This makes a big difference. If the client recognizes the hoarding as a problem and wants to stop hoarding, we just need to reach an agreement on whether to start working on the hoarding now or whether to work on the depression and anxiety first (I'd usually work on the depression and anxiety first). If they don't want to work on their hoarding, then I'm faced with the question of whether it is a big enough problem for them that I should work to get them to the point where they are willing to work on the hoarding.

If we start working on the hoarding, my first step would be to try to understand it. I'll want to get a good history of the hoarding and to find out about the client's thoughts and feelings when they decide to keep something that they hoard, their thoughts and feelings when they think of throwing something out and decide not to, and their thoughts and feelings if they are forced to throw something out.

I have a client currently who is pretty typical. For the past three years she has been trying to clean up her house so that it can be sold. When she tries to discard worn-out items, old newspapers, etc. she becomes quite uncomfortable (anxiety) and reports thinking "It could [still] be used," "I might want it someday," "It is wasteful [to throw it out]," and "memories are very important [therefore I shouldn't throw out any momentos]."

My plan is to address these thoughts cognitively and to make sure that she has a realistic view of pros and cons of hoarding. Then we'll start systematically having her clean up the mess and discard all the useless stuff she's accumulated, taking it in manageable steps and addressing all the various cognitions which are likely to interfer. As she discards things from her piles she'll become quite anxious, but it she persists despite the anxiety she will gradually become more comfortable and more able to make reasonable decisions about what to keep and what to discard.

With my client, and many hoarders, the pattern is similar to OCD. A client with a handwashing compulsion might touch something "dirty," imagine catastrophic consequences, become quite anxious, and wash her hands (thereby obtaining relief from the anxiety). My client thinks of discarding an object, imagines catastrophic consequences, becomes anxious, and decides to keep the item (thereby obtaining relief from the anxiety). Exposure and Response Prevention works well in both scenarios.

Obviously, my treatment plan would be different if the person was hoarding for other reasons (i.e. command hallucinations, paranoia, or whatever).