← Breaking the Rules: A Clinician's Guide to Treating OCD
Breaking the Rules: A Clinician's Guide to Treating OCD
Helping someone with a hoarding disorder takes more than throwing away their stuff
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- [00:04]
A
This is Breaking the Rules, a show for mental health professionals designed to help you build confidence in treating obsessive compulsive disorder. I'm Dr. Celine Galgett and I'm a clinical psychologist who works extensively with OCD.
- [00:17]
B
And I'm Dr. Victoria Miller, but you can call me Tori. And I'm a clinical psychologist who works with young people, including those with ocd. Through our shared professional experience, we've found that effective treatment of OCD requires commitment, creativity and the recognition that things can sometimes get a little messy.
- [00:34]
A
They sure can. We want to empower clinicians to be able to work with their patients in new ways to treat OCD with confidence. Most of us have seen TV shows about hoarding where people go into houses that are filled with quote, unquote stuff. We see people going in with a gung ho approach to discarding, removing and donating items. But is this what we do when it comes to treating hoarding disorder?
- [01:01]
B
In today's episode, we are going to talk about how to recognise hoarding disorder and how to differentiate it from just being a collector or perhaps having hoarding themed ocd. We have a lot to share about how to provide intervention for individuals with hoarding disorder and hoarding ocd, as well as how to navigate the intense shame that often comes along with it. Let's get started. Another skills episode. Great to be back.
- [01:29]
A
Yes.
- [01:30]
B
So we're going to be talking about hoarding today and hoarding themed ocd, which are two similar but different things. I think we get quite a few questions about hoarding, so I think it's a good topic to talk about because we're fresh off the back of you recording, being interviewed on the Conversation Hour on ABC Radio with Rochelle Hunt and Warwick Long on the topic of hoarding and ocd. I have a little bit of experience with hoarding, but not as much as you. And so it's actually something that I want to know more about and want to spend some time thinking about and just to kind of look at how we treat it. Is ERP still how we treat it? Is it more in the CBT space, depending on how we're formulating what the hoarding is. And I just think I'd like to just listen to you speak for 25 minutes on this topic and I'll just take some notes.
- [02:29]
A
Oh, my goodness, no. This is definitely something we can talk about together and be curious about together because there is so many things that overlap between hoarding and ocd. And hoarding used to be thought of just another subtype of OCD until the most recent edition of the dsm, when it's now classified as a separate disorder underneath the umbrella of obsessive compulsive and related disorders. So I don't think we really even knew much about it until more recently. And there are so many fascinating developments coming out.
- [03:00]
B
Why do you think that was? Why do you think we didn't know much about it?
- [03:03]
A
Yeah.
- [03:04]
B
Say that only because hoarding as a concept has been a part of our culture for a long time. I mean, it's constantly featured in films and television and. And, you know, there's reality TV shows about it and cleaning experts, and there is a company set up to assist people who experience hoarding. So why is it that we don't know that much about it?
- [03:26]
A
Because it was thought of as ocd. I think people just thought it's just another type of OCD and focused more on the OCD aspect of it, as opposed to hoarding in and of itself, if that makes sense. And oftentimes, like we've noticed with other disorders and whatnot, and even ocd, which used to be classified as an anxiety disorder, once it kind of came out on its own, we started researching it more specifically. And I feel like that's in the last decade, what we've been doing with hoarding as well, in terms of researching it more specifically, separate to ocd, just to really understand those nuances. And some really interesting things, like the. There's a lot of research at the moment that's coming out and finding links between hoarding disorder and adhd, which is really fascinating. Flagging things like struggling to make decisions, organizational, struggling with organizational skills. You know, that sort of stuff has been an interesting link as well. So I think now that, you know, over the last decade or so, potentially a little bit longer, that we're giving it the respect it deserves in terms of it being its own condition and not just ocd. We're able to research those nuances a little bit more. So I think that's where we're getting more of that understanding, which has been really helpful.
- [04:43]
B
Well, that's good, because one thing I do know about hoarding is that it can generate an enormous amounts of shame and embarrassment.
- [04:49]
A
Yeah.
- [04:49]
B
And people often, they live in the shadows, and they often don't want to talk about it or seek help for it because they feel quite humiliated by their symptoms and the experience. And it'd be great if we understood it better so that people could access help, because I know that functionally, the impairments can be quite significant.
- [05:07]
A
Absolutely. And you know, you work a lot with young people. Right. So you wouldn't necessarily see it too much in the cohort that you work with.
- [05:14]
B
And when I have seen it hasn't been, it's been relatively sort of mild to moderate rather than really severe. And that's because I think the parents come in and kind of feel like, no, no, no, we're clearing this out.
- [05:25]
A
And like teens more so, you know. But I'm wondering too, like even working with young people who are children of hoarders and the impact it has on them and how it impacts the family, and that's kind of just an extension of what you were saying earlier. When people carry a lot of shame, a lot of guilt, a lot of grief, a lot of embarrassment and start isolating themselves, it then impacts their wider family network, whoever else is living at home with them, and so on and so forth. So it's, it can be a pretty serious condition.
- [06:00]
B
Yeah. Would you want to tell us about sort of the definition of hoarding and how we sort of differentiate someone who is a hefty collector of things versus what would actually be diagnosed as hoarding disorder? And then also the, by extension then the obsessive theme of hoarding under the umbrella of ocd?
- [06:23]
A
Yeah, they're all so different, aren't they? So let's start with the hefty collecting. I think a lot of people can relate to the idea of collecting things, whether it be a love of books or. I think psychologists are really good at collecting books and.
- [06:41]
B
Resources, not laughing. I can't relate to this at all.
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A
And you know, having piles on your nightstand.
- [06:49]
B
My daughters have literally started to say, when books arrive in the mail, have you finished the books on your nightstand?
- [06:56]
A
If you haven't finished them no more.
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B
You'Re not allowed to buy anymore. Do you've read the ones you've got? But they want them.
- [07:04]
A
Right here. And I suffer from that too. 100. From that to sneakers. Sneakers is a popular one for a lot of people, especially with younger people. You might have collections of stamps, coins, like items from movies, memorabilia, sporting memorabilia, the list goes on. Right. We all have an interest and alike and whatever and it's like, oh, it would be nice to have these things. But the difference there is there's usually a place for them, there's a function for them and it doesn't really stop us from using other things in our house the way that we should be using them. And it doesn't impact on our day to day functioning and it doesn't impact on the people that we live with, if we do live with other people, some people live alone. And it doesn't stop us from becoming more and more isolated, if that makes sense. Hoarding, on the other hand, is different in a sense that the items that are accumulated, some of them are sentimental and some of them certainly can be collections of certain items, but it extends from that. So it could also be receipts, newspapers, it can be pamphlets at a workshop that you might attend. It might be, you know, going to the shopping center and collecting catalogs and then not discarding them and just keeping them to the point where, let's just say for argument's sake, in the kitchen, you can barely get into the kitchen and the countertop is so full of things that you can't even use the stove and you end up just using the microwave to warm up dinner. You can't wash dishes in the sink because it's piled high with stuff. Often that means that dirt and grime build up as well. And so it then we then end up with what's called squalor. So it's just messy in that way as well. Bathrooms can get filled up to the point where people can't shower regularly and end up having to need to use a shower at the gym or at work if their work has a shower or whatnot, because things around the house lose their functionality, if that makes sense. And a lot of the items are tied to sentimentality. Sometimes it's a. I'm just going to keep this just in case. Actually, one of the co panelists that were on the Conversation Hour provided a really lovely example of the sentimentality of keeping items. He described a client he was working with who was collecting presents over the years of relatives who they had lost contact with and really wanted to keep that relationship and weren't discarding of the items because they were worried that that would mean that it would be the end of that relationship. So, you know, there's just really a lot of examples of how that sits and how people struggle to let some of these things go. One of the callers that called up was an OP shopper. So they'd go around to a lot of OP shops and then obviously built connections and a network for themselves because they were living alone and would constantly buy all these things and would feel really happy about it, but then, you know, wouldn't be able to let them go either. I think he described something like having 500 shirts, 250 pairs of pants, and so on and so forth. So you can see the difference between that picture and just collecting things, hopefully, yeah. Different to again, hoarding ocd, which we will diagnose OCD if people are hanging onto things because they're linked to the more typical themes of ocd. So if we think about the typical themes of OCD being things like scrupulosity, harm, contamination, et cetera, let's just say for argument's sake, someone's collecting a stack of newspapers because they had an intrusive thought when they were holding that newspaper about harm coming to a loved one and if they discarded it, then that would mean that the bad thing would come true, so they then hung onto it. So we would then classify that as being OCD with a subtype of hoarding because it's linked to the theme of harm and you've got that link of the magical thinking happening different to what you would see. That's more typical of hoarding disorder. That's a little bit different.
- [11:33]
B
Yeah. Also my guess would be that if it was hoarding OCD that you'd probably see, like we often do, other obsessions as well. So there'd be other themes, other compulsion. So this would be part of the picture, not the whole picture. Whereas with hoarding disorder it might seem more exclusively. I mean, not that there wouldn't be co occurring difficulties like you're talking before about ADHD being associated with and then hoarding disorder and anxiety and depression and, and things. But I can imagine that it would be very unusual for someone to just exclusively have hoarding themed OCD and no other themes.
- [12:06]
A
Yep, you're not wrong. Like it's more likely that you would see other themes. With hoarding ocd you would also see Hoarding disorder and then OCD in terms of their. Like you said, because you know, you can have co occurring conditions but they'd be usually not linked, tied in together. A lot of the times though, they can be. But with hoarding disorder you're more likely to see underlying perfectionism, but the type where things feel so overwhelming that the person just chooses not to do anything about it, you know, the avoidance type.
- [12:40]
B
I'm really paralysed by the anxiety associated with doing the right thing.
- [12:44]
A
Absolutely. Hey, Tori.
- [12:47]
B
Hi, Celine.
- [12:49]
A
Did you know that we run our own courses here at Melbourne Wellbeing Group?
- [12:53]
B
I did know that. In fact, it's one of my favourite things we do here because it's a great way to help psychologists and other clinicians learn more about ocd, which means.
- [13:02]
A
We get to help more people. So if you're a clinician who works in mental health and you're interested in learning from us, then get in touch.
- [13:10]
B
For more information, head to www.melbournewellbeinggroup.com and click on the Webinars and Books tab.
- [13:18]
A
Alrighty, back to the show.
- [13:23]
B
So then, when it comes to intervention, then, is it ERP for hoarding disorder?
- [13:28]
A
It's more CBT based. Definitely. There's elements of exposure, but firstly you have to consider things like safety and whatnot. You know, what's a fire hazard, what's a safety hazard, what's a falls risk or a tripping hazard. You know, all those sorts of things. You need to take all them into account. Health and hygiene, obviously, is another risk factor that you need to hold in mind. So once you've assessed all of those risk factors, if they are risky and there's elements of that that you need to address, you'd start tackling them first and you'd do it in a graded way. So that's where the exposure element comes in. Where, from an exposure perspective, you gradually teach distress tolerance skills, as you would with ocd. Here's where it's different. You'd also work on identifying some of the beliefs that are around those items.
- [14:18]
B
That's what I was wondering about, whether actually in this space you could do some more direct, challenging. Yeah, Some of that more cognitive work and likelihood of things happening where that belief comes from, whether there's maladaptive thinking patterns, things like that.
- [14:31]
A
Yep. And that's the one thing that's different and that's the bit that you bring back in, so to speak, when you're treating hoarding disorder. Everything else can look very similar in a sense that, you know, you've got the graded exposure to the items, you're doing it slowly. Not like the TV shows where they go in and they clean it out in a day. So distressing for people. Yeah. So all those elements are absolutely the same or very similar also.
- [14:58]
B
Like, if you did it that way, I might be wrong, but my hypothesis would be, is that you'd have a tidy house, but what internal work has been conducted through that process? If the house is just cleaned up for a person, have they been able to develop their capacity to tolerate the uncertainty of whether the relationship with their loved one is lost or not by virtue of getting rid of something or tolerating the discomfort of not knowing if throwing out a newspaper actually will cause harm to a loved one or belief? Like. Yeah, I just struggle to believe that that would actually generate change long term.
- [15:37]
A
Absolutely right. You've hit the nail on the head. Like, it doesn't address any of those underlying issues. And aesthetically it might be fine, but it just means that that person is now in like significant amounts of distress and likely going to start collecting or going back out there and getting things back or whatever else it might be. Ordering things again, you know, packaging is a huge one that people find really hard to get rid of. So it's just one of these things where if we're not doing that groundwork, then we're not actually addressing the issue, which is putting a band aid on it really.
- [16:12]
B
My suspicion would be that if it's hoarding disorder, still doing the exposure, the behavioral intervention, and that's something that I've got experience with with some of my younger people with doing some hoarding stones, things picked up on walks, tags from clothes that have been bought, empty bottles, all sorts of things. Not throwing away old baby clothes, not wanting to part with toys, old toys. Yeah, that goes over and above sort of sentimentality and nostalgia. But if it was hoarding disorder, doing sort of still the exposure and the behavioral route, but also doing some of that cognitive challenging. However, if it was hoarding ocd, if it was attached to an obsession, then it's much more sitting with uncertainty, urge surfing, leaning into don't know, don't know if it will or won't, leaning into principles of if that thing happened, you will deal with the aftermath of that.
- [17:07]
A
Yeah, and that's an important key difference that you highlight. Because what we don't want to do is if we are dealing with hoarding ocd, then just start up a reassurance seeking trap versus not wanting to cause too much distress and not address some of those underlying beliefs. If it is hoarding disorder in terms of whether it's adjusting case or sentimentality or whatever else it might be that's driving the need to keep what it is that they're wanting to. The other thing is, is it could just be a struggle with organization or difficulty making decisions which we can address using a lot of the CBT type approaches as well. So yeah, it is different.
- [17:51]
B
That's great, Celine. That's really good for any condition. If someone presents with concerns about themselves or a loved one with these difficulties, then just like with all psychological conditions, we're talking about an exploration of functional impact to differentiate from collecting versus hoarding disorder. And then through that work, let's say you do think that someone meets criteria for hoarding disorder, then it's worth just exploring for co occurring difficulties like ocd. And if there is some of that, then like we would do with any assessment of OCD is just explore the meaning behind the compulsive behaviour. So the choices that people are making and why and just looking for evidence of hoarding. OCD versus just hoarding. Sounds like part of the assessment needs to be just around health and safety and making some decisions with the person around how to attend to those things. As a really important part of therapy, before just launching into doing exposure work is just making sure that someone is safe. And then the fundamentals then are very similar to how we would do other sort of interventions for ocd, which is building a hierarchy or an exposure menu, teaching distress tolerance skills, exploring willingness, which I imagine in this space would be really important, ensuring that you've got a really good relationship, that it's a judgment free zone. Just like when we treat ocd.
- [19:23]
A
Building trust in that way.
- [19:24]
B
Yeah, building trust and then exploring piece by piece at the rate that is right for the person. Because goodness knows, people can go all in. And we need to believe in our clients ability to generate change so we don't have to go slowly so we can go all in. But it's about being with the client and reducing safety behaviors and ensuring that we are demonstrating confidence in them and then working through the hoarding behaviors.
- [19:54]
A
Yeah, absolutely. And in this case, when working through those hoarding behaviors, making sure that we're getting to the bottom of what's driving those behaviors at the same time as well, if they do want to go a bit harder, but not shying away from that too. Like you said, meet your client where they're at.
- [20:13]
B
And you know, I'm really glad we've talked about this day because like I was saying before, but also before we started recording that I have a little bit of experience, but I think for some reason, and probably just like all of us, I think I thought that if I was to meet someone, say an adult with fairly profound hoarding disorder with really significant functional impact, that there, there must be something that I don't understand that I would need to understand. But I think sometimes we as clinicians can be overwhelmed by the symptoms and we can think quite quickly like, I'm not experienced enough for this. I don't have experience treating anyone with hoarding disorder before, therefore I shouldn't do it because this person needs the best treatment and they'd be better off with someone. And look, sometimes that is true, sometimes. But at the same time, what we've unpacked today is that in fact the principles are very, very familiar.
- [21:04]
A
Yeah.
- [21:05]
B
And it is just the application of those Same principles that we apply to lots of difficulties, but just in a slightly different space, which actually, now that we talk about it, is actually very.
- [21:16]
A
Familiar to me, especially given that we work with OCD as well. You know, there's a lot of that overlap in terms of the understanding.
- [21:23]
B
Yeah. I think sometimes as psychologists, we can get in our own way, and we can. I think. I mean, that's partly why we started the podcast, isn't it? Because so many clinicians were doing beautiful work with clients, they had beautiful relationships with their clients, lovely rapport, really good therapeutic alliance, yet they would say, I don't have enough experience with ocd, I have to refer you on. And we just don't believe that that's true.
- [21:46]
A
Yeah. Especially when you're having those honest discussions with your client. And the most important thing is to get to know the person. Right. Symptoms are symptoms, but let's get to know the person. And if we're having those honest discussions with our clients and saying, hey, you know, I've only worked with a couple of people with hoarding. I've got this understanding, I've got this training behind me, I've got the skill sets. Would you be willing to walk with me and I walk with you, while I learn a little bit more about it through supervision, education and just be more curious with you, which we should be doing anyway with our clients. I would say asking lots of questions and really taking the time to gain that understanding and work with it, you'd be surprising at how willing clients would be to kind of hold that space with you as you go along. Because we all start with our very first client of something like, we don't go in with 20 years of experience. Experience, yeah, that's exactly right. If you've had zero training or have no idea what CBT is or whatnot.
- [22:52]
B
Or you've not done a workshop on erp, you've done no reading, definitely.
- [22:56]
A
But if you've got that there and you've had some experience and you want to dive in, go for it.
- [23:03]
B
Yeah, agreed.
- [23:04]
A
All right.
- [23:04]
B
This has been fun. Thanks, Celine. I really appreciate that today.
- [23:07]
A
Oh, thank you. Bye. You've been listening to Breaking the Rules, a show for mental health professionals designed to help you build confidence in treating obsessive compulsive disorder.
- [23:21]
B
This podcast is brought to you by Melbourne Wellbeing Group, a psychology practice based in Melbourne with a special focus on treating OCD. To find out more, head to our website, melbournewellbeinggroup.comau all one word. That's MelbourneWellbeingGroup.comau you.
- [23:38]
A
This podcast was made with strategy and production support from Wavelength Creative. To make sure you don't miss an episode of Breaking the Rules, be sure to subscribe to or follow the show in your podcast app. And while you're there, leave us a five star review. It really helps others find the show. I'm Celine Galgett.
- [23:56]
B
And I'm Tori Miller.
- [23:58]
A
And we'll be back next episode with more reasons to convince you to get messy, have fun and Break the Rules.