Breaking the Rules: A Clinician’s Guide to Treating OCD
Episode: Helping someone with a hoarding disorder takes more than throwing away their stuff
Hosts: Dr. Celine Gelgec and Dr. Victoria Miller
Date: January 6, 2025
Episode Overview
In this episode, Dr. Celine Gelgec and Dr. Victoria (“Tori”) Miller dissect the nuanced differences between hoarding disorder, collecting, and hoarding-themed OCD. Highlighting hoarding disorder’s classification as a distinct mental health condition, the hosts break down functional impacts, treatment methods, and the crucial role of empathy and curiosity for clinicians. The conversation debunks “quick fix” approaches, addresses common clinician self-doubt, and empowers professionals to engage truly transformative work with patients dealing with hoarding-related difficulties.
Key Discussion Points and Insights
1. Hoarding in the Public Eye vs. Clinical Reality
- The hosts open with a critique of popular media portrayals, noting how TV shows often depict aggressive clearing of homes, which doesn’t align with effective clinical practice.
- “Most of us have seen TV shows about hoarding...with a gung ho approach to discarding...But is this what we do when it comes to treating hoarding disorder?”
— Dr. Celine, [00:34]
- “Most of us have seen TV shows about hoarding...with a gung ho approach to discarding...But is this what we do when it comes to treating hoarding disorder?”
2. Defining and Differentiating Hoarding Disorder, Collecting, and Hoarding-Themed OCD
- Collectors vs. Hoarders
- Collecting: Items are organized, functional, and don’t impede life or relationships.
- Hoarding Disorder: Accumulation causes functional impairments (e.g., blocked kitchens or bathrooms, squalor) and significantly affects health and relationships.
- Sentimentality and “just in case” thinking often drive hoarding.
- Illustrative anecdote: someone keeping gifts from estranged relatives, fearing that discarding means losing the relationship ([07:58]–[10:00]).
- Hoarding-Themed OCD
- Driven by core OCD themes (harm, scrupulosity, contamination, etc.) and associated magical thinking.
- For example, saving a newspaper due to the intrusive thought that discarding it could cause harm to a loved one ([10:36]–[11:33]).
- “If it was hoarding OCD...there'd be other themes, other compulsion...part of the picture, not the whole picture.”
— Dr. Tori, [11:33]
3. New Understandings and Research
- Hoarding disorder was previously considered a subtype of OCD, now a standalone diagnosis under “obsessive compulsive and related disorders.”
- Recent research is exploring its links to ADHD, highlighting difficulties with organization and decision-making ([03:25]).
- Shame and isolation are pervasive among those with hoarding disorder; family impact and social withdrawal are common ([04:42], [05:25]).
4. Treatment Approaches: Why It’s Not Simply ‘Throwing Things Out’
- Assessment comes first:
- Evaluate health and safety issues (fire hazard, falls risk, hygiene, etc.) before any exposure intervention ([13:27]–[14:17]).
- CBT for Hoarding Disorder:
- Focuses on cognitive restructuring, distress tolerance skills, and gradual exposure to discarding items.
- Cognitive work is more direct: challenge beliefs about the necessity, sentimentality, or anticipated consequences of discarding ([14:17]–[14:31]).
- Exposure work is graded, collaborative, and never as abrupt or forceful as on reality TV shows ([14:31]–[15:37]).
- “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.”
— Dr. Celine, [15:49]
- For Hoarding-Themed OCD:
- Leans into ERP (Exposure and Response Prevention) principles: sitting with uncertainty, “urge surfing,” and resisting reassurance ([16:12]–[17:06]).
- Focus is on tolerating anxiety about an obsession, rather than reorganizing cognitive beliefs about the items in question.
5. Co-occurrence and Functional Impact
- Always explore comorbidities and the full functional impact—differentiate collecting from hoarding disorder by examining disruption to daily life and relationships ([17:50]).
- Consider perfectionism and avoidance as traits underlying many cases of hoarding disorder ([12:06]–[12:39]).
6. Therapeutic Attitude and Self-Efficacy for Clinicians
- Clinicians are often intimidated by hoarding cases due to perceived lack of experience.
- Dr. Tori underscores that foundational principles from OCD treatment (hierarchies, distress tolerance, alliance, curiosity) still apply.
- “In fact the principles are very, very familiar...it is just the application of those same principles that we apply to lots of difficulties, but just in a slightly different space.”
— Dr. Tori, [21:04]
- “In fact the principles are very, very familiar...it is just the application of those same principles that we apply to lots of difficulties, but just in a slightly different space.”
- Building trust, offering a judgment-free space, and being “curious” with the client are essential ([21:45], [22:51]).
- Honest discussions about clinician experience and a willingness to learn reciprocally with the client can strengthen therapeutic alliance ([21:45]–[22:56]).
- “We all start with our very first client of something...we don’t go in with 20 years of experience.”
— Dr. Celine, [22:31]
- “We all start with our very first client of something...we don’t go in with 20 years of experience.”
Memorable Quotes and Moments
- “Once [hoarding] kind of came out on its own [in the DSM], we started researching it more specifically...now we’re giving it the respect it deserves in terms of it being its own condition and not just OCD.”
— Dr. Celine, [03:25] - “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.”
— Dr. Tori, [04:49] - “Collectors… there’s a function for [the items] and it doesn’t really stop us using other things…doesn’t impact our day-to-day functioning…the difference [with hoarding] is the items often lose all function and cause significant impairment.”
— Dr. Celine, [07:04] - “If the house is cleaned up for a person, have they been able to develop their capacity to tolerate the uncertainty…or tolerating the discomfort of not knowing if throwing out a newspaper actually will cause harm to a loved one?”
— Dr. Tori, [14:58] - “Let’s get to know the person. Symptoms are symptoms, but let’s get to know the person...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?”
— Dr. Celine, [21:45]
Timestamps for Key Segments
| Timestamp | Topic | |------------|-----------------------------------------------------------------------| | 00:34 - 01:00 | Media portrayal of hoarding vs. clinical approach | | 03:25 - 04:42 | DSM classification, research advances, links to ADHD | | 06:22 - 10:36 | Differentiating collecting, hoarding disorder, and hoarding OCD | | 13:23 - 14:17 | Risk assessment and safety before intervention | | 14:17 - 15:37 | Cognitive work and exposure in CBT for hoarding disorder | | 16:12 - 17:50 | ERP focus in hoarding-themed OCD; functional and comorbid impacts | | 19:22 - 21:16 | Therapist stance: rapport, working at the client’s pace | | 21:45 - 22:56 | Navigating inexperience, honesty, and learning together |
Conclusion
Dr. Celine Gelgec and Dr. Tori Miller emphasize that effectively treating hoarding disorder is not about forced cleanouts but a patient-centered, collaborative, and nuanced process. They encourage clinicians to apply familiar CBT and ERP principles, remain curious, and trust that their core clinical competencies will translate—reminding listeners that human connection, trust, and gradual exposure are central to supporting clients in making meaningful, sustainable change.