Monthly Archives: March 2023

Treatment of hoarding induced trauma

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.

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Pedro and Graeme, part two

So, we ask senior analysts: do you really want to know all the shit we want to say to you as parents/instructors, objects? Maroda (2022) suggests there’s something of a “developmental tilt” phenomenon happening here: Are senior analysts truly responsive to the patient’s needs, or might developmental deficit theories allow a senior analyst to identify with the patient who lacked early nurturing, thereby bypassing that person’s threat as a voracious adult? We can be seen as eager children, but with strong limits defined, we are called upon to perform “mature tasks” as analysts – not something in the realm of the good-enough. What do supervisors want here? This creates a confusion (Ferenczi, 1933) that is only solved if you are seen doing the work the way you are told to do the work, which subjects a clinician to projective identification, because a supervisor can identify with a protoge and be satisfied. In one of our institutes, an ongoing joke circulates about an analyst who thought she was told ad verbatim to tell her patient that what he wanted was for her to “water his balls” like someone would water plants to make them grow. This was a message that a supervisor told the analyst in a humorous and contemplative moment, though what unfolded was an equally humorous incorporation of the supervisor figure rather than an internalization of his thoughts and analytic stance. The analyst actually spoke the supervisor’s exact formulation to the patient, who not surprisingly got up and left, outraged. Examples like this reflect an eagerness to please the adult/parent/supervisor as a vulnerable child would, perhaps even mimicking a supervisor’s expressions. Moreover, supervisors sometimes use their supervising hour to relax between their own clinical sessions, which may create moments where they speak more freely.

So, are principals at institutes going to allow newcomers to change things? Or should we, the newcomers, simply do as we are told? One of us had a one-time consultation with an experienced senior foreign analyst. After discussing eroticized aspects of transference-countertransference pertaining to the case, he commented that we’d have a hard time explaining what was going on in that case to another senior analyst without that person becoming suspicious of acting out behavior within the case’s treatment. Regarding supervision, the foreign analyst observed: “You will have to dance the dance”. Not exactly “fake it until you make it”, but maybe “fake it until they think you make it”.

How false might a professional self become in this kind of atmosphere? Stumbling, hesitant, overworked, we hold fast to illusions, as Winnicott (1951) suggested, of a mediated space between ourselves and our objects, between inner and outer worlds, of fantasy and play, that would serve us well in our training. The capacity for illusion formation enables creativity, makes us participate well, be flexible in our thinking, not fixed in ideas, serving a false position of delusion. We’ve kept hope. Things changed during training without us noticing. Now we might differentiate from former supervisory figures and alter how we separate from objects. We might observe a shift in how we relate to our patients, especially upon their leaving us. We’d feel excluded, dropped even as we eventually let them go, but with more equanimity, perhaps. We’re not the primary objects after all, Steiner (2008) reminds us. 

Disillusionments. Disappointments. We can be rejected yet—in short, fail—or else we can be told “no” with respect to various requests or demands, or worse still, we can be told to wait, or to endure perennial tasks, extra consultations, more work and learning. There is always more, we’ve thought greedily and warily, and it will all seem like a privilege if there is a carrot of acceptance, plus something more still, at the end of a non-linear process. We understand that this doesn’t happen to everybody. The prosaic, tacit basics of inclusion and exclusion: surely, not everyone is enfolded into the analytic community and thereafter practices happily as psychoanalysts. There have always been runts in classes, outliers in groups, haven’t there? We think psychoanalysis doesn’t serve the delusion that it’s different in this respect, though Tucket et al (2008) report that at psychoanalytic federation conferences training analysts speak of their reluctance to reject members, thinking it tantamount to professional murder. Well, it seems we give and receive a taste of blood along the way: fielding reviews with comments that paint with broad strokes and linger in our neurotic minds; meanwhile, we push back with anonymous online feedback, suggestions for how seminars can be improved. 

Some amongst us have been more ambitious, having extended their disappointments and their capacities for illusion to the realm of social unconscious. At the San Francisco Center for Psychoanalysis, a faction of students and faculty collaborated in 2021 on what they’d topically call the Anti-Racism Task Force (ARTF) Report. Seventeen pages deep, the report lamented what it termed the “realization that we are implicated in creating an organization that many would identify as racist and elitist. We feel very deeply that this is not who we are or what we are about”. Established in June 2020 amidst the furor surrounding the killing of American citizen George Floyd, the ARTF sought to review policies of the center’s psychoanalytic education division, its procedures and standards, to identify areas of exclusion, inequity, inaccessibility, and racism, and to make recommendations for changes necessary to become an equitable, accessible, inclusive, diverse and anti-racist psychoanalytic community. Among the report’s findings were criticisms of an overly subjective application procedure that rendered applicants susceptible to interviewer bias; that application forms lacked explicit statements regarding anti-racist policies, and that requirements for participation were too rigorous.  

More specifically, the report challenged the use of ambiguous terms like “suitability” and “analytic process” in policy statements, plus the lack of clear and transparent guidelines for admissions as well as the tracking of candidate progress within the program; that step-by-step procedures for recognizing bias in the assessment of candidates were lacking, and that no procedures determined the efficacy of requirements that diverged from those of The American Psychoanalytic Association (ApsaA) or the International Psychoanalytic Association (IPA). Within weeks a faculty response was published, bristling in defense of program integrity, and providing data that disputed the ARTF’s premise that recent admissions trends reflected a lack of racial diversity. The call for more transparency, plus so-called “objective” standards further seemed to offend the sensibilities of some. Amid the distance of the contemporaneous Covid crisis, murmurings across Zoom calls bemoaned this would-be “reification” of training standards, plus a general atmosphere of “calling out”, which seems to live in binary opposition to a fear of being called out. Some kind of illusion was under threat. Suddenly, it seemed that an analytic stance of “not knowing”, of neutrality, might be re-cast as hapless denial, or worse, a form of ethical cowardice. In seminars, presenters speak of not knowing, evincing an ethic of humility and calm, speaking to the presumedly like-minded about the value of an analyst’s discomfort. Ultimately, we stir over an aggregate of critiques, challenges, some that insult, others less so, that cut back and forth across contexts. Today, we wonder how many will have noticed the altered flavor, the audacities of candidate complaints pushing back—the upped ante of illusion and disappointment. 


Ferenczi, S. (1939/1988). Confusion of Tongues Between Adults and the Child. Contemporary Psychoanalysis, 24:196-206

Freud, S. (1913) On Beginning the Treatment. The Standard Edition of the Complete Psychological Works of Sigmund Freud 12: 121-144

Gabbard, G.O., & Ogden, T.H. (2009) On Becoming a Psychoanalyst. International Journal of Psychoanalysis 90: 311-327

Junkers, G., Tuckett, D., & Zachrissson, A. (2008). To Be or Not to Be a Psychoanalyst. Psychoanalytic Inquiry 28: 288-308

Maroda, K. (2022). The Analyst’s Vulnerability. London and New York:Routledge.

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