Dr Robert London

Is Decluttering a Form of Therapy?

Clinical Psychiatry News - Volume 38, Issue 9, Page 7 (September 2010)

Requests for professional intervention for people who are disorganized, surrounded by clutter, and overwhelmed by the mess at home, work, or both appear to be increasing. Some of these people either are—or could be—our patients.

Some years ago, I devoted a column to obsessive-compulsive personality disorder, or OCPD (“Helping OCPD Patients Break Free,” The Psychiatrist's Toolbox, July 2007, p. 19). In that column, I focused on a treatment strategy for a rigid, controlling, angry person who felt driven to be meticulous and who was stressing out not only himself but those around him with his OCPD behaviors.

However, a tendency toward extreme clutter, chaos, or hoarding might also be a sign or component of OCPD or obsessive-compulsive disorder (OCD). The differential diagnosis should include schizophrenia, stimulant abuse, attention-deficit/hyperactivity disorder, autism spectrum disorders, and anorexia nervosa, because these disorders might also involve hoarding.

Members of the DSM-5 Obsessive-Compulsive Spectrum Sub-Work Group of the anxiety disorders work group are recommending that a diagnosis called “hoarding disorder” be included in either the main manual or in an Appendix for Further Research. I would like to see a separate diagnosis for hoarding in the main manual, because its specificity and occurrence are recognized more and more as mental health problems. A few years ago, neurology researchers at the University of Iowa, Iowa City, found that primitive subcortical brain areas are involved in the hoarding drive, “specifically a tiny area called the right mesial frontal cortex” (Explore 2005;1:415-9).

Effective Approaches

In my own efforts to help OCPD or OCD hoarders over the years, I have used guided imagery aimed first at separating into categories items to be disposed of and then linking a pleasant experience with the act of disposing of the items. In addition, I have used a cognitive-behavioral approach, challenging the absolute need for certain items with a broader range of possibilities and probabilities. For example, I'd ask the patients: It is possible that you might need that item, but what is the probability that you would need it?

I've found this cognitive approach to be therapeutic when challenging all-or-nothing concepts involving fixed, rigid perceptions. Of course, the patients would need to carry the ideas that come from those office visits into their own environments to successfully achieve control of the OCPD or OCD hoarding problems.

Today, in the United States, however, we have a cadre of organizing professionals who assist people in cleaning up the mess. More than 400,000 organizational experts are members of the National Association of Professional Organizers. The number attempting to help hoarders with the DSM Axis I diagnosis of OCD or the Axis II diagnosis of OCPD or any other disorder that might include hoarding is unclear. Nevertheless, the strategies used by these experts might be viewed as comparable to those used in complementary and alternative medicine, which focus on mind/body medicine such as yoga and acupuncture; nutritional products, including dietary supplements; and manipulative practices, including spinal manipulation and massage therapy (“Yoga: A Beneficial Integrative Therapy,” The Psychiatrist's Toolbox, December 2007, p. 20).

In addition to addressing hoarding problems, professional organizers often deal with emotional situations, where anxiety, shame, embarrassment, depression, and family stressors are at play. Other factors they must address are social/environmental issues such as hygiene, fire safety, and landlord-tenant problems.

Clearly, proponents of yoga, mind/body medicine, and nutritional supplements do not make diagnostic proclamations when they address anxiety, stress, depression, and a myriad of mental health issues that bring people to these practitioners. This is also the case with declutter experts. Is the tendency to use these nonmedical professionals a positive development—or not?

My first thought is that this makes no sense. After all, these folks are potentially treating psychiatric disorders. Then I remembered the old days of the 1960s and 1970s, when flying became a popular mode of transportation, and there were people specializing in treating flying phobias. These single-phobia experts were not mental health experts but were quite successful. They took groups to airports, held learning seminars, and accompanied people onto aircraft while on the ground and subsequently onto flights in an effort to desensitize thousands. This approach is in stark contrast to traditional talk therapy, which might have managed to help the person understand why he was afraid to fly rather than enable the person to get on a plane and take flight.

While thinking through these issues, I decided to consult with an organizational expert, and I contacted Gillian Wells. Ms. Wells, who studied architecture at the prestigious Cooper Union in New York City, runs her own successful business in organizing homes, apartments, and offices. Ms. Wells had a lot to say about the cleanups she facilitates, and indeed, I had to slow her down. My focus was on the mental health aspect involved in Ms. Wells helping people with the accumulation of clutter or the process of hoarding—people who might be emotionally troubled with any number of problems. I asked about her expertise and her strategies for helping her clients cope with these disorders.

Ms. Wells quickly pointed out that her clients seek her out and are motivated for a change in their cluttered lifestyles, and that they do not mention a psychiatric or psychological problem. She also made it clear that she is not a mental health expert of any sort—not a psychiatrist, a psychologist, or any other kind of mental health expert. Rather, Ms. Wells is simply a person who has been asked to consult and solve problems of disorganization.

She gets to know her client's personality style in her first 3-hour session in order to assess the person's actual needs. This initial consultation also gives Ms. Wells a clear understanding of the person's budget and the direction the organizational work should take.

Interestingly, she refers to her work with clients as “sessions.” At first, I was taken aback by that terminology, but as I listened, I realized that we in the psychotherapy world do not have a monopoly on that term. As Ms. Wells began to describe how she approaches clients, it began to sound like cognitive-behavioral therapy (CBT), a method I know well.

Challenging the Client

First, the client who requests her services needs to be willing to “surrender” the “mess” in order to get organized. The client also might be surrendering some of her autonomy (i.e., control) but needs to be part of the process in order for it to work and for the client to feel comfortable in this surrender. Second, Ms. Wells aims to discover what the client wants in the cleanup and suggests that the client focus on one item at a time, for example, papers one day and clothes another day. Such a stepwise approach challenges the client in a positive way. Often, Ms. Wells notes, many people have a rigid all-or-nothing approach to keeping the clutter.

Third, she points out, many of her clients feel embarrassment or shame about the mess and clutter, and she makes it clear that many, many people accumulate a lot of stuff. Her job is to help the client solve the problem and begin the client on a road to less mess. In the future, this approach might ripple over into other areas of the client's life, if necessary, and with or without her help. Again, all of this sounded like cognitive-behavioral therapy to me, coupled with action to get things done in a positive, nonstressful manner.

I asked Ms. Wells whether she ever gives up on a client because the emotional issues are deep-rooted and complicated, and her answer was, “Of course, yes.” Just like other professionals, organizational experts find that they are unable to work with some people.

As we know, one broad-based notion in mental health care is that symptom removal without a deeper understanding of the problem will not work—even though the history of behavior modification and CBT has shown that traditional idea to be false. Ms. Wells told me that she ran into a former client a few weeks ago who reminded her about the cleanup and apartment sale a year ago where a lot of clothes, books, and jewelry had been sold. Interestingly, the client remarked: “I can't remember any of it and don't miss it.”

Complementary and alternative medicine practitioners, exercise therapists, and nutritionists offer relief from specific, well-circumscribed problems. Their solutions not only make life simpler but might enhance mental functioning. After all, much of cognitive therapy is done by challenging unsuccessful behaviors, ideas, and thinking, and offering new and broader-based ideas without the open-ended intrapsychic exploration of the traditional psychotherapies. Reciprocal inhibition and desensitization processes are most often done in vitro, producing good office-based results. Professional organizers go right to the home or office to do their work. Their approach is not unlike those used years ago, when behavioral therapists rode elevators or traveled through tunnels with their phobic patients or clients in the desensitization process.

We cannot ignore the people from many disciplines and training who are in the business of helping people with potential psychiatric disorders. Perhaps psychiatrists or psychologists should have a role in training the many professionals who perform this helping service, but that remains an open question.

Let me know your thoughts about these professionals who might interact with our patients in the course of their work.