Research That Matters (January 17 - 20, 2008)

Compulsive hoarding has been recognized recently as a serious behavioral and mental health problem that is difficult to treat using standard methods successful for other similar problems (Steketee & Frost, 2003). The present NIMH-funded pilot study and controlled trial sought to improve on treatment outcomes using a manualized cognitive-behavioral treatment based on a formal model for understanding hoarding symptoms. Fourteen adults with significant clutter, difficulty discarding, excessive acquiring, distress and/or impairment who considered this their main problem completed 26 sessions of individual treatment including monthly home visits over a 7-12 month period. Standardized outcome measures of hoarding symptoms and general psychiatric status showed significant decreases at post-treatment for the 10 completers. According to therapist-rated Clinical Global Improvement (CGI) 50% were "much″ or "very much improved″ after treatment and 60% showed clinically significant change (Jacobson & Truax, 1991) on the main standardized outcome measure. Homework compliance predicted symptom improvement.

Following this, 42 participants were randomly assigned to the 26-session treatment or a 12-week waitlist followed by full treatment (n=18 completers in each group). Significant interactions between time (pre to week 12) and treatment condition (Treatment vs. Waitlist) for three main hoarding measures indicated that treated clients improved significantly more than waitlisted ones; Fs (1,34) = 6.23 to 14.0, ps < .02, with moderate to large effect sizes of η²_p =.155 to .310. Treated clients showed significant reductions in symptoms over 12 weeks, whereas waitlisted clients showed minimal and nonsignificant declines. On CGI ratings 41% of treated clients were rated "much improved″ compared to none of the waitlisted clients. Both samples were combined after all had received 26 therapy sessions. Participants improved significantly on all measures, with large effect sizes for most analyses. Although symptom reductions were modest (22% to 37%), 83% of clients reported themselves "much″ or "very much″ improved on the CGI. Clinically significant change on the Saving Inventory-Revised was observed in 46% of treated clients, considerably higher than the 31% rate observed when traditional treatments for OCD have been applied to hoarding (Abramowitz et al., 2003). Therapists addressed ambivalence evident in many clients using motivational enhancement methods. Multiple regression analyses indicated that the action subscale predicted outcome on 3 of the 4 measures of hoarding problems after pre-test symptom scores and depression entered the equation – higher action scores were associated with less clutter. Homework adherence predicted improvement on therapist-rated but not client measures.

CBT with specialized components to address motivation problems, skills for organizing, and exposure plus cognitive methods for reducing acquiring and clutter appears to be a promising intervention for compulsive hoarding, a condition traditionally thought to be resistant to treatment. However, this treatment is long and costly and will require improvements in content and format for ready use in service settings. Ongoing research is investigating group and distance interventions that may enhance outcomes at lower cost.