Bibliotherapy and Group Interventions for Hoarding: An Eye Toward Stepped Care

Background and Purpose: Hoarding is characterized by difficulty discarding and excessive acquiring leading to substantial clutter and causing distress and/or impairing daily functioning (Frost & Hartl, 1996; Saxena, 2008). Recent pilot and waitlist controlled trials for individual cognitive behavioral treatment (CBT) designed specifically for hoarding have shown promising results but motivation problems, treatment length, and access to expert providers remains a barrier (Steketee, Frost, Tolin, Rasmussen, & Brown, in press; Tolin, Frost, & Steketee, 2007). Group CBT for hoarding has also shown modest effects (Muroff et al., 2009). A limited number of home visits are included in the protocols; however, home visits are time consuming, costly, and not always feasible for clinicians. Non-clinician home assistants may be especially useful in addressing problems of dissemination, adherence, and duration, and would provide the added benefit of delivering more sessions of treatment in the client's home for this fundamentally home-based problem. This pilot study tested whether non-clinician home assistants enhance group CBT treatment outcomes for hoarding, as part of a stepped-care model.

Methods: All study participants endorsed compulsive hoarding as their primary mental health problem. Participants were randomized to one of 3 conditions to address their hoarding: (1) group CBT with non-clinician home assistants (HA; N=13), (2) group CBT without HA (N=14), (3) and bibliotherapy (BIB; N=13). The groups were led by two therapists. Over the 20 weeks, the groups convened once weekly for 2 hours plus 4 home visits with one of the group co-therapists. One group was randomized to receive additional home assistance. BIB participants read a book about the nature of hoarding and describing specific skills to reduce hoarding over the 20 week period. All participants were assessed at pretest, week 10 (midpoint) and week 20 (post-test) using the self-reported Saving Inventory-Revised (SI-R).

Results: Paired t-tests show statistically significant reductions in hoarding symptoms on the SI-R for groups with (t(12) = 5.8, p<.001) and without HA (t(13) = 4.2, p<.01). Group participants with home assistants showed slightly greater improvement (µ = 26%) than those without assistance (µ = 21%); however, these differences were not statistically significant. Participants in the BIB alone condition showed minimal change (µ = 8%) in hoarding symptoms; although paired t-tests were significant (p<.05). Regression analyses show that being in the groups with (p<.001) or without assistants (p<.05) was associated with significantly greater improvement than being in the BIB condition.

Conclusions and Implications: Findings suggest that non-clinician home assistance may enhance group CBT outcomes and bibliotherapy may not be sufficient to address hoarding symptoms. This has implications for a stepped-care model for compulsive hoarding, further examination of enhancements for group treatment, and additional research on the role of coaches in hoarding.