by Debbie Stanley, LPC, NCC, CPO-CD
RESEARCHERS HAVE INVESTIGATED the cognitive-behavioral pattern known as hoarding for well over a decade, but within the last few years it has also become a media spectacle. With compelling video of people living secret lives in overfilled homes, hoarding is now practically synonymous with reality television. Unfortunately, these portrayals fail to present an accurate picture of hoarding, and they do an even poorer job of explaining the impact of co-occurring conditions such as ADHD.
Hoarding is the acquiring and keeping of so many possessions that areas of the home become unusable, yet the person continues to avoid any meaningful reduction of the belongings. My clients express a variety of reasons for this avoidance, but along the way they usually realize that their hoarding developed as a means of coping with something painful, frightening, or traumatic.
There are several “lookalike” conditions and circumstances that are commonly mislabeled as hoarding, including collecting, cluttering, and chronic disorganization. Understanding each of these is crucial to understand how ADHD fits into the hoarding picture.
For people with ADHD, keeping one or more collections is a natural response to their intellectual curiosity, but organizing those collections can be a challenge. Still, that doesn’t make it hoarding. Cluttering is another behavior typical in folks with ADHD. Leaving items out as visual cues is a common way of compensating for an unreliable memory or inadequate time-management system, but to the untrained eye it can resemble hoarding. Chronic disorganization, also common with ADHD, frequently results in cluttering that the person is hard-pressed to correct, further increasing the odds that she or he will be misconstrued as hoarding.
Yes, this really is quite a complicated picture, but it is possible and often simple to distinguish hoarding from collecting, cluttering, or chronic disorganization. In a nutshell, hoarding is not about “the stuff;” it’s about the person’s attachments to the items. With appropriate assistance, a chronically disorganized person who is not burdened with emotional attachments to the belongings can usually participate in the development of an organizing system and choose a meaningful percentage of items to be discarded. Conversely, a person who hoards will often resist large-scale rearrangement of belongings and will have difficulty discarding more than a token number of items, even when, in general, he or she recognizes the excess and wants to reduce it.
ADHD complicates the picture for both chronic disorganization and hoarding. In either case, those with ADHD benefit from the presence of someone serving as a focus anchor, guiding their decision-making process without judgment, aggressive pacing, or bullying. People who are experienced in this very specific role provide not only focus, but also a safe space for the client to make decisions— sometimes painful or frightening decisions—without feeling pressured or shamed into discarding. In this ideal arrangement, it is not unusual to discover that a person labeled as hoarding is actually chronically disorganized and able to discard a significant amount with the proper assistance. If discarding is still highly challenging, the experienced helper can recommend further options, such as counseling, and can also advocate with the client’s family, landlord, or involved authorities to prevent a forced clean-out and allow the client time to work at a tolerable pace.
The harm reduction approach
People who hoard often trace the origin of the behavior to a past incident or era of trauma. In this way, hoarding can be described as a coping mechanism a maladaptive one, certainly, but nonetheless a somewhat effective one. As paradoxical as this may sound, it is imperative to begin from a position of respect for the person’s hoarding as an attempt at self-care. From that perspective, it becomes easy to understand why a forced clean-out would be harmful and should be avoided unless there is imminent, life-threatening danger.
Perhaps the most harmful result of reality television shows portraying hoarding is that they normalize fast clean-outs. There have been countless moments of drama in these shows in which the client becomes agitated and actively resists the intervention. The repetition of that dynamic week after week has taught many viewers that this is the appropriate way to address hoarding. It is not. Stripping away a person’s coping mechanism before a new one has been developed is both unethical and ineffective, and it is also unnecessary. The preferred alternative is an approach called “harm reduction.”
The harm reduction model can be summarized with the phrase “good enough.” It emphasizes working collaboratively with the person, to the extent that his or her insight will allow, to develop a plan that addresses the hoard in priority order: Safety first, optimal function next, and aesthetics last if at all. Throughout a harm-reduction-based project, the client is recognized as the decision-maker, again to the extent that his or her insight will allow. This does not mean that unpopular decisions are simply overruled. The fact that a person is resistant to discarding is not necessarily a sign that he or she is unqualified to make independent decisions; more often it is a sign that the approach has been ineffective. If the person is defensive, consider what might have been said or done that was offensive. Simply dismissing resistance as stubbornness or incompetence is harmful.
If the person has ADHD, the potential for overwhelm during this process is that much higher. Overwhelm is well-known to cause defensiveness, decision paralysis, frustration, avoidance, and outbursts, all of which can and will happen with an overly aggressive hoarding reduction. Developing a clear plan based on the client’s priorities and carrying it out on a realistic schedule (a year, for example, not a weekend) is far more likely to result in lasting change.
For those who have a personal relationship with someone who hoards, the greatest challenges are likely to be remaining patient with slow progress and accepting an end result that is not as beautiful as hoped. A hoarding reduction is considered successful when there are no remaining safety concerns (for example, utilities are functioning, exits are clear) and the person is able to function in the home (sleep in a bed, use the kitchen to prepare food, bathe in at least one bathtub or shower, use at least one toilet). There might still be piles of papers, boxes of belongings, clutter on the coffee table, and too many clothes in the closets, but if the person can live safely, function adequately, and avoid re-hoarding, that level of “good enough” is truly a win.
People who hoard eventually become isolated, and their greatest motivation to change is often to reconnect with their loved ones. Once they’ve made enough progress to have people over, instead of demanding more, the most helpful thing that the person’s loved ones can do is visit often and enjoy his or her company without nagging for further progress. Your ongoing presence will support the person’s maintenance habits, and those regular, pleasant visits will remind him or her that all of the effort has paid off.
Debbie Stanley, MA, MS, LPC, NCC, CPO-CD, has worked with chronically disorganized and hoarding clients since 1997, originally as an industrial psychologist and professional organizer and now as a licensed counselor. She holds a master of science in mental health counseling and a master of arts in industrial and organizational psychology as well as the credentials of National Certified Counselor and Certified Professional Organizer in Chronic Disorganization. Her practice, Thoughts In Order Counseling and Consulting PLLC (thoughtsinorder.com), includes counseling, coaching, and corporate consultation by telephone, real-time video (Skype or FaceTime), or onsite in the client’s home or office; case consultation for peers; and frequent speaking and writing. Stanley is also a popular media guest and enjoys interviews for print, radio, television, and internet media.