers share their responses. Group leaders should again assess whether participants have accurately assessed whether their behavior is in line with their values. If a participant states that it would be consistent with their values to discard the item, ask them to do so.

4. Homework Outline the homework for this week: 1. Reread information from week 9 (including Rita’s story). 2. Practice using the In and Out Log every day.

140 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide 3. 4. 5. 6.

Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring items from home to class next week. Other: ________________________________________________________

As in prior sessions, spend the remainder of the group having each participant briefly set a SMART goal to be checked in on at the beginning of the next session. Ensure that the goals are properly challenging. Unless a goal was not achieved last week, this week’s goal should be somewhat more challenging. If a goal was not achieved last week and the participant wants to retry the goal this week, discuss with them what will be different this time around such that the goal is more likely to be completed.



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Sample Answers to Common Questions Question: What’s the difference between a value and a goal? Answer: For the purposes of this group, we like to think of values and goals as being somewhat different. Goals can be conceptualized as very specific, measurable tasks that you want to achieve. Your weekly SMART goals are a good example of this. Values, on the other hand, are broader ideas that we live by and that are important to us, but that we will rarely ever fully achieve. Some examples might be “honesty,” “being generous and compassionate to others in need,” or “being a responsive and attentive mother.” While we can act in the service of these values and use them to guide our actions, it is unlikely we will ever achieve them perfectly, and that’s OK. In this chapter’s exercises, we want you to take a look at both your goals (specific and measurable tasks that will get you where you want to be) and your broader values that guide your actions.

Chapter 10

Waxing and Waning Motivation Part 2

1. Homework Review (15 minutes) 2. Improving Motivation to Discard (20 minutes) Visualize your Decluttered Space Class Task: Using Your Imagination to Visualize Your Decluttered Space 3. Being Motivated By Your Values (25 minutes) 4. Checking In on Long‐Term SMART Goals (10 minutes) 5. “Bad Guy” Re‐evaluation (5 minutes) 6. Homework (15 minutes)

143 144 144 144 145 146 146 147

Overview As in previous sessions, the group starts with a review of homework completion since the prior session, focusing on whether participants have completed the personal SMART goals they set for themselves at the end of the last session. The session then discusses additional ways of enhancing and maintaining motivation for decluttering. Participants are asked to visualize the way that they want their decluttered space to look. This exercise is also used to identify possible cognitions that may arise when participants imagine their decluttered home. Participants typically report positive cognitions and accompanying emotions but also may report negative cognitions about living in a cleared environment. This exercise also helps participants visualize what items they may prioritize in their decluttered home. Participants can be asked, “If you imagine your ideal space, is this item in that space? If so, where is it?” CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.



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Use of the visualization exercise is designed to increase motivation as it gives participants a goal to work toward. In addition, this facilitates prioritizing of items to be kept, as participants can be asked where the kept item is located in their visualization. If they are unable to state where the item is in their ideal home, they can be asked to reconsider keeping the object. Participants are then encouraged to practice the motivational skills as necessary. Group leaders can help participants apply relevant skills, such as the motivation and discarding worksheet, weighing pros and cons, or using the decluttered home visualization. This extra practice is to consolidate learning and to assist participants in applying skills appropriately. Next, participants are asked to practice decluttering in session, using motivational techniques as necessary, including the motivation and discarding worksheet, weighing pros and cons, and reviewing personal goals and values. As usual, the session ends with a review of homework assignments for the week and setting of personal SMART goals.

1.  Homework Review CLASS TASK: Homework Review Review homework with class participants. The homework tasks were: 1. 2. 3. 4. 5. 6.

Reread information from week 9 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring items from home to class next week. Other: ________________________________________________________

Go around the room reviewing with each participant whether they were able to complete their personal SMART goal for the last week. Participants can also be asked if they are keeping up with the task of spending at least 30 minutes per day sorting and discarding. If participants did not accomplish their SMART goal, ask how they plan to change things this week so that their SMART goal is achieved. Group members can be encouraged to help to brainstorm and problem solve any difficulties in homework completion. If more than 75% of group members have completed their personal SMART goals, inform them that they have earned a point this week. Remind the group how many points they have earned toward the second group reward (the end‐of‐group party). Did at least 75% of the group complete their personal SMART goal this week?

❑ YES   ❑ NO

144 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide Have all participants turn in their In/Out Logs from the last week. Group leaders should set out the boxes/receptacles for any in‐session discarding. Remind participants that they are free to use the receptacles at any time as long as they do not distract the class. Now let’s talk more about motivation.

2.  Improving Motivation to Discard In the last chapter we talked about some ways to improve motivation to reduce clutter, and we discussed how it is normal for motivation to go up and down over time. Another way to boost motivation can be to visualize what you want your home to look like.

Visualize your Decluttered Space Often this is difficult for people to do because it has been such a long time since the house was clear – so you will need to use your imagination. As a class, close your eyes and imagine a certain room in your home being clear. Use as many of your senses as possible – what would the room look like, what would it smell like, where would the furniture be? Let’s first practice as a group.

CLASS TASK: Using Your Imagination to Visualize Your Decluttered Space Choose one room in your house and imagine that it is clear and tidy. How is it decorated? How does it smell? Where is the furniture placed in the room? Close your eyes and spend a few minutes imagining the room. Once group members have done this: Now, on page 115 of your workbook, write down what your decluttered space looks like. Group leaders can ask group members to share their thoughts about their visualization. Oftentimes participants will report pleasurable feelings and thoughts, but some group members may report ambivalence or even dislike of clear spaces. Group leaders can help them brainstorm ways that they can achieve perceived “pros” of clutter (e.g., a secure feeling, a “cozy” home) in a decluttered home. What do you like about the room? Why do you want it to look this way? How do you think family, friends, and others might react to the space as you are imagining it? Did any of you have negative emotions when you imagined the uncluttered space?



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Sometimes we find that some people experience some negative emotions, too, such as sense of loss, or a feeling that things are not “cozy.” Now let’s try something a little different. Let’s do this while you practice d­iscarding. You will need to select an item from your box of belongings to practice this. Have each group member select an item from their box. Ask participants to write where this item belongs in their home at the top of the worksheet on page 117 of  the participant workbooks. Below this, participants should write what this particular room looks like when it is tidy and the way they desire it. Participants are then asked to select yes or no in answer to the following questions about the item: 1. When you picture the room as you would like it to be, does the item that you are considering holding on to fit in the picture? 2. Is keeping this item going to help you achieve the image that you see in your imagination? Did any of you answer “No” to both of these questions? If so, can you consider discarding your possession now?

3.  Being Motivated By Your Values Next we are going to practice combining the skills from the last two chapters as we practice discarding. You can use any of the motivational skills from the past chapter to help you, such as: ●●

●●

●●

Filling out extra copies of the motivation and discarding worksheet (you can do this on scratch paper) Revisiting the previous chapter (pages 104–105 in the participant workbook) if you cannot remember some of things you listed as your personal goals and values Weighing the pros and cons of changing your behavior

Lay out bins for sorting and discarding and encourage participants to begin to practice sorting and discarding in session. Observe participants as they sort and discard. If participants elect to keep an item, ask where this item belongs in their visualized decluttered space. If participants struggle to make decisions about items, the group leaders can ask the following questions: 1. Would discarding this item help or hurt your top 3 goals and values? If you believe that it fits in with your values, please tell the group how so that they can better help you evaluate it. 2. If it would help your goals/values to discard, can you discard the item now?

146 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide 3. If no, why are you saving the item? Is this reason more important to you than your top 3 values and goals? 4. Is decluttering something that is very important to you right now? Why?

4.  Checking In on Long‐Term SMART Goals In Chapter 2 we spent some time setting a few short‐term and long‐term SMART goals. It is important to review these goals to make sure that you are on track to achieving them.

CLASS TASK: Checking In on Long-Term SMART Goals Look back to the long‐term SMART goals that you made at the start of treatment (page 25 of your workbooks). Discuss as a group whether you are on track to achieving your long‐term SMART goals. Consider whether you are making progress at a rate you are satisfied with. One way to do this is to consider how long you have been in the group. At this point in treatment you have been in the group for at least 2 months. If you continue at this rate of progress, how long will it take you to clear your home to a point that it is satisfactory to you? If you feel that you are p­rogressing at too slow a rate, that may signify that your plan of  attack needs to change somehow, or you may need to change the scope of your goal. Have group participants discuss any desired/needed changes to their plan to meet their goals. Have them list their plan specifics in the blanks on page 118 of their workbooks.

5.  “Bad Guy” Re‐evaluation CLASS TASK: “Bad Guy” Re-evaluation Over the past two weeks we have talked about motivation. Take some time to evaluate how much you think this “bad guy” is contributing to your acquiring behavior and difficulty discarding. On pages 118–119 of your workbooks, you will see scales to rerate how much you think motivational issues are getting in the way for you over the past couple of weeks; one scale is for acquiring and one is for discarding. Take some time now to rate from 0 (not a problem for me) to 10 (a very big problem for me).



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Acquiring: How much do you think low motivation is getting in the way of you resisting acquiring? In other words, are you feeling like you don’t want to work on your clutter problem right now? 0

1

2

3

4

5

6

7

8

9

10

0 = Not a problem for me 10 = A very big problem for me Discarding: How much do you think low motivation is getting in the way of you  discarding? In other words, are you feeling unmotivated to work on your d­iscarding right now? Or are you thinking that maybe your clutter isn’t such a big problem after all? 0

1

2

3

4

5

6

7

8

9

10

0 = Not a problem for me 10 = A very big problem for me Do you think your motivation for change has improved since the start of treatment? Or, if you started out with a high level of motivation, has it been maintained? Are you confident that you can keep up a good level of motivation for change? What skills from the previous two chapters might you need to practice more?

6. Homework Have participants open to page 119 to review the homework assignments for this week. Your homework this week is: 1. 2. 3. 4. 5. 6.

Reread information from week 10 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring lots of items from home to class next week. Other: ________________________________________________________

As usual, go around the group quickly, having each participant set a personal goal for the week that follows the SMART guidelines and is appropriately challenging. They can write their SMART goals on page 119 of their workbooks.

Chapter 11

Putting It All Together Part 1

1. Homework Review (15 minutes) 2. Troubleshooting Common Barriers (30 minutes) Barrier 1: Areas Getting Recluttered Barrier 2: Cannot Access the “Final Home” for Objects 3. Putting It All Together (30 minutes) 4. Homework (15 minutes)

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Overview As in prior sessions, the group starts with a review of homework completion, checking in with each participant to see if they completed the personal SMART goal set at the last session. The first two potential barriers are introduced and discussed. These barriers are (a) difficulty maintaining areas that have been decluttered, and (b) being unable to access the “final home” for objects due to remaining clutter. To maintain areas that have been decluttered, participants are encouraged to create plans for maintenance of upkeep tasks that should be done on a regular basis. Participants with the second problem are instructed to use temporary housing for the type of object. For example, a participant who cannot access storage underneath her sink may temporarily place all cleaners and brushes in a box marked “cleaning supplies.” The intent is to remove the items from the box and place them in their final home as soon as possible, to minimize the amount of temporary locations used. CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.



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This box should be placed near its final home to facilitate easy finding when the c­ategory of object is desired and easy transfer when the area is cleared. Participants often report that at this point in the group, areas that they have p­reviously decluttered are gradually getting recluttered. These areas are often commonly used areas such as tables and counters, and tend to easily get recluttered by lack of upkeep of maintenance tasks such as dish washing, sorting through mail, or doing laundry. Early in the group, participants are encouraged to focus on one area at a time for decluttering. They are also encouraged to limit categories for objects, ideally having a single “final home” for most objects. However, participants often complain that they are unable to follow these recommendations as they have an intended final home for an object but are unable to access the area due to clutter.

1.  Homework Review CLASS TASK: Homework Review Check whether participants have completed their homework tasks: 1. 2. 3. 4. 5. 6.

Reread information from week 10 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring lots of items from home to class next week. Other: ________________________________________________________ Let’s begin as we normally do, by going around and checking with everyone to see whether they have achieved their SMART goals. Did at least 75% of the group complete their personal SMART goal this week?

❑ YES   ❑ NO

Collect In/Out Logs from each participant. Review with the group how many points they have toward the group reward. Inform them how many sessions they have left prior to the end of group and how many points need to be obtained by then in order to receive the group reward. You have now learned about all the “bad guys” and how they contribute to your problem with clutter. You have also learned some practical techniques for addressing each of these “bad guys”. In the remaining sessions of the Declutter Class we will get lots of practice using the skills that we have gone over so far. It is very important that you bring in many belongings from home for every session, because we will focus mainly on discarding

150 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide over the remaining weeks. You will also need to bring a greater number of belongings than you have in previous classes. In each of the “Putting it together” classes we will also talk about some common barriers to discarding. These are problems that our other class members have discussed in the past. You are also welcome to bring up any other barriers you feel are getting in your way, so that as a group we can talk about/brainstorm ways of addressing this barrier or applying the skills that we have learned to overcome it. Let’s start by first looking at a couple of these barriers.

2.  Troubleshooting Common Barriers Barrier 1: Areas Getting Recluttered “Even after I successfully declutter a particular area, it gets cluttered again – pretty quickly.” Even after you have successfully decluttered a target area, it’s very easy to slip back into your old ways. In order to prevent this from happening, we recommend implementing a plan for regular upkeeping and strategies to maintain your motivation. Regular upkeeping You’ll need a plan for keeping up with new items that come into your home (e.g., mail) and regular chores you have to do. By having a routine time or day for items such as mail, laundry, trash, etc., you will be better able to keep new clutter from developing. Just like with your decluttering, we highly recommend that you make an effort to do these things on a routine basis – doing them at a certain time every day or every week helps make them a habit! Here are some suggestions for routines for regular upkeeping (listed on page 124 of your workbooks): ●● ●● ●● ●● ●● ●● ●● ●●

Pick a time to sort new mail and papers daily. Empty your trash twice per week or more if needed. Take the trash out at the same time every week. Wash the dishes every day. Wash your clothes once a week or more if needed. Set up a time and system for paying bills by the due date. Put away new items as soon as you bring them home, or at least that same day. Clean out refrigerator at least once per week.

Let’s come up with a plan for regular upkeeping for you. On page 124 of your workbook, write down your plan of how you will keep up with tasks such as mail, bills, dishes, laundry, and other incoming items. Are there other items for which you need to come up with a plan? Ask your fellow group members and group leaders for suggestions if needed.



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Barrier 2: Cannot Access the “Final Home” for Objects “Where do I put things when its ‘final home’ is inaccessible? I am just churning.” This is a difficult challenge. As you learned previously, we want to minimize churning and delaying making a decision about where to put an item. As much as possible, we want to make a decision once about whether to keep an item, where it belongs, and then put it there. But when you are at the beginning of your work on overcoming clutter, this can be hard to do as the intended place for your item may already be cluttered with other items, and it’s not possible to put the intended item there. In these cases, we recommend you use an “intermediate staging area.” This  would be an area (or a box) where you put items that you have decided to  keep, but the place where you intend to put the item is too cluttered right now or is inaccessible for some other reason. It is often helpful to label this box with the location that these items will go once you can reach that area. Ideally, you should have only a small number of these intermediate “homes” for objects, as the objects should go to their final home as soon as possible (which, as you have learned in a previous chapter, should only be one or two locations in your home). Take a few minutes to think about areas in your home that are currently too c­luttered and where you may have to use a staging area until you declutter that area. On page 125 of your workbooks there is a table for you to write down any rooms/ areas that may be in need of a staging area, and to think about what you may use as a staging area as you work on that section. If you feel you will need to do this, you may want to take a moment to complete this table now.

3.  Putting It All Together Over the remaining weeks you will use a flowchart and practice the skills we have talked about previously to help you to discard. The flowchart is designed to help you know where and when to apply certain skills from the group. First choose an item from your box of belongings, then follow the flowchart. Over time we want you to be able to work through the flowchart relatively quickly. Is someone willing to do a sample item in front of the group now so that we can work through the flowchart? Work through the flowchart with one or two examples from the group, having the group help apply skills as necessary. It might be useful to draw the flowchart on the whiteboard so that participants can quickly learn the discarding system (which will be used over the next 4 weeks).

152 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide Sample flowchart What is the item? _________________________________________________ Can I discard this item?

Yes

No

Place in correct location • Trash can • Recycling box • Donation box

Which “bad guy(s)” is getting in the way?

Decision making and problem solving

Intense emotions

Unhelpful thinking

Motivation

What skills from the declutter class can I use to help me overcome this “bad guy”?

Practice using the skill and reassess next week

CLASS TASK: Putting the Skills Together We now want you to practice discarding your belongings. You have extra copies of the flowchart on page 126 to help you make decisions about which group skills may be useful. If you run into a difficult item, please let group leaders know. The group can help you apply skills to make a decision or help you tolerate the emotions. After you make a decision about one item, move onto the next item. The goal is to discard as much as possible. The only way to reduce the clutter in your home is to discard your items. You can’t have a clear house and keep all your belongings. The idea is to choose what is absolutely necessary and most important to you. Please begin discarding now. Once all members of the group have sorted and discarded for around 10 minutes: So now that you’ve practiced discarding while paying attention to the “bad guys,” what did you learn? On page 126 of your workbooks, write down which of the “bad guys” you feel is still interfering most with your discarding. What skills might be h­elpful here?



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If you noticed that a certain “bad guy” keeps coming up, we recommend reviewing the appropriate chapters and practicing the skills described in that chapter. For example, if intense emotions kept getting in the way, use the strategies introduced in Chapters 5 and 6 when attempting to discard.

4. Homework Have participants open to page 127 to review the homework assignments for this week. Your homework this week is: 1. 2. 3. 4. 5. 6.

Reread information from week 11 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring lots of items from home to class next week. Other: ________________________________________________________

As usual, go around the group quickly, having each group member set a personal goal for the week that follows the SMART guidelines and is appropriately challenging.

Chapter 12

Putting It All Together Part 2

1. Homework Review (15 minutes) 2. Troubleshooting Common Barriers (30 minutes) Barrier 3: Conditions That Interfere with Discarding Barrier 4: Not Having Information About What to Keep or Not Keep 3. Putting It All Together (30 minutes) 4. Homework (15 minutes)

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Overview The session begins with a check‐in to see if participants have completed SMART goals set at the end of the last session. Next, the second two potential barriers are introduced: (a) medical and mental health conditions that may interfere with discarding, and (b) having a lack of information about what items should be kept for future reference. This conversation tends to focus on paper items, such as receipts, paycheck stubs, tax forms, and other personal records. The second barrier is designed to help participants obtain guidelines about what items are normatively kept. Participants are reminded that most paper items are available online, and are encouraged to use online records in place of retaining paper records whenever possible. As in the previously conducted “How Much Is Too Much?” module, group members can discuss what items may be needed. Group leaders can facilitate a discussion of whether participants may be overestimating the likelihood or severity of negative CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.



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outcomes that could arise from not having the items. Opinions in the room are likely to vary, and group leaders can use this variance as a way to demonstrate that there are many opinions about how long records should be kept. Group leaders can then focus on teaching participants a more scientific method of decision‐making. Potential questions for discussion include how to make decisions based on disparate information, what sources to consult, and how many sources to consult in order to be confident in one’s conclusions. A large portion of the session is then spent on in‐session sorting and discarding, having participants use a flowchart if necessary to prompt them to use previously learned skills. As with all prior sessions, the session ends with having each participant briefly set their SMART goal for the week.

1.  Homework Review CLASS TASK: Homework Review Review each participant’s homework compliance. The homework tasks from last week were: 1. 2. 3. 4. 5. 6.

Reread information from week 11 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring lots of items from home to class next week. Other: __________________________________________________________ Let’s begin as we normally do, by going around and checking with everyone to see whether they have achieved their SMART goals. Did at least 75% of the group complete their personal SMART goal this week?

❑ YES   ❑ NO

Review with the group how many points they have toward the group reward. Inform them how many sessions they have left prior to the end of group and how many points need to be obtained by then in order to receive the group reward. Have all participants turn in their In/Out Logs from the last week.

2.  Troubleshooting Common Barriers Just as we did in the last chapter, let’s talk about some other barriers that past groups have told us often get in the way.

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Barrier 3: Conditions That Interfere with Discarding “I have chronic pain or medical conditions that make it hard for me to practice discarding.” If the group does not have any medical or mental health conditions that they ­perceive as interfering, remind them that these issues can occur in the future, and therefore it is good to preemptively address this barrier. In addition, this problem can also arise when people are just generally feeling ill, fatigued, or otherwise incapacitated, and therefore it is good to problem solve. Sometimes people have other medical conditions that affect their mobility and make it difficult for them to practice sorting and discarding. However, at the same time, if you don’t practice discarding then your house won’t become clear, so it is important to work out a way for you to still practice your discarding, but to do it in a manner that also allows you to manage your medical conditions. The best way to do this is to pace the discarding. In the Declutter Class we have emphasized discarding for 30 minutes a day, and this is the minimum that people require in order to make a significant dent in their clutter. However, this does not mean that it has to be 30 minutes all at once. Past class members have broken this up into more manageable time limits for themselves, such as two 15‐minute intervals or three 10‐minute intervals. The point is that across the day your discarding adds up to at least 30 minutes. Of course, if you can do more than 30 minutes a day we highly encourage that. So if you find that your medical conditions are getting in the way of you discarding, then it might be best to pace the level of discarding to one that suits you. Remember, though, that discarding is an essential component of clearing your home, so it is important that you devote the time to it, but make the discarding time work for you. We have also found that discarding can often still be done when you are reclining or seated. Some time sorting through a pile of paperwork or mail can be a good choice in this case. We have also found that some individuals in past groups have enlisted a supportive helper – someone who is willing to sort through, carry, or discard objects for them, but who will be supportive and still allow you control over your objects. This type of person can be hard to find sometimes, but can often be quite helpful. If this barrier is a problem for you, what might be some ways you can work around it? You may want to write these down. There is a space on page 131 of your workbook for you to do this if you wish. You may also want to revisit the three steps of problem solving to help you deal with this problem: ●● ●● ●●

Step 1: Name the problem Step 2: Brainstorm solutions and consider the pros and cons of each solution Step 3: Select preferred solution(s)



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Barrier 4: Not Having Information About What to Keep or Not Keep “I feel like I am not sure what I really need to keep, or how long to keep it.” Even after working through the skills of the Declutter Class, some people say that they are still not sure what they should keep and what is not necessary to keep. This is normal – often people want to be certain that they are not making a mistake about something. Certainly, there are things, which tend to be paper records like tax returns, that it is good to hang on to for a little while. However, you may be unsure what items to keep, and for how long. In this situation it might be helpful to go back and revisit some of the information we talked about previously. Chapter 8 In Chapter 8 we talked about some of the questions that can be helpful to ask yourself when you are thinking about discarding something. Some of the most important questions that apply to this situation include the following: ●●

●●

●●

Would someone without a clutter problem keep the item?  If someone without a clutter problem would keep the item, then you may also need to keep it. This would include important documentation like birth certificates, passports, insurance information, and so on. However, if someone without a problem with clutter would throw it away, then you could also probably throw it away. Would you be able to get the item again in the future if you needed it?  If you are able to get the item or information again in the future if you needed it, then you probably don’t need to keep it and it can be discarded. Keep in mind that nearly everything informational is available via computer these days, and holding on to paper documentation is generally much less necessary. If you discarded the item would something bad happen to you?  If there is a bad consequence of not keeping the item then you may need to keep it. A bad consequence might be something like losing your house or needing to pay a lot of money as a result. However, if the only negative consequence is one of intense emotions, then you can most likely discard the item because, as we learned in the Declutter Class, intense emotions will decline over time.

However, keep in mind that you may be perceiving that there will be a bad consequence and that it will be severe, but this may not be the case. If you are unsure if something bad will happen to you, or how severe it might be, you may want to ask people who do not have a clutter problem whether they hang on to such an item, and for how long. It is probably best to survey several individuals (who do not have a clutter problem ­themselves!) to get a sense of how long they hang onto an item.

158 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide If you are unsure whether it is risky to dispose of an item, it may help to consult an expert. For example, if you are worried about how long you should keep your tax paperwork, you may want to consult a professional accountant. There is often a lot of misinformation about how long to keep items so you may want to consult a knowledgeable person instead of hanging onto the information “just in case.” Chapter 3 In Chapter 3 we talked about guidelines for discarding. A lot of people find it helpful to go back and review these guidelines from time to time and in this situation some of the following rules may help.

●●

●●

The 12‐month rule.  If you haven’t used the item in the last 12 months, then chances are you are able to discard it. The throw‐it‐away rule.  If your item is damaged in any way  –  stained, has  holes in it, or is not working properly  –  then it is best just to throw it away.

In Chapter  3 we also talked about how much is too much to keep of any particular item. It might also be helpful to go back and revisit that part of your paperwork. It may help to answer the question about whether or not you need to keep the item. If you have reviewed the Declutter Class materials and you are still unsure about whether or not you should throw the item away, then chances are you probably don’t need to keep it and the item can be discarded. We understand that making the call on when to throw things away is difficult, but if you are not sure, then chances are you probably don’t need it. The good news is that over time you will find that making these decisions will become easier.

3.  Putting It All Together Last week we practiced putting all the skills together and learned how to practice discarding using the discarding flowchart. In this class we will practice discarding again. Just like last week you will stop your discarding and discuss your progress with the class from time to time. We want you to practice discarding as many items as possible. Again, use the flowchart to assess each item and ask your group leader if you need help. Please begin discarding now.



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Sample Flowchart What is the item? ___________________________________________________ Can I discard this item?

Yes

No

Place in correct location • Trash can • Recycling box • Donation box

Which “bad guy(s)” is getting in the way?

Decision making and problem solving

Intense emotions

Unhelpful thinking

Motivation

What skills from the declutter class can I use to help me overcome this “bad guy”?

Practice using the skill and reassess next week

Ensure that participants have brought a diversity of items that are sufficiently ­challenging for them. We often find that at this point in treatment participants are bringing in “safe” items that they can discard in front of the group to demonstrate success, not bringing in random or challenging items as requested. Group leaders may need to remind the group that the point of these discarding sessions is to practice making difficult decisions, not just to spend time discarding (since discarding of easier items can be done outside the session).

4. Homework Have participants open to page 134 to review the homework assignments for this week. 1. 2. 3. 4. 5. 6.

Reread information from week 12 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring lots of items from home to class next week. Other: ____________________________________________________________

As usual, go around the group quickly, having each group member set a personal goal for the week that follows the SMART guidelines and is appropriately challenging.

Chapter 13

Putting It All Together Part 3

1. Homework Review (15 minutes) 2. Troubleshooting Common Barriers (30 minutes) Barrier 5: My Family Member Also Has Hoarding Disorder Barrier 6: I Feel Like I Can’t Get Rid of Items If They Are Worth Money 3. Putting It All Together (30 minutes) 4. Homework (15 minutes)

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Overview As usual, the group starts out with a review of completion of SMART goals set at the end of the previous session. Potential barriers 5 and 6 are then introduced. Barrier 5 discusses what to do if there is another individual in the home (typically a spouse) who is also perceived to have hoarding disorder, or who is uncooperative with decluttering efforts. Barrier 6 is designed to help participants who feel an excessive need to sell items, despite high levels of time and effort spent in the selling process with relatively low monetary return. As in the prior session, much of the remaining time is spent completing in‐session sorting and discarding practice. Again, participants are encouraged to use the skill flowchart to aid in application of group skills as necessary. Due to the high heritability of hoarding disorder (Samuels, Bienvenu, et al., 2007), participants in the group are likely to have family members with hoarding disorder. It is not uncommon for participants to state that they grew up in a home with clutter, CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.



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having had a parent who hoarded items; or to have a spouse who also saves or acquires excessively. Group members often express frustration that some items or areas of the home are off‐limits as they “belong” to the family member. In this case, participants are encouraged to focus on the areas that they do have control over. We have found that participants often get stuck on the few areas they do not have perceived control over, and de‐emphasize areas that they may be able to have more success with. Participants who desire to sell items are encouraged to choose methods of sale that are quick, easy, and result in a decent rate of return. Participants are encouraged to use quick methods such as tag sales to sell many items at once, instead of methods such as eBay or craigslist that require listing each item. As many participants will often insist on selling items, they are encouraged to set reasonable limits of how much time the item will be for sale before it is discarded or donated. The group can provide feedback about whether the time limits are reasonable or excessive.

1.  Homework Review CLASS TASK: Homework Review Review each participant’s homework. The homework tasks from last week were: 1. 2. 3. 4. 5. 6.

Reread information from week 12 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring lots of items from home to class next week. Other: ________________________________________________________ Go around the room reviewing quickly with each participant whether they have met their personal SMART goal set at the end of last week’s session. Participants can also be asked if they are keeping up with the task of spending at least 30 minutes per day sorting and discarding. If participants did not accomplish their SMART goal, ask how they plan to change things this week so that their SMART goal is achieved. Group members can be encouraged to help to brainstorm and problem solve any difficulties in homework completion.

Did at least 75% of the group complete their personal SMART goal this week?

❑ YES   ❑ NO

162 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide If more than 75% of group members have completed their personal SMART goals, tell them that they have earned a point this week. Inform the group how many points they have earned toward the group reward (the end‐of‐group party). Have all participants turn in their In/Out Logs from the last week. Group leaders should then set out the boxes/receptacles for any in‐session discarding. Remind participants that they are free to use the receptacles at any time.

2.  Troubleshooting Common Barriers As we have done in the previous weeks, we will also discuss solutions and strategies to deal with some common problems that can come up when people are decluttering.

Barrier 5: My Family Member Also Has Hoarding Disorder “I am having a hard time decluttering because many items aren’t mine, and my family member isn’t helping maintain the areas I’ve already d­ecluttered.” As we discussed earlier in the Declutter Class, hoarding has a strong genetic influence. This means that often we find that family members of our class members also often have problems with clutter. Sometimes the family member is aware of the problem and wants to address it, but sometimes they do not want to change their behavior. If the family member does want to address their problem, then it might be helpful for them to enroll in a class like the Declutter Class where they will learn skills to help them discard and reduce the clutter in their home. We generally don’t recommend that you try to teach your family member the skills. Other times the family member does not want to change, or does not recognize that there is a problem. This can be a tricky situation for our class members because they are working hard to clear parts of the home while their family member does not want them to discard items or fills the home up with other items. In situations such as this, we encourage you to focus on what you can change. Remember that you cannot change others. However, by acting as a good role model for your loved one, they may see that change is possible. They may begin to observe benefits from having less cluttered space, and they may see that decluttering is p­ossible, and that it may not be as difficult as believed. Also, provide positive feedback to your loved one when they make efforts to declutter and help you declutter. If they do try to make changes, however small, praise their efforts and let them know you appreciate it. We also often find that even if loved ones or others in the home do not have hoarding disorder, sometimes they are not exactly cooperative with efforts to declutter. Have any of you experienced this? Have any of you found ways of dealing with this that have been helpful?



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Barrier 6: I Feel Like I Can’t Get Rid of Items If They Are Worth Money Often people have difficulty discarding because they feel like they cannot discard anything if it is worth money, even a very small amount of money. Often this leads people to want to sell the item rather than discard it. This makes sense because often people with a problem with clutter do not want to be wasteful; however, selling the item often takes a lot more planning and effort than just discarding it. Because people with hoarding disorder often have trouble with planning and following through with their plans, we recommend that people discard most items and try to sell very few items. We find that often when people try to sell an item they just end up keeping it because it is too much effort. This means that it takes a lot longer to clear out your home. Remember that when you are trying very rigidly to avoid being wasteful, you are letting your emotions drive the bus. In these instances, you are likely wasting time, money, and effort. Consider whether selling something is worth your time, effort, and trouble, or whether you are doing so just to avoid feeling wasteful. If this is a barrier that you find yourself coming up against, then it might be helpful to make some deadlines for yourself. For instance, “If I don’t sell the item within two weeks then I must discard it by throwing it in the trash or donating it to charity.” Have participants write their responses to the following questions on pages 139–140 of the participant workbooks. ●●

●● ●● ●●

What are some items in your home that you are reluctant to discard because you believe they are worth money? Can you sell these items quickly? If so, how? What is a reasonable deadline to sell it within (e.g., 1 week or 2 weeks)? How will you discard the item if you do not sell it by the deadline?

3.  Putting It All Together We know that when we are learning any new behavior we have to practice a lot before we get really good at it. This is the point of the remaining classes. We want you to practice discarding over and over so that you become very good at making decisions about discarding. This will allow you to practice the skills until they become automatic. Did everyone bring items with them to sort and discard? Bringing many items to work on in these remaining sessions is extremely important. Is everyone bringing challenging items that they would like help with? As a reminder, please do not bring items you have already made decisions about. We would like you to practice using the group skills in session, so having items that are difficult to decide on is typically most helpful. For those of you who have

164 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide particularly troublesome categories of items that you have been reluctant to work on so far, please try to bring some of these items into session to discuss. In the class this week we will practice discarding again, and from time to time we will stop and review your progress. Use the flowchart (if you need to) on page 140 of your workbooks to assess each item and ask your group leaders if you need help. For now, please try to stay focused on your own items. Please take some time to go through several items now. Again, the flowchart guides participants through questioning which “bad guy” may be interfering with discarding the object. Once participants have practiced discarding several objects on their own, have some group members share an item with the group, working through an example in front of the entire group. Ask the group to help identify: ●● ●●

●● ●●

Which “bad guys” might be present? What skills learned in the group might be helpful in deciding about/discarding the object? How can we apply this skill? If you decide to keep an item, where is its final home – where does it belong in your ideal home?

4. Homework Have participants open to page 141 to review the homework assignments for this week. 1. 2. 3. 4. 5. 6.

Reread information from week 13 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring lots of items from home to class next week. Other: ________________________________________________________

As usual, go around the group quickly, having each group member set a personal goal for the week that follows the SMART guidelines and is appropriately challenging.

Chapter 14

Putting It All Together Part 4

1. Homework Review (15 minutes) 2. Troubleshooting Common Barriers (30 minutes) Barrier 7: Being Overly Careful When Discarding Additional Barriers (Optional) 3. Putting It All Together (30 minutes) 4. Homework (15 minutes)

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Overview As usual, the session begins with a review of completed homework, with particular attention to whether participants have completed the SMART goals that they set for themselves at the end of last week’s session. Barrier 7 is then introduced. This barrier discusses safety behaviors that participants often use when they are discarding, such as checking, spending large amounts of time making decisions about objects, and researching places to donate or sell the object. Together these activities are greatly time consuming and lead to inefficient discarding. They often cause participants to feel overwhelmed about discarding and as if they are not making the amount of progress that they would like. These behaviors are discussed as rigid safety behaviors that protect individuals from negative affect, but that also inhibit new learning and lead to increased negative affect as progress is hindered (e.g., Deacon & Maack, 2008). Participants are encouraged both to identify areas in which they may have these rigid safety behaviors and to begin to experiment CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.

166 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide with these behaviors in order to (a) test out feared outcomes, (b) habituate to d­iscomfort, and (c) obtain self‐efficacy in coping. At this point in the group, participants are often discarding items but continue to do so relatively inefficiently. Group leaders may want to spend some time discussing with participants how they may begin to design exposures to reducing safety behaviors. In our experience, participants are particularly hesitant to let go of these behaviors. Therefore, group leaders may want to discuss small behavioral experiments that participants can do to begin to test out reduction of safety behaviors. Some examples may be reducing the amount of reading of paperwork prior to discarding it, or choosing only one place to sell or donate items. Time in the session is set aside to discuss a final additional barrier that may be relevant to the group. The group is asked to provide suggestions for this final barrier; alternatively, the group leaders may select an additional barrier that they feel the group is struggling with. The session ends with in‐session practice in sorting and discarding. Participants are encouraged to use the skill flowchart as necessary.

1.  Homework Review CLASS TASK: Homework Review Review each participant’s homework compliance. The homework tasks from last week were: 1. 2. 3. 4. 5. 6.

Reread information from week 13 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring lots of items from home to class next week. Other: ________________________________________________________

Go around the room reviewing quickly with each participant whether they have met their personal SMART goal set at the end of last week’s session. Participants can also be asked if they are keeping up with the task of spending at least 30 minutes per day sorting and discarding. If participants did not accomplish their SMART goal, ask how they plan to change things this week so that their SMART goal is achieved. Group members can be encouraged to help to brainstorm and problem solve any difficulties in homework completion.

Did at least 75% of the group complete their personal SMART goal this week?

❑ YES   ❑ NO



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If more than 75% of group members have completed their personal SMART goals, inform them that they have earned a point this week. Tell the group how many points they have earned toward the group reward (the end‐of‐group party). Have all participants turn in their In/Out Logs from the last week. Group leaders should then set out the boxes/receptacles for in‐session discarding.

2.  Troubleshooting Common Barriers As we have done in the previous weeks we will also discuss solutions and strategies to deal with some common problems that can come up when people are decluttering. This week we will address one common barrier. We also want you to come up with another barrier that you have been experiencing and discuss as a class how you can overcome this barrier.

Barrier 7: Being Overly Careful When Discarding “I can discard things, but first I have to do a lot of time‐consuming preparation.” This is a common barrier that often comes up for people in our class. Often what happens is that they discard things, but first they have to do a lot of time‐consuming activities such as calling others to see if they want the item, reading through paperwork, shredding every piece of paper, making sure items go in the correct recycling bin or that they go to a donation center rather than in the trash. Often when people face this barrier they have very rigid rules around how to discard these items and they don’t like to do it any other way. A key message from the Declutter Class is to discard things quickly and to clear your home as much as possible within a short period of time. Obviously if discarding a single item takes a lot of time, then you won’t get your house as decluttered as you would like. Just like we discussed last week, if you are running into this problem, you are likely letting a fear of strong emotions get in your way. If this is a barrier for you we recommend practicing discarding things the “wrong” way; this means being less rigid and discarding things without following your strict rules. For instance, discarding an item without calling others to check if they want it, or throwing away paper in the trash without shredding it first. This will allow you to discard much faster and get through more items in your sorting and discarding sessions. This will ultimately mean a clear house much faster. This is not an easy thing to do, but with practice it will become easier and you will see that you are clearing more items in your home. On page 146, write down some of the strict rules you have that might be getting in the way of discarding items quickly and efficiently. Some examples are “I must recycle everything,” or “I must check these magazines for important information.”

168 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide Once participants have completed this section, ask if they are willing to share some of their rules. If there are clear rules that participants have that they have not voiced, bring up the rule you have noticed and ask the participant to consider writing down that rule as well. Are there ways that you can begin to not follow these rules so rigidly? This might be a good thing to integrate into your SMART goal this week.

Additional Barriers (Optional) Next, select an additional barrier to address. Group leaders may choose a barrier that they have noticed is common to the group, or ask the group to choose a barrier to work on. Ensure that this is a barrier that hasn’t been already covered by group materials. Barrier 8: __________________________________________________ Ask the group to brainstorm potential solutions/ways of addressing this barrier. They can be informed that there is space on page 146 of their workbooks to write down notes about this barrier if they desire.

3.  Putting It All Together For the last few weeks we practiced putting all the skills together and learned how to practice discarding using the discarding flowchart. We know that when we are learning any new behavior we have to practice a lot before we get really good at it. This is the point of the remaining classes. We want you to practice discarding over and over so that you become very good at making decisions about discarding. You  will probably notice that you are getting better with making decisions about discarding. Hopefully you can also discard much faster than you could previously. Let’s spend more time practicing. Please take out the items that you brought from home to practice sorting and discarding with. Again, on page 147 you will notice the flowchart that we have been using to practice. Please use this flowchart to help you if needed. Please spend some time sorting and discarding your items from home now. After participants have spent 10–15 minutes discarding, ask a participant to choose an item to practice with the group. It is often most helpful to select a participant who appears to be struggling with applying skills. The group can be used to help this person identify which “bad guys” may be getting in the way and what skills from group can be used. It is also often helpful to remind participants at this stage that the goal of the group is to get rid of items, and that it is important to stay on track with helping the individual apply skills. During this stage group members will often get sidetracked



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easily, wanting to ask for detail and background about the object, or provide not so helpful suggestions, such as suggesting time‐consuming ways to find potential homes for the object. Remind the group that the point of the practice (and the group!) is to discard items/make decisions quickly.

4. Homework Have participants open to page 148 to review the homework assignments for this week. 1. 2. 3. 4. 5. 6.

Reread information from week 14 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring lots of items from home to class next week. Other: ________________________________________________________

As usual, go around the group quickly, having each group member set a personal goal for the week that follows the SMART guidelines and is appropriately challenging.

Chapter 15

Staying Clutter Free in the Future Part 1

1. Homework Review (15 minutes) 2. Reviewing Progress (30 minutes) What You’ve Learned Choosing How You Think About Progress Class Task: Write Down Your Thoughts About Your Progress 3. Practice Discarding (30 minutes) Class Task: Practice Discarding 4. Homework (15 minutes)

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Overview The session begins with the usual review of homework, having each participant report on whether they met their SMART goal set at the end of the last session. This and the subsequent session focus on relapse prevention. This first session on relapse prevention provides participants with a review of the skills they have learned in the group, and asks them to identify which skills have been the most helpful. Participants are encouraged to make a note of these skills so that they can continue to rely on them in the future. Participants are then led through a discussion on their cognitions about their progress and their ability to maintain gains. Participants are encouraged to challenge any negative thoughts about progress using previously learned cognitive challenging skills. Participants are encouraged not to be overly pessimistic about slips in acquiring or intermittent difficulty discarding, as these are normative. CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.



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The session ends with a large portion of time spent in in‐session sorting and ­ iscarding. In the last 10–15 minutes of the session, participants are asked to set d their final weekly SMART goal. Participants are informally educated about the abstinence violation effect (AVE; Marlatt & Gordon, 1985). The concept of the AVE comes from the literature base on addictive behaviors, particularly substance use disorders. According to this model, negative cognitions in response to “slips” in behavior result in further negative affect, increased urges to use, more maladaptive coping behaviors, and therefore an increased likelihood of continuing to engage in the addictive behavior. A slip in a behavior one was trying to control becomes a “relapse” rather than just a “lapse.” Marlatt and Gordon (1985) therefore state that avoiding a relapse (a return to reliance on the maladaptive behavior) can be facilitated by learning to view the slip as simply a “lapse,” after which the individual can decide to get back on the wagon or engage in a full relapse. Applying this model to hoarding disorder, participants are encouraged to view natural ups and downs in their progress as normative and are encouraged to stay the course with positive coping thoughts rather than self‐berating thoughts.

1.  Homework Review CLASS TASK: Homework Review Go around the class checking in with each person as to whether they completed the homework, particularly whether they have achieved the SMART goal that they set at the end of the last treatment session. The homework tasks included: 1. 2. 3. 4. 5. 6.

Reread information from week 14 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Bring lots of items from home to class next week. Other: ________________________________________________________

If participants were unable to complete the SMART goal, briefly problem solve with them. How can they make it more likely that they will succeed next week? Did at least 75% of the group complete their personal SMART goal this week?

❑ YES   ❑ NO

If more than 75% of group members have completed their personal SMART goals, inform them that they have earned a point this week. Tell the group whether

172 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide they have earned the group reward of the end‐of‐class party. If so, praise them for their hard work and let them know that the end‐of‐class party will be at the next session! Next week, since it is our last session together, we will spend some time looking at before and after pictures of your home! So please take photos of each room of your home, along with any other relevant areas (e.g., porch, car). You may send these via email to the group leaders, or bring them to share at the next session. As always, these photos are important so please bring or send them. Please take photos of all of the rooms of your home, not just the ones that you have been working on. We will look at the progress you have made and discuss your goals going forward. Have all participants turn in their In/Out Logs from the last week. Group leaders should then set out the boxes/receptacles for any in‐session discarding.

2.  Reviewing Progress What You’ve Learned Now you know how to recognize and fight all the “bad guys” that contribute to your hoarding behaviors. Below is a reminder list of some of the main things you’ve learned. As we review the list, check off the ones that you think have been the most helpful. 1.  Making efficient decisions and solving problems effectively ●● Use the problem‐solving model: Brainstorm possible solutions without judging. Try the solution(s) and evaluate the results. ●● Use the 10 guidelines for discarding and stopping acquiring. ●● Schedule times for discarding. ●● Improve organization by having a home for every category of items. ●● Know and avoid high‐risk situations. 2.  Not so intense emotions ●● Notice your emotions and describe/accept them; you don’t need to let them be the boss. ●● “Ride the wave”: All strong emotions will decrease with time if you let them. 3.  More helpful thinking ●● Question the thoughts: Rather than accepting your thoughts, question them. Are they helpful or unhelpful? ●● Act as you would advise a friend: Respond to situations as you would advise a friend, rather than just accepting your thoughts as truth. 4.  Maintaining strong motivation ●● Increase your motivation by writing down the costs and benefits of discarding, or the costs and benefits of acquiring.



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Maintain motivation by setting realistic, concrete goals and making sure that you reward yourself after you accomplish your goal. Focus on your goals and values to help you to resist acquiring and increase your discarding. Use your imagination to help you see a house that is clutter free.

Now, on page 153 of your workbooks, write down the top three skills from the Declutter Class that you have found to be the most helpful. Once the group has written them down, ask for volunteers to share what skills they have found the most helpful.

Choosing How You Think About Progress Remember that progress takes time. You did not acquire all of your items overnight! It was likely a gradual process over many years. However, remember that you have complete control over how much time you devote to your decluttering, and how quickly you make decisions about your possessions. You have also come a long way in this program. By completing this program, you are all well on your way to achieving your goals of having a clear home! Oftentimes, we hear class members having mixed reactions to their progress, such as “Well, that’s good progress, but I still have so much to do!” Or possibly more negative thoughts such as “I didn’t achieve as much as I hoped.”

CLASS TASK: Write Down Your Thoughts About Your Progress On page 153  of your workbooks, please write down the thoughts that you have about your progress. Have participants discuss their thoughts with the group. Are these thoughts negative? Are they literally true? Are they helpful or unproductive? Remember that our thoughts influence how we feel, and how we behave! And remember that our thoughts are not necessarily true. Share your thoughts with the group. Are they accurate? Might they influence how you behave? Would you judge another group member as harshly? When we feel overly pessimistic about our progress and don’t give ourselves credit for the hard work that we do, it is even more difficult to keep up the hard work that decluttering takes. Remember to celebrate your successes, and to focus on what you have done, not just what is left to do. Keep in mind that you have total control over how much progress you make from here on out: Now you have the skills, so keep practicing them so they become more and more automatic.

174 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide

3.  Practice Discarding Earlier in the class you identified the aspects of the class that you found the most helpful. While this is important, it is also helpful to identify those skills that you still need more practice with. What are the aspects of the class that you think you need to practice more in order to achieve your goals? This might be using the skills to address one of the “bad guys”, or it might just be more practice discarding. On page 154  of your workbooks, write down at least three decluttering skills that you need to continue to practice.

CLASS TASK: Practice Discarding For the rest of the class we will again practice discarding. Please take out the items that you brought from home and begin to practice sorting and discarding. When you run into an item you are having a difficult time parting with or making a decision about, please let us know. We will ask you questions about your items as you go. Also, just a reminder: As we help others sort and discard, please keep in mind that the goal is to get rid of items efficiently. Please try to stay focused on helping to use skills from group to truly decide if that item is absolutely necessary to keep. Please begin sorting through your items now. Group leaders should observe participants as they sort and discard. If participants appear to have difficulty (i.e., appear to be spending long amounts of time making decisions, or are not discarding items), ask the participant to walk through discarding the item with the class, having the class assist with asking helpful questions. Ensure that the group discussion stays focused on helpful discarding questions and applications of group skills. Often participants will want to “tell the story” of the object before parting with it. We view this as adaptive and helpful, as long as the story is brief and the item parted with relatively quickly. Allow participants to share history and emotions surrounding objects when necessary, but ensure that participants are not using storytelling about the object to avoid making decisions.

4. Homework Have participants open to page 154  to review the homework assignments for this week. Again, since next week is our last scheduled group, please bring “post” photos of the main areas of your home. If you borrowed a camera from us you will also need to bring it back. We will spend some time in group next week examining photos, reviewing progress, and setting goals for the future!

1. 2. 3. 4. 5.

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Reread information from week 15 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Other: __________________________________________________________

As usual, go around the group quickly, having each group member set a personal goal for the week that follows the SMART guidelines and is appropriately challenging.

Chapter 16

Staying Clutter Free in the Future Part 2

1. Homework Review (30 minutes) 2. Maintaining Motivation (50 minutes) My Rewards for Working on My Hoarding Problem Class Task: Identify Some Goals and Rewards 3. Wrap‐Up and Questions (10 minutes)

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Overview The session begins with a review of completion of personal SMART goals set at the end of the last session. If participants have earned the group reward of the end‐of‐class party, the last session can also be used to celebrate. Post‐treatment photos of the home can be shared with the class and provide a good launching point for a discussion of goals going forward. The session then reviews previously discussed ways of maintaining motivation for discarding, such as using reward systems and practicing realistic thinking p­atterns. Participants are encouraged to set both short‐ and long‐term goals to be accomplished after group completion, and to set rewards for accomplishing these goals. The session ends with a treatment wrap‐up, in which therapists praise participants for their hard work and encourage them to ask any remaining questions. If the group met the requirements for the group reward, there will also be an end‐of‐class party. During the party we typically order pizza and hand out certificates of completion. CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.



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Accountability is emphasized through the use of the behavioral contingency (the end‐of‐class party, which we have found most groups do earn), and by sharing photos and personal goals with the class. Review of goal setting and reward systems is used as we have found that participants have often faltered in self‐administration of rewards at this point in treatment.

1.  Homework Review CLASS TASK: Homework Review Go around the class checking in with each person as to whether they completed the homework, particularly whether they have achieved the SMART goal that they set at the end of the last treatment session. The homework tasks were: 1. 2. 3. 4. 5.

Reread information from week 15 (including Rita’s story). Practice using the In and Out Log every day. Practice discarding for a minimum of 30 minutes per day. Complete weekly SMART goal. Other: _________________________________________________________

If participants were unable to complete the SMART goal, briefly problem solve with them. How will they change things going forward to make it more likely their goal is achieved? If group members have earned the group reward of the end‐of‐class party, now is a good time to celebrate and review before and after photos. In reviewing photos with the class, ask participants to point out areas of progress, and areas they intend to work on in the near future. We have found it helpful to also have pre‐treatment photos at this session, in order to compare and to help participants see progress that they have made. Group leaders should then set out the boxes/receptacles for any in‐session discarding.

2.  Maintaining Motivation Overcoming hoarding is hard work and it takes time (usually longer than the 16‐week Declutter Class). In order to make progress on your hoarding problem, it’s important that you find ways to sustain your motivation. Here are some ­suggestions from past participants in our class: 1. Reward yourself.  One way to keep up your motivation is to make sure that you are rewarding yourself for your efforts and your successes. Reward yourself each time you complete a sorting session – the amount of time you set out

178 CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide to sort. These rewards don’t have to be time consuming or costly. Think about what kind of things you would find rewarding, and write them down on the following page. Make sure that you reward yourself after each sorting session, but not until you actually sort for the designated amount of time or clear the particular area. 2. Be patient with yourself.  Remember that overcoming hoarding is hard work, and changes are not going to happen overnight. For many people who begin sorting/discarding, the clutter may actually appear to worsen in the beginning. Remember that the goal of sorting/discarding is NOT to do things perfectly. It’s OK if you’re not 100% sure where to put a particular item. Just pick the best choice possible in that moment, and move on. You can always come back to things later and change them, if you really need to. Also remember that sorting and discarding will get easier with ­practice – that is, the more you practice sorting, the better you will become about making decisions (keep, let go, choose category and location). You will also find that the more you practice sorting and discarding, the less distressing the task will become. 3. Use the skills you’ve learned so far – enhancing motivation and cognitive strategies.  If you’re feeling less motivated, go back to the Motivation sessions. Review the goals you set out at the beginning of the group (“Personal Goals”). If you are feeling overwhelmed just thinking about discarding or reading through this workbook, go back to review the “unhelpful thinking” sessions.

My Rewards for Working on My Hoarding Problem At this point, group leaders can discuss participants’ goals for continuation of decluttering and maintaining progress after the group. Participants in the hoarding group often tend to underutilize rewards for accomplishing goals and taking steps toward goals. Group leaders may want to brainstorm possible rewards again in group so that participants have a list of potential rewards going forward.

CLASS TASK: Identify Some Goals and Rewards In order to make sure that you continue to try to meet your goals after the group, let’s spend some time now identifying a few goals and rewards for yourself. There is a place to do this on page 160 of your workbooks. Take time now to list some goals for yourself to be worked on after the group, along with some rewards for accomplishing



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those goals. Include some short‐term goals (over the next week) and some long‐term goals (to achieve over the next few months or years). Often long‐term goals are b­igger goals (which should also attract bigger rewards)! Remind participants to pick goals that are specific, concrete, and realistic.

3.  Wrap‐Up and Questions Congratulations on completing the Declutter Class! You have put a lot of effort into getting to this point, and we hope that your progress will continue over the coming weeks and months. We encourage you all to stay in touch with each other after completion of the group. We have found that past groups sometimes like to share information and talk or get together after the end of the group. If you wish to do so, that is OK with us. The group leaders are also happy to answer any other questions that you might have at this time. Great job!

References

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.

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Appendix A

Clock Sign

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CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.

Appendix B

“Bad Guy” Reminder Cards for Participants

Chapters 3 and 4: Decision‐Making and Problem Solving

Chapters 5 and 6: Intense Emotions

10 Rules for Stopping Acquiring 1.  Have a budget 2.  Use a list 3.  Don’t use shopping cart/trolley 4.  Use the closest entrance/exit 5.  24‐hour rule 6.  Ditch the credit card 7.  Use the five steps to be your own boss 8.  Cancel subscriptions 9.  Avoid high‐risk areas/people/things 10.  Only acquire for “healthy” reasons

My Coping Statements for Intense E­motions: 1.  __________________

My Rules for Discarding: 1.  _____________________

Steps for Coping with Intense Emotions: 1.  Identify the emotion – notice and observe it. 2.  Use coping statements: “It’s OK to feel this way.” “I can cope with this feeling.”

___________________

2.  _____________________

___________________

________________

2.  __________________

________________

CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.

182

Appendix B: “Bad Guy” Reminder Cards for Participants

Chapters 7 and 8: Unhelpful Thoughts

Chapters 9 and 10: Waxing and Waning Motivation

Challenging Thoughts About Acquiring • Do I have a space for this in my home right now? • If I don’t acquire this, will anything bad happen? • Is this item in good working order/undamaged? • Can I comfortably afford this?

“Will‐Powering” Alone Doesn’t Work! You will need to set up your life to make it more likely that you will succeed. Reward yourself for your hard work. Avoid high‐risk situations. Set aside time for sorting and discarding each day. Recruit others who can help keep you motivated.

Unhelpful Thinking Remember that your thoughts are not always accurate.

My Most Important Values and Goals Why am I working on this right now? Why is this important to me? Why should I continue when I am feeling discouraged, fatigued, or overwhelmed?

Index

Acquiring, 4, 46, 64–65 decision‐making and, 61, 88, 94 emotions and, 10, 98–104, 109–114 family reaction to, 5, 45 guidelines for,77, 85, 88–92 impulsivity and, 10, 15 In/Out Logs and, 56, 68 measurement of, 31 modeling and, 7 motivation and, 11, 133–139, 146–147 other disorders and, 6 problem‐solving and, 92–95 relapse prevention and, 170–173 stimulus control and, 87–90 thoughts and, 9, 62, 103, 119–123, 126–131 treatment contract and, 44 triggers for, 84, 88–90 Troubleshooting and, 27–28, 125 virtual store and, 23, 28, 100–101, 109 Animal hoarding, 24 Attachment see Beliefs anthropomorphization and, 9 Attention biases of, 125, 128 impairment in, 6, 8, 13, 20, 29, 61, 72

Attention‐Deficit/Hyperactivity Disorder, 6, 17, 24 Avoidance, 4, 5, 10, 15, 62, 86, 88–89, 91, 99–100, 102, 105, 108, 110–111, 113–114, 116, 120, 163, 171 “Bad guys”, 22, 37, 47, 54–56, 60–66, 125, 149, 152–153, 164, 168, 172, 174 assessment of, 64–66 decision‐making and problem solving, 60, 96–97 intense emotions, 114–115 unhelpful thinking, 131–132 waxing and waning motivation, 146–147 Beliefs attachment‐related,9, 12, 122 avoidance and, 10 control‐related, 9 delusional, 11 emotion‐related, 104–105, 122 identifying, 121–123 identity‐related, 9, 116, 122 information‐related, 8, 9, 120, 167 memory‐related, 8, 122 perfectionism‐related, 9 pessimism‐related, 123 responsibility‐related, 9, 121

CBT for Hoarding Disorder: A Group Therapy Program Therapist’s Guide, First Edition. David F. Tolin, Blaise L. Worden, Bethany M. Wootton, and Christina M. Gilliam. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.

Index 191 as a target, 9, 13–14 usefulness‐related, 121 valuation‐related, 122 wastefulness‐related, 9, 118, 122, 163 Categorization, 8–9, 11–13, 72–73, 81–84, 149 “Churning”, 12, 17, 22, 36, 39, 41, 55, 62, 72, 76, 78, 100, 151 Clutter, 3, 4, 46 “churning” and, 39 collecting and, 52–53 decision‐making and, 90 difficulty discarding and, 10 disorganization and, 11, 61 emotions and, 100–102 expectations for, 47 family contribution to,159 family reaction to, 5, 46 goals and, 66–67, 136–137 health risk and, 4–5, 46 measurement of, 23, 31–32, 40–41 modeling and, 157 motivation and, 41, 64, 66, 133–136, 142 other disorders and, 7 relapse and, 30 social impact of, 5, 46 Cognitive restructuring, 13–14, 128–131 Cohesion, 21 problems of, 29 Comorbidity, 6–7 Confidentiality, 24, 29, 35–36, 41, 42 contract, 45 mandatory reporting and, 24 Contingency management, 16–17, 19–20, 23, 55–56, 58–60, 67, 176 administering, 76, 85, 97, 107, 140, 147, 166–167, 171–172, 176–177 self‐reinforcement and, 16, 20, 55, 58–59, 76, 107, 172, 177–178 Decision‐making categorization and, 73 disorganization and, 12 emotions and, 127 minimizing distractions and, 72–73 motivation and, 144–145 organization and, 81–84 perfectionism and, 9

problem‐solving and, 92–96 as a target, 8–9, 13, 61–62 Decision‐making training, 13, 22, 36, 38–39, 61–62, 73–97, 152, 172 Dementia, 7, 24 Depression, 6, 24, 63, 69, 101, 117, 128 Diagnostic and Statistical Manual of Mental Disorders (DSM), 3, 4, 6, 24 Difficulty discarding, 3, 4, 46 avoidance and, 10, 15 decision‐making and, 8, 61–62 emotions and, 60, 98, 101, 112 measurement of, 31 motivation and, 11, 135, 138, 144–145 other disorders and, 6 relapse prevention and, 167–168 thoughts and, 121, 128–131, 163 Troubleshooting and, 27 Disorganization clutter and, 53 decision‐making and, 61 as a target, 11–12 training for, 81–84 Donations, 13, 22, 27, 36, 38, 39, 75, 76, 84, 93, 95, 160, 161, 163, 165, 166 Economic impact, 5–6 Efficacy, evidence of, 18–19 Emotion regulation distress tolerance and, 10, 14, 28, 97, 102–103, 109, 114, 149 experiential avoidance and, 10 as a target, 9–10, 14–15 Emotion regulation training, 99–115 acceptance and, 14, 19, 99, 109–114, 116, 171 distancing and, 19 exposure and, 14, 166 goal‐directed behavior and, 15, 109–112 Emotions anger, 62, 101, 105, 115 anxiety, 5, 6, 9, 14, 19, 24, 52, 62, 63, 100, 102, 103, 110, 111, 125, 128 beliefs about, 104–105, 122 excitement, 10, 63, 100, 101, 110, 119 fear, 8–10, 62, 98, 101, 105, 116, 127, 166, 167 grief, 9, 62, 100, 101 joy, 100, 102

192 Index Emotions (cont’d) loneliness, 62, 88, 100, 101 sadness, 9, 10, 62, 63, 88, 100, 101, 104–106, 110, 111, 116, 119, 120, 122, 125 Executive function, 6, 8, 11, 13, 16, 25, 29, 37 Genetics, 7, 8, 162 Goal setting see SMART goals Impulsivity, 10–11, 15, 16, 19 In/Out Logs, 21, 56, 68, 87, 90, 109, 119, 127, 134, 144, 149, 155, 162, 167, 172 Insight, 5, 11, 24, 70 Homework assigning, 13, 21, 27, 49, 68, 85, 97, 106, 115, 124, 132, 139–140, 147, 153, 159, 164, 174–175 contingency management and, 23, 58 contracting and, 44 efficacy and, 18 reviewing, 25, 57–58, 73–74, 87, 99, 109, 119, 127, 134, 143, 149, 155, 166, 171, 177 rules for, 15, 27 treatment compliance and, 11, 15 Medical conditions, 6, 24, 25, 27, 51, 93, 154, 156 Memory beliefs about, 8, 122, 124 impairment in, 8, 12 Motivation reward and, 16, 55–56, 58–59, 69 as a target, 11, 16–17, 63–34, 76, 133–147 Motivational interviewing, 16, 18, 25 developing discrepancy in, 16, 138 empathy in, 16 pros and cons in, 16, 135–136 values in, 136–139, 145–146 visualization in, 144–145 Obsessive‐compulsive disorder (OCD), 3, 6, 9, 14, 24, 127 Obsessive‐Compulsive Personality Disorder (OCPD), 6 “OHIO (Only Handle it Once)” rule, 17, 36, 39, 71, 75

Personality disorders, 6, 21 Photographs, 23, 36, 40–41, 49, 54–55, 57–58, 75, 124, 126, 172, 174, 176 Prevalence, 3 Problem‐solving impairment in, 6, 8–9 as a target, 13, 61–62 treatment compliance and, 26–27, 156 training for, 74, 92–95, 172 Professional organizers, 17, 27 Recycling, 13, 22, 39, 75, 82, 84, 167 Relapse, 30–31 abstinence violation effect and, 171 prevention, 170–175 Rewards see Contingency management Saving see Difficulty discarding Scheduling, 70, 72–73, 77–79, 172 Schizophrenia, 5, 6 Self‐control, 10–11, 20 Selling, 39, 53, 160, 161, 163, 165, 166 SMART goals, 55, 56, 59, 67–68, 72–74, 85, 87, 97, 99, 106–107, 109, 110, 114, 115, 119, 124, 127, 132, 134, 140, 143, 146–149, 153–155, 159, 161, 164, 166, 168, 169, 171, 175, 177 Sorting, 8, 13, 22, 36, 38–39, 72–73, 75–79, 139, 145, 149, 152, 155, 164, 166, 171, 174 Stigma, 20 Stimulus control, 15, 19, 89–92, 99 Structure, 13, 20, 21, 37, 42 Tangential or circumstantial speech, 12, 21, 26, 28–29 clock sign and, 28–29, 40, 43 Therapeutic reactance, 14, 15, 21, 29–30 Trauma, 7, 8, 24, 37 Treatment compliance homework and, 11, 15 motivation and, 16, 26–27, 69 Troubleshooting for, 16, 25, 27, 52 Treatment contract, 21, 26, 27, 36, 37, 42–44, 49, 51 “Virtual store”, 23, 28, 91, 102, 111–112, 123, 129, 138