Treatment of Hoarding-Induced Trauma and Perpetration
The American Psychiatric Association’s Diagnostic Standards Manual, Edition V (2013) reports that between 2 and 6% of the general population have a hoarding disorder. Once considered a type of obsessive compulsive disorder (OCD), hoarding is now regarded as a serious clinical condition co-morbid with diagnoses of depression, social phobia, generalized anxiety disorders, attention deficit disorder, and sometimes psychosis given the delusional levels of denial that hoarders often present (Frost, Stekelee, Tolin, 2011).
Hoarders engage in excessive acquisition of items, whether those items have real world value or not, as well as excessive shopping. This behavior often results in living environments that are seriously compromised, if not uninhabitable: blocked entrances and exits, leading to fire hazards; hygiene and safety problems resulting from the acquisition of consumer products, items of supposed sentimental value, plus a plethora of strange items, including trash and feces.
Imagine the life of someone living with a hoarder. Imagine what it must be like to live in perpetual squalor, or to fear being trapped in the event of a fire or some other emergency, or more commonly, to lack space for one’s own personal belongings. Other consequences include: sleeping in beds that double as storage areas, or losing valuable items because they are buried or crushed beneath a hoarder’s accumulated belongings; discovering beloved animals neglected or deceased, or the discovery of unwelcome creatures, such as rodents. Imagine having one’s entire household space or the interior of vehicles rendered unusable, unsafe or unhygienic.
Partners and other family members are the invisible and sometimes buried victims of hoarding behaviors. Invisible because while traditional treatments for hoarding behaviors have focused clinical attention upon the perpetrators of hoarding, they have focused much less so upon supportive or instructive interventions for or on the behalf of impacted loved ones. Within existing treatment models, there is no established diagnostic criteria nor intervention strategy for the treatment of hoarding induced trauma (HIT), a condition based upon discovery of PTSD symptoms related to similar acting out disorders, such as sex addiction, leading to treatment models like sex addiction induced trauma (SAIT) (Minwalla, O., 2012)
This is a serious omission in the field of obsessive compulsive disorder treatment. Treating the problem of hoarding simply as an obsessive-compulsive disorder, or even as a disorder co-morbid with mood, anxiety or psychotic disorders, while avoiding the proper diagnosis and treatment of the accompanying abuse of others, constitutes a significant area of clinical neglect. The perpetration of hoarding behaviors entails much more than the pathologically excessive acquisition of items. The condition further entails the maintaining of an elaborate thought system that compartmentalizes a protected reality, a routinized impingement upon a partner or family member’s living space, plus a manipulation of such victims’ reality. Hoarding perpetrators hide belongings in obscure or secret spaces, deceiving others as to the extent of their hoarding behaviors. They make false promises about cleaning unhygienic surfaces, or tidying cluttered spaces, without follow-up on such promises.
Alternatively, perpetrators invoke false rationales, such as casting spilled garbage as ‘compost’ merely awaiting appropriate elimination, or normalizing lack of hygiene by comparing the accumulation of feces in common areas to implicitly virtuous, eco-friendly “dry toilets” such as those prominent in emerging world economies. Or, they declare disingenuously that items unused or placed in inaccessible areas will be “used at some point in the future” and must therefore be kept in their existing, congested spaces. However, when real attempts are made by others to tidy or clean household areas, perpetrators regress from glibly-stated organizational goals, are prone to bullying behaviors, which they subsequently deny and indeed project onto their plaintive loved ones, ever assuming the role of victim rather than accepting responsibility. These calculated rather than compulsive tactics result not only in frustration for others, but also a sense of betrayal and confusion, plus a feeling of being gaslighted in a world of relational danger.
Meanwhile, if the rationales employed by perpetrators seem bizarre, the underlying motives for hoarding behaviors may seem entirely inexplicable. This is another area of clinical neglect in the treatment of hoarding behaviors. Though Cognitive Behavioral Therapy has been shown to reduce symptoms of hoarding behavior (Gillman et al, 2011), there is little evidence that such approaches unearth the compartmentalized realities protected by perpetrators. These realities include deep feelings of emptiness that are self-medicated by excessive accumulations; distorted and excessive self-identifications with personal belongings, or the behavior of clinging to objects as a symbolic substitute for unresolved abandonment depression. Existing treatment models do little to explain such dynamics to either perpetrators or their impacted loved ones. Instead, partners and other family members are told they have “enabled” perpetrators, become “co-hoarders” by providing or perpetuating the kind of living environments that make possible accumulating behavior. This is like telling a burglary victim that he or she has enabled a thief, become a “co-thief”, via the practice of homeownership and consumerism in a capitalist society. Otherwise, partners and family members are simply encouraged to be patient with hoarding perpetrators, or they are coached to not yell at or criticize them, as if protecting the hoarder from feelings of shame or decompensation were the paramount, if not exclusive purpose of treatment.
Such approaches fail to address the hoarder’s lack of awareness about the real-world impact of their behavior. They express little about the intrapsychic, familial and social underpinnings of hoarding behavior, such as anal personality structure, or gender-based subversive/oppositional reactions to patriarchal norms of property ownership. Perpetrators erect alongside their hoarding behaviors a complex conscious and unconscious system of relational reality that perpetuates a pattern of abuse upon loved ones that is tantamount to human rights violations. A perpetrator’s interior/exterior reality is translational, crosses physical and symbolic relational boundaries in a manner that Laplanche (2005) describes. Living in a psychic vacuum, needing a vacuum of another kind, they induce a like interior/exterior reality in others. Their system of behavior and psychic manipulation denies fair allocation of space to others, not to mention filling space that could be made available to visitors, resulting in social isolation plus the exclusion of outsiders, potential residents, immigrants. It places loved ones in danger while imposing upon overpopulated or housing-limited communities a cruelly ironic waste of personal and collective space.
The hoarding induced trauma (HIT) model is a directive, didactic, and intensive clinical method designed to galvanize awareness in a perpetrator of a complex and destructive pathology. Coordinated clinical intervention with individuals and families, coupled with psychiatric intervention to contain psychotic symptoms, is designed to outline thirteen different areas of distinct trauma suffered by victims of hoarding behaviors, and to confront the intersection of hoarding, personality disorder and distorted social constructs that perpetrators typically exhibit. The hoarding induced trauma (HIT) model aims to comprehensively address and treat the abusive impact of that pathology upon all who live with this terrible disorder.
American Psychiatric Association, (2013). Diagnostic and Statistical Manual of Mental Disorders (fifth edition). Arlington, VA. American Psychiatric Publishing.
Frost, A., Stekelee, G., Tolin, A. (2011). Comorbidity in Hoarding Disorder. Depression and Anxiety. October 3: 28(10). 876-884.
Gillman, C.M., Norbury, M.M, Villavicencio, A., Morrison, S., Hannan, S.E., Tolin, D.F. (2011). Group Cognitive Behavioral Therapy for Hoarding Disorder: an open trial. Behavior Research and Therapy, 49 (11), 802-807.
Laplanche, J. (2005). Freud and the Sexual: Essays 2000-2006. Transl. J. Fletcher, J. House, and N. Ray. New York: International Psychoanalytic Books, 2011.
Minwalla, O. (2012, July 23). Partners of Sex Addicts Need Treatment for Trauma. The National Psychologist.