We are all more or less attached to things. Consumer culture exploits our human propensity to acquire new things and our vulnerability to seeing ourselves reflected in our possessions. But people with compulsive hoarding, who account for about 2–6% of the population of the United States and Europe (American Psychiatric Association [APA], 2013), are off the scale when it comes to their relationship to possessions. They are extremely attached to things. They cannot resist urges to bring new things into their homes however useless they may seem to others. Nor can they bring themselves to throw out or recycle things for which they no longer have any practical or even sentimental need.

People with compulsive hoarding seem to lack the mental ability to sort through their possessions in an ongoing manner, stay task focused, and get the job done, something that is fairly easy for most of us. As a result, their accumulation of stuff often prevents them from using the rooms in their homes for their designed purpose. In milder cases, people with compulsive hoarding cannot have anybody over for dinner because all table surfaces are packed with stuff that would require hours to clear. In extreme cases, people with compulsive hoarding sleep on a tiny space on the floor because their beds are filled with items. Tragically, their attachment to inanimate objects is often stronger than their relationship to people. It is not uncommon for them to lose connection to their adult children or have younger children removed by social services. They are often lonely people living on the margins of society.

When people with compulsive hoarding present to general mental health programs—usually following pressure from a concerned family member—many clinicians feel at a loss for how to best help them. This in part has to do with therapists’ lack of specialized knowledge of this problem and what a best practice approach looks like. The other part involves the clients themselves. People with compulsive hoarding often lack insight into their behavior. One client stated she had a problem with “sorting paper” and seemed genuinely unaware of the extent to which her clutter prevented her from moving around freely in her home. One study found that only 15% acknowledged the irrationality of their behavior (Kim, Steketee, & Frost, 2001). It fairly quickly becomes apparent that the client is ambivalent about seeking help, that they feel some pressure from other people in their lives to make changes, and that they do not see much point in coming to a therapist’s office when their only problem is at home. For some, though, the problems go beyond their homes and cause significant impairment at work. If working, their general disorganization can make it difficult to manage projects at work, sort through emails, files, or whatever else their work may involve. They obviously also struggle with keeping their work spaces and shared offices tidy. Regardless of whether the hoarding problem is confined to their homes or spills into other areas of life, people with compulsive hoarding are difficult to engage in therapy, often miss sessions, and more often than not drop out of any treatment that is not highly hoarding specific.

When people with compulsive hoarding present to mental health programs that offer specific treatment for OCD, the scenario is usually brighter but still far from optimal. Hoarding has until 2013 been considered a diagnostic subtype of OCD and therefore been treated with the same CBT approach. In programs where group CBT is available, therapists naturally feel compelled to accept people with compulsive hoarding into their CBT groups for OCD. Commonly, we have about one or two members with compulsive hoarding in CBGT for OCD. But, although they share features with other types of OCD, they are quite distinct. Most noticeably, they are not as distressed—compared to the other OCD members in the group—about their compulsions. They do not “buy in” to the CBT treatment rationale as readily as the rest of the group, their progress is painfully slow, they stand out as “very different” in a number of ways from the rest of the group, and they often do not gel. They also tend to be older, usually above age 50, compared to the rest of the group. They have thus lived longer with their hoarding behavior, which makes it more challenging to reverse. The group therapists feel bewildered about what “to do” in terms of exposures, particularly in the absence of being able to offer home visits or other more specific hoarding support. As we shall see in the following text, the unfeasibility of home visits may not be as big of a barrier to effective hoarding treatment as clinicians assume. This growing frustration among clinicians, along with helpful research into the cognitive and psychological processes of the minds of people with compulsive hoarding, has finally resulted in hoarding being removed from the OCD diagnostic category.

With the arrival of DSM-5 (APA, 2013), hoarding now has its own distinct disorder status along with formal diagnostic criteria. CBGT therapists for OCD welcome this. The pressure to include people with compulsive hoarding into our groups has lessened, but we feel a corresponding responsibility to offer helpful and appropriate treatment to alleviate their suffering as living conditions worsen. Risks of evictions from apartments because of fire hazards and reality-based fears of homelessness loom large. I hope this chapter on CBGT for hoarding will encourage mental health services to develop separate group programs for people with compulsive hoarding. There is solid research literature on the benefits of a modified CBT approach for hoarding-specific CBT and CBGT.

This chapter first reviews the new diagnosis of hoarding disorder and associated features and then the literature on CBT and CBGT for hoarding. I will present an example of what hoarding-specific CBGT typically involves. Indeed, it is a different kind of CBGT group and probably requires a different kind of therapist too. If transportation is a problem—as it often is because hoarding is associated with poverty and disability—therapists may have to travel from their familiar therapy rooms and find a community hall in which to conduct the groups. Sometimes, groups are also held in the homes of people with compulsive hoarding. Therapists may need to be prepared to do home visits or supervise them, which can include wearing masks or other protective gear in cases where unsanitary conditions are likely to exceed anything clinicians have previously encountered. The safety of the home may need to be inspected before inviting students or other clients to enter. Tall stacks of items could fall or fires ignite with flammable materials that are placed on propane tanks, stoves, or heaters.

The Diagnosis and Features of Hoarding Disorder

According to DSM-5 (APA, 2013), hoarding now belongs to the class of disorders called Obsessive–Compulsive and Related Disorders. Hoarding disorder is characterized by a persistent difficulty parting with possessions, regardless of their actual value (Criterion A). This difficulty is due to a perceived need to save items and to the distress associated with discarding them (Criterion B). People with hoarding compulsions accumulate possessions that congest and clutter their active living areas and substantially compromise their intended use (Criterion C). The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintenance of a safe environment for self and others; Criterion D). The hoarding is not attributable to another medical condition (Criterion E) and is not better explained by the symptoms of another mental disorder (e.g., obsessions in OCD, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interest in autism spectrum disorders; Criterion F). Clinicians diagnosing hoarding have the option of specifying if the problems come with excessive acquisition, good or fair insight, poor insight, or absent insight/delusional beliefs.