Tag Archives: exposure

Living with anxiety

By Bethany Bray May 24, 2017

Anxiety disorders are the most common mental illness in the United States, affecting 18 percent of the adult population, or more than 40 million people, according to the National Institutes of Health. Among adolescents the prevalence is even higher: 25 percent of youth ages 13 to 18 live with some type of anxiety disorder.

Anxiety disorders are often coupled with sleeplessness, depression, panic attacks, racing thoughts, headaches or other physical issues. Anxiety can run in families and be a lifelong challenge that spills over into all facets of life, from relationships and parenting to the workplace.

The good news is that anxiety disorders are manageable, and counselors have a plethora of tools to help clients lessen the impact of anxiety. Caitlyn McKinzie Bennett, a licensed mental health counselor, says she regularly talks this through with her clients at her private practice in Orlando, Florida. She often uses an analogy of ocean waves with clients: Anxiety comes in waves, and managing the disorder means learning coping tools and strategies to help surf those waves rather than expecting the waves to disappear entirely.

“Anxiety can be a long-term thing,” says Bennett, who is also a doctoral student in counselor education at the University of Central Florida. “With clients, I try and explain that [anxiety] is the body’s response that something’s not right — based off of what’s happened to you [such as past trauma] or what’s happening currently. Then we can work to accept it, cope and be happier in your life. Some things you can’t necessarily get rid of in their entirety, and that’s OK. It’s learning to be you and have a fulfilling life with anxiety, where you’re able to feel anxious and [still] be productive and be a mother, a student, a partner. I try and normalize that [anxiety is] going to come and go. It’s OK, and it’s human.”

Anxiety doesn’t happen in isolation

Everyone experiences anxiety from time to time, such as worry over an upcoming work responsibility, school exam or first date. Anxiety disorders, however, are marked by worry and racing thoughts that become debilitating and interfere with everyday functioning.

“It’s a normal part of life to experience occasional anxiety,” writes the Anxiety and Depression Association of America on its website (ADAA.org). “But you may experience anxiety that is persistent, seemingly uncontrollable and overwhelming. If it’s an excessive, irrational dread of everyday situations, it can be disabling. When anxiety interferes with daily activities, you may have an anxiety disorder.”

A number of related issues fall under the heading of anxiety disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), including specific phobia, panic disorder, separation anxiety disorder, social anxiety disorder, generalized anxiety disorder and others. According to the DSM-5, anxiety disorders “include disorders that share features of excessive fear and anxiety and related behavioral disturbances. Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat.”

Racing thoughts, rumination and overthinking possibilities — from social interactions to decision-making — are central to anxiety. In addition, people with anxiety often struggle with insomnia or sleeplessness and physical symptoms such as a racing heart, sweaty palms and headaches, says Bennett, an American Counseling Association member who is currently leading a study for her doctoral dissertation on the effects of neurofeedback training on college students with anxiety. Adolescents sometimes turn to self-harming behaviors such as cutting or hair pulling to cope with anxiety. In adults and adolescents, anxiety can manifest in physiological issues such as stomachaches or irritable bowel syndrome. Although adults may channel their anxiety into physical problems, they’re also generally much more capable than adolescents and children of identifying and articulating the anxious thoughts, ruminations and social struggles that they’re facing, Bennett says.

Bennett worked with a 14-year-old female client whose anxiety had manifested as the behaviors of obsessive-compulsive disorder (OCD), including avoiding the number six, leaving her closet door open a certain way and struggling with crossing thresholds. Bennett worked with the client to identify her triggers and find coping mechanisms, such as connecting with friends and her Christian faith.

“A big part of her improvement was creating the awareness of what was happening,” Bennett says. “Typically there’s a large, irrational fear. With her, she was afraid that her mom was going to die. She would focus on it so much that it would cause her to start the [OCD] behavior. … For her, it felt so real. It was so scary for her that she felt compelled to do these behaviors to keep her mom alive, so to speak.”

Bennett worked with the young client to confront her fears in small doses through exposure therapy, such as listening to a song at volume level six and talking through how she felt afterward. This method allowed Bennett to first address the client’s OCD behaviors and then — once trust was built and the client had progressed — move on to work through the bigger, deeper issue of her fear of her mother’s death.

“It helped her to feel safe enough and have the confidence to work through some smaller things and move on to work on bigger things,” Bennett says. “For her it was talking it out, normalizing that for her and drawing attention to [her anxious behaviors].”

Christopher Pisarik is an associate professor in the Division of Academic Enhancement at the University of Georgia and a licensed professional counselor (LPC) who works with students in need of academic support. He says that stress and irregular sleep and eating patterns — which are often ubiquitous parts of college life — can go hand in hand with anxiety.

“Sleep is a big one — if they’re just not sleeping, or sleeping too much,” says Pisarik, who also treats many college-age clients at his private practice in Athens, Georgia. “This is really, really common — clients who can’t get to bed until 4 a.m., and then they can’t get to class, and it snowballs. Their thoughts just race with worry. … Sleep seems to be a big diagnostic indicator [for anxiety], and not being able to go to bed. [I ask clients,] ‘What are you thinking about, and can you stop thinking about this? Is that what’s keeping you from getting back to sleep?’ They get tired and fatigued, and it’s perpetuated.”

In addition, anxiety is often coupled with — or is an outgrowth of — other mental illnesses, most commonly depression. Counselors will need to treat a client’s anxiety alongside other diagnoses, Bennett says. For example, a client with schizophrenia will have hallucinations that provoke extreme anxiety. If the counselor doesn’t address the client’s anxiety, those symptoms will get worse, explains Bennett.

“Depression and anxiety are like brother and sister,” she adds. “They play off of each other and exacerbate the symptoms. You need to work through both. I don’t think I’ve ever worked with anyone who solely experienced anxiety.”

Stephanie Kuhn, an ACA member and LPC at the Anxiety Treatment Center of Greater Chicago, agrees. She regularly sees client anxiety paired with other issues such as specific phobias, insomnia, chronic pain issues, depression, panic disorders and OCD.

“It’s never really one thing,” Kuhn says. “It’s never just anxiety.”

Pumping the brakes on racing thoughts

The first step for many people who struggle with anxiety is to create awareness of their thoughts and then learn to manage those thoughts with a counselor’s help. Although the strategy of identifying negative self-talk and addressing one’s thoughts is old hat to most counselors, it may be an entirely new concept for some people, especially younger clients, says Pisarik, an ACA member who uses cognitive behavior therapy (CBT) in his private practice. Clients with anxiety often polarize, exaggerate or catastrophize details in their minds as they ruminate over them, he explains.

“Even being able to identify anxious thoughts is big,” Pisarik says. “They just assume it’s normal to walk around [feeling] anxious because of these thoughts. … It gives them a language and a real usable and rudimentary skill they can use in the moment when they’re walking in [to a stressful exam]. They can identify that their inner narrative isn’t healthy.”

For example, a college student might come to a counselor expressing worry about an upcoming exam in a class that he or she needs to pass for a major in pre-med. The student might have allowed negative and catastrophic thoughts to snowball: “If I get a C on this test, I will never get into medical school, which will derail my entire career plan and make my parents angry and disappointed.”

“For … a student who is 20 years old and [still] learning to think critically, it would be easy to blow everything out of proportion and catastrophize everything,” Pisarik says. “I am really big on helping them understand negative thinking and false cognitions, and getting them to self-monitor and renarrate [their unhealthy thoughts].”

Following the CBT approach, Pisarik says he would talk such clients through their thought patterns to identify and restructure their negative thoughts about the exam. He would also suggest that they focus on and remind themselves of prior successes, such as other exams or classes in which they earned A’s and B’s.

“I would try and systematically educate the client [about] what type of thinking that is,” Pisarik continues. “There are many doctors out there who got C’s and got into medical school, and probably [who] got C’s in medical school. I will explain that they are catastrophizing this … [and] try and get them to think about it in a different way, evaluate it carefully and create a different narrative about it. Are there people who have gotten C’s and gotten into medical school? If it stops you from getting into medical school, would that be the worst thing in the world?”

“It takes a consistent effort to practice and challenge one’s thinking,” adds Pisarik, who co-authored the article “A Phenomenological Study of Career Anxiety Among College Students.” The article will be published in the December issue of The Career Development Quarterly, the journal of the National Career Development Association, a division of ACA.

CBT works well for anxiety because “it lets people see that their own thinking and their behaviors are not productive for the way they want to live or the life they’re living right now,” says Kuhn, who uses both CBT and exposure therapy with her clients at the Anxiety Treatment Center of Greater Chicago. “It’s giving people an outside perspective — getting them to look at their own thoughts and behaviors objectively rather than letting those anxious thoughts take over everything, making it harder to function.”

One way Kuhn works with clients on challenging their unhealthy thoughts is by asking them to identify the best, worst and most likely outcomes of situations they are ruminating over. “I ask, ‘Would [the outcome] matter in a week, a month or a year from now?’ Typically the answer is no,” Kuhn says. “After we go through that, we reframe the original thought [and] transform it into something more rational, more realistic.”

Both Pisarik and Kuhn encourage their clients to keep thought logs to track anxious thoughts and the situations that triggered them. This exercise increases self-awareness, helps identify triggers and creates an opportunity to discuss how the client might change the negative narrative.

“Writing helps a lot because it slows people’s minds down, and they can go back and read about it,” Kuhn says. “Creating that awareness is the only way to understand yourself, understand what you’re worried about and be able to accept it and push it away.”

In addition to using thought logs, Pisarik gives his clients a list of automatic negative thoughts, or ANTs, to check themselves against. The collection lists the most common types of unhealthy, anxious thoughts and types of thinking, including catastrophizing and either-or thinking (polarizing).

Kuhn has a particular phrase that she often repeats with clients: “Handle it.” She acknowledges that it’s not the most empathic of mantras, but it does help to focus on the manageability of anxiety. With clients, she works toward a goal of “being able to sit with the uncomfortableness [of anxious thoughts] and tolerate the stress.”

Kuhn says her style when working with clients matches her personality: “Let’s go forward and hit our fears hard instead of tiptoeing around them.”

Exposure therapy, which introduces things in small, controlled increments in session that make a client anxious, is another good way to focus on handling anxiety, Kuhn adds. Whether the scenario is a fear of speaking up in class or a fear of being rejected by a loved one, exposure therapy can help clients learn to live with the issue and the anxious feelings that come with it.

“When I talk to people about ‘handling it,’ it’s creating that awareness and understanding [of] themselves that they’re able to manage or take on more than they think they can,” Kuhn says. “Anxiety a lot of the time makes us believe that we can’t handle the tiniest things. That’s why our body has created or learned how to respond to things in an overactive or hypersensitive way.” This is most commonly experienced in our fight-or-flight response, she says.

Managing worry and taming anxiety

From CBT and mindfulness to a focus on wellness and coping strategies, professional counselors have a wide range of tools to help clients who struggle with anxiety. Here are some ideas and techniques that can be particularly useful.

> Controlling the controllables. Kuhn says it can be helpful for clients to talk through and identify what is out of their control during situations that make them anxious. “A lot of times, anxious clients want control over everything, and that’s just not realistic,” Kuhn says. “It’s important to go over what’s controllable and what’s not. That creates awareness and a pathway to reevaluate [their] own thinking and behavior. I like to call it ‘controlling the controllables.’ I talk with clients about this a lot.”

Kuhn often uses an exercise with clients in which she draws a target with concentric circles. Things that clients can control, such as their own thoughts and behaviors, go in the center circle. Things that they partially control, such as their emotions or what they focus on sometimes, go in the middle ring. Things that are out of their control, such as what other people think or do, go in the outside circle. In a simpler alternative, Kuhn draws a center line down a piece of paper and works with clients to list what is and isn’t in their control in situations that make them anxious.

> Creating common ground. Kuhn says she also talks openly with clients about how common anxiety is, alerting them that they are among literally millions of Americans who are battling the same challenge. “I let them know they are not alone. It creates a universality,” Kuhn says. “To let people know that they’re not the only ones suffering like this can help. … It does create a common ground for people not to feel ashamed of [their anxiety] or feel like they can’t talk to someone about it. Just creating that education typically makes people feel a ton better.”

> Acknowledging and naming worry. Journaling and making lists to document anxious thoughts can help clients address and reframe the everyday rumination that accompanies anxiety. Kuhn offers two variations on this intervention: worry time and the worry tree.

With “worry time,” clients set aside a dedicated amount of time (Kuhn suggests 30 minutes) every day to write down any anxious thoughts that are troubling them. Clients don’t need to engage in long-form writing to complete this exercise, Kuhn says. Making a bulleted list or jotting thoughts down on sticky notes will work just as well. When the designated time is up, clients put all the notes in a box or container that they have set aside for this purpose. This action signifies that they are leaving those thoughts behind and can move on with the day.

“They have to leave those thoughts or sticky notes there and be done with them,” she says. “Obviously more [anxious] thoughts will come, but you have to remind yourself to leave them behind.”

With Kuhn’s “worry tree” intervention, clients create a flowchart of their anxious thoughts. With each item, clients ask themselves whether their worry is productive or unproductive (see image, below). “Is it something that you can actually do something about?” Kuhn asks. “If it’s unproductive, then you need to just let it go. Do something you enjoy or focus on something else to reset [your mind].”


> Mind-body focus and exercise. Mindfulness, meditation and other calming interventions can be particularly helpful for clients with anxiety. Kuhn recommends the smartphone app Pacifica, which prompts users with breathing, relaxation and mindfulness exercises, for both practitioners and clients. Kuhn, who has a background in sports counseling, and Pisarik, who is a runner himself, also prescribe exercise to anxious clients. Exercise boosts serotonin, a neurotransmitter connected to feelings of well-being, and comes with a host of other wellness benefits. In addition, exercise allows a person to get outdoors or disengage from work and home activities and other people for a brief period to “have time to hear your thoughts and challenge them,” Pisarik says. “You have to hear your thoughts if you’re going to challenge them.”

> The butterfly hug. Beth Patterson, an ACA member and LPC with a private practice in Denver, teaches deep breathing exercises to anxious clients to help them become grounded, focusing on the flow of energy through the body. She also recommends the “butterfly hug” technique. With this technique, clients cross their arms across their chests, just below the collarbone, with both feet planted firmly on the floor.

Clients tap themselves gently, alternating between their right and left hands. This motion introduces bilateral stimulation, the rhythmic left-right patterns that are used in eye movement desensitization and reprocessing. “It’s phenomenally self-soothing,” Patterson says. “Doing that with deep breathing really helps with anxiety. I love the idea that you’re hugging yourself. Even just doing that helps.”

> Walk it out. Along with deep breathing and grounding, Patterson also recommends walking and movement for clients who are feeling anxious. She instructs clients to focus on the feeling of each foot hitting the ground instead of their anxious thoughts. As with the butterfly hug, this action creates bilateral stimulation, Patterson notes.

Bennett also uses walking as a way to help clients refocus their thoughts. She will take clients out of the office during a session for a “mindful walk” up and down the block. During the walk, they talk about what they’re sensing, from the sunshine to the breeze to the smell of flowers. Bennett says this allows her to work with clients “in the moment,” recognizing and refocusing anxious thoughts as they come. Afterward, they process and talk through the experience back in the office.

“It’s a lesson that [anxious] thoughts are going to come up for you, and you can refocus on your sense of touch or hearing,” Bennett says. “Thoughts will come up, and it’s really easy to attach to those thoughts and become anxious, but we can acknowledge the thought, be accepting of it in the moment and refocus. Change and connection can come that way.”

> This is not that. Clients commonly transfer anxiety-provoking personal issues onto relationships or situations in other facets of life, including the workplace, Patterson says. For example, Patterson worked with a client who had a very domineering, controlling mother, and this client felt triggered by a female boss in her workplace. Patterson introduced the client to the mantra “this is not that,” and they worked on reframing the anxiety the client experienced when she felt her boss was being controlling.

“She had to work through it in a beneficial and compassionate way for herself and really remember ‘this is not that,’” Patterson says. “Our minds are brilliant, but they’re binary computers. When something happens, it will immediately associate it with something else it knows. If a co-worker is being overly competitive, it might trigger feelings about sibling rivalry. This [mantra] offers a great opportunity to work through family-of-origin issues [with clients] when you see them replicated in the workplace.”

> Abstain from negativity. Another empowering tool clients can use is to become conscious of and then avoid unhealthy or toxic situations and people who trigger their anxiety, Pisarik says. He advises clients to “stay away from groups of people or individuals who they know will engage in negative self-talk or negativity. If you’re feeling anxious already, the last thing you want to do is to go and talk to that toxic person.”

Similarly, he commonly advises anxious students to avoid waiting outside the room where they’re about to take a big exam, surrounded by 30 classmates who might be saying that they are going to fail, they didn’t study enough, they don’t feel prepared and so on. Counselors can coach anxious clients to think ahead and prepare ways to remove themselves from these types of situations, regroup and redirect their thinking, Pisarik says.

> Lifestyle choices. Counselors can also educate clients on the connection between anxiety and lifestyle choices such as sleep patterns, exercise and diet, Pisarik says. For young clients especially, this also includes social media use, he notes.

Pisarik says he frequently talks with his college-age clients about their alcohol consumption, drug use, irregular diet and other aspects of the modern university experience. “The lifestyle of a college student is absolutely conducive to generating anxiety,” he says. “While they are college students, I get that — their job is to have fun and sleep whenever [they] want. But building some sort of healthy routine is important, [including] getting enough sleep and making sure they eat well. I tell them to try and maintain the diet they had at home. … If you’re struggling with anxiety to begin with, any one of those [elements] can add to it, and those are really easy fixes.”

For Bennett, conversations with clients about lifestyle also include questions about smoking and caffeine use. Both tobacco and caffeine can make a person shaky or make his or her heart and mind race, which can trigger or exacerbate anxiety, she points out.

In addition to social media use, Pisarik also asks clients about their social engagement, such as participating in sports or other hobbies. Clients who struggle with anxiety often isolate themselves, he notes, so he works with them to identify social outlets, from volunteering to joining a school club. This sense of connection can reduce anxiety, he says.

> Narrative therapy and externalization. Patterson finds narrative therapy helpful when working with clients with anxiety because it allows them to externalize what they’re feeling. When clients uses phrases such as “I am worried” or “I am anxious,” Patterson will gently redirect them by saying, “No, you’re Susan, and you have a problem called worry.”

“Externalize the problem,” Patterson explains to clients. “Externalize it and dis-identify it. See it outside of yourself. … ‘I can deal with that because it’s not who I am.’ … If you’re carrying it around as if it’s you, you can’t do anything about it. The truth of the matter is, it’s not you.”

Counselors can also help clients with anxiety to focus on a time in their lives when they faced a similar challenge and got through it, Patterson says. She asks clients questions to help them probe deeper. For example: How did you handle that challenge? What worked, and what didn’t work?


Working with clients on medication

Anti-anxiety medications are commonly prescribed in the United States. Their prevalence means that counselors are likely to encounter clients who are taking medication to control their anxiety symptoms.

Regardless of their feelings about the use of psychotropic medications, practitioners must treat and support clients who are taking such medications the same as they would any other client, Kuhn says. “I never treat someone differently based on their medication. They get the same CBT therapy that anyone else would get,” she says, adding that the most important thing is to ensure that clients don’t feel judged by the counselor.

Kuhn has seen anti-anxiety medications work well for some clients. “It can take that little edge off that they need to get through the day and be able to function,” she says. At the same time, she also has clients who express a desire to be able to stop taking their medication eventually.

Pisarik notes that for anti-anxiety medication to work well, clients must remember to take it faithfully, keep track of how it makes them feel and schedule the repeated appointments needed to monitor and adjust dosage levels. Each of these elements can pose a challenge to college-age clients. “It’s a lot of work, and [college students] often lack the discipline and time to get it right,” Pisarik says.

Bennett agrees, suggesting that even though professional counselors are not the ones prescribing medications, they still need to discuss and explore medication use with their clients. She also stresses that practitioners should be knowledgeable about the different kinds of medications that clients may be taking and their possible side effects.

Bennett sometimes conducts conference calls with her clients and the medical professionals who are prescribing them medications so that she can help clients ask questions and otherwise be a support to them. “We [counselors] don’t prescribe, but at the same time it’s very important to collaborate with whoever is prescribing the [client’s] medication,” she says. “Be supportive and involve the client in conversations: How long have you taken it? Have you noticed any side effects? Has it been helping? Talk about how often they’re supposed to take it and if they’re adhering to that. There can be stigma about taking medications, so it’s important to normalize it. … It’s comforting too for the client to know that you’re on their side, and part of that is collaboration [about medication].”


See the person, not the anxiety

Given how common anxiety disorders are, it’s likely that any counselor’s caseload will be filled with clients presenting with symptoms of anxiety. It is important, however, for counselors to treat each client as an individual and to tailor the therapeutic approach to meet that client’s unique needs, Bennett emphasizes.

Building trust and a healthy therapeutic relationship are key in treating anxiety because clients can feel very vulnerable as they talk about what makes them anxious, Bennett points out. That is why it is critical to get to know these clients as individuals rather than through the lens of their anxiety.

“Don’t assume that because they’re anxious, they’re going to think and behave like other people with anxiety,” Bennett says. “Meet them where they are and find out what’s most effective for them based off of their interests. It can be empowering for clients to integrate their own interests and life experiences into the therapeutic process. Not only does this create buy-in for the client, but it can also help in creating a safe space to begin exploring the vulnerabilities that come along with anxiety. … Hear their story, find their strengths and give them a voice in the process. It’s important to honor them as individuals.”




To contact the counselors interviewed for this article, email:




Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

Letters to the editor: ct@counseling.org




Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Help for those who hoard

By Laurie Meyers February 29, 2016

TV shows such as Hoarding: Buried Alive and Hoarders have brought hoarding disorder (HD) to a new level of public consciousness. The shows provide portraits of people who hoard, typically at a moment of crisis when they are on the brink of being evicted or having their houses condemned. Years of collecting “stuff” — much of which often has no monetary value — has narrowed their living space to a single room, part of a room or even just a place to sit.

Often, the living conditions are almost unimaginable. In many instances, kitchens have become unusable and utilities, including running water, have been cut off. Food has been left to rot, garbage Branding-Images_Hoarderis everywhere, and in the case of those who hoard animals, the resident lives among animal feces and even dead and dying animals.

Because these shows typically provide only a snapshot of the more sensational aspects of the lives of those who hoard, however, viewers rarely receive insights into the mental health disorder behind the chaos. Viewers are also unlikely to understand that the dramatic assisted cleanups that conclude the shows are not truly the end of the story; unless the person’s behavior is treated, all the “tidying up” will be for naught, because the same problematic actions and habits will reemerge. In fact, say counselors who work with those who hoard, treating the hoarding behavior is a difficult and often yearslong process.

Hoarding as a distinct disorder

In the past, hoarding was classified as a symptom of obsessive-compulsive disorder (OCD) or obsessive-compulsive personality disorder. However, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders classified hoarding as a distinct disorder related to OCD. This is because OCD and HD may share certain characteristics, but they also feature significant differences, says Victoria Kress, an American Counseling Association member and past president of the Ohio Counseling Association who studies hoarding.

“Individuals with OCD and HD both have obsessive thoughts, rational or irrational, that affect their daily lives. These obsessions link certain behaviors with grave and undesirable consequences,” she explains. “For example, those with OCD might obsessively believe that they will get into an automobile accident if they do not lock their front door three times before leaving the house. On the other hand, those with HD might believe that they will suffer great sadness and loss if they discard an item of sentimental value. A fear of discarding items is one of the most notable features of HD, and those with this disorder often fear that they will accidentally discard an item that is valuable or will become valuable.”

Experts estimate that approximately 2 to 6 percent of the U.S. population has HD. Although often associated with those older than 50 — the average age at which those with HD seek help — in most cases the behavior begins during adolescence or young adulthood.

As a person with HD gets older, symptoms increase. Hoarding behavior may become more pronounced by a person’s mid-30s but often does not become truly debilitating until one’s 50s, Kress says. “This is due to a number of reasons,” she explains. “Primarily, individuals with this disorder do not experience debilitating consequences as the result of hoarding until the behaviors have increased and material items have collected over time.”

In addition, those who are younger often live with others — parents, roommates, partners or spouses — which can help keep the behavior in check, notes Nicole Stargell, an ACA member who also studies HD and has co-authored several studies with Kress. In fact, in some cases, the death of a spouse or partner contributes to the disorder spiraling out of control, she says.

Even when individuals with HD are not keeping the behavior in check, they can often hide it from friends and family simply by never letting anyone else enter their homes, says Kress, a national certified counselor who has experience working with this client population. However, as hoarding symptoms become more severe over time, the behavior begins to create significant social isolation, financial difficulty and hazardous living conditions, she says.

Hoarding behavior

As is the case with many other mental health disorders, researchers have not been able to pinpoint what causes HD. According to Kress, HD is characterized by a client’s desire to obtain and accumulate possessions but does not seem to be associated with poverty-related factors such as lack of food, shelter, clothing or money. She adds that the disorder can be exacerbated by — but is not caused by — trauma.

Hoarding is also not the same as, or even a natural progression of, allowing clutter to accumulate, experts say. Although the behaviors may share a superficial resemblance, they are quite different, says Mark Chidley, a licensed mental health counselor in Fort Myers, Florida, who works with clients struggling with HD. “The difference lies in the compulsive nature of acquiring [objects and possessions inherent with HD] and the distress when faced with discarding [them],” he explains.

Those with HD also don’t seem to recognize that being unable to use a room for its intended purpose — for instance, using a bathroom instead as a storage locker — is indicative of a significant problem, continues Chidley, who is also the author of Helping Hoarders: A Guide for Families, Counselors and First Responders.

“Lots of folks get a bit messy for a time, but [they] will act to clean up before they lose use of a space and do not show … compulsivity and distress when they go to clean up,” he says. “Cleaning up a cluttered space remains just a pain in the derriere for most of us, not something to be avoided at all costs.”

People who hoard find it nearly impossible to discard items because they attach significant emotional value to those objects, say Stargell and Kress. Although the objects sometimes have monetary value, they are just as likely to be items that are normally discarded as trash, such as napkins, cups or straws, says Stargell, an assistant professor of counseling and the field placement and testing coordinator at the University of North Carolina at Pembroke. Regardless, clients who hoard will consider the items to be tremendously valuable.

“The value that individuals with HD place on hoarded objects is often not monetary. They are valuable due to their usefulness or sentimental qualities,” says Kress, who is the community counseling clinic director, clinical mental health counseling program coordinator and addiction counseling program coordinator at Youngstown State University in Ohio. “Individuals with HD place unjustified value on objects and fear harmful, often unrealistic consequences if they are discarded.”

For example, someone who collects napkins might cite a particular napkin as having value because it was used at an anniversary dinner with a spouse, Stargell says. “However, it’s not just that napkin — it’s every napkin from every dinner ever,” she stresses. Another example of misplaced value would be someone who collects cups from a fast-food restaurant because the cups may be “useful” someday. In the process, however, the person gathers and keeps hundreds of cups, Stargell says.

But for those with HD, it’s never just one item, and it’s never enough, experts say.

Health risks

As hoarding behavior progresses, it can pose significant risks to both physical and mental health. “The functional impairment associated with HD is often compared to [that of] schizophrenia and bipolar disorders,” Kress points out.

The conditions under which people who hoard live are frequently unsafe and unsanitary, compromising their well-being. “Medically, this can run the full gamut of conditions that are created or pre-existing conditions that are worsened by being in close proximity to decaying materials, coupled with an increasingly sedentary lifestyle,” Chidley explains. Decaying matter and the potential for accompanying pest infestations can exacerbate these individuals’ respiratory conditions, increase their likelihood of contracting an infectious disease or even expose them to toxic materials, he says. The flammable detritus around them can pose a fire hazard, while the lack of clear walking space increases the risk of injuries from tripping and falling, he adds.

“If a hoarder has a chronic condition such as diabetes, self-care is usually limited or nonexistent, and the disease trajectory is accelerated,” Chidley concludes.

Hoarding can be life-threatening not just because of the attendant health risks, but also due to the person’s reluctance to let outsiders in. “[One client] fell and injured herself in her home and, after making it to her bed, she lay in her own feces without food or water for four days before realizing she was going to die if she didn’t call for help,” says Polly Kahl, a licensed professional counselor in West Lawn, Pennsylvania, who specializes in treating clients with HD.

“Shaming reactions from those around them make hoarders less likely to call for help,” Kahl explains. “[They sometimes choose] unsanitary and unsafe living conditions without plumbing or electricity rather than risk being embarrassed and shamed.”

Some of the most horrific living conditions involve those who hoard animals. Although these individuals believe they are saving the animals, the truth is that they are not able to care for them properly. Those who hoard animals often have an almost unimaginable number of animals living in the home with them. Stargell knows of one case in which the person had collected 200 dogs. Because those who hoard take on so many animals, they are often surrounded by feces and the bodies of the animals that have died due to neglect. Those who hoard animals also have a tendency to bring in sick animals, thus introducing extra health risks to themselves and the animals they already have, Stargell says.

Kress and Stargell say animal hoarding is characterized not just by the denial or lack of insight that accompanies object hoarding, but also by delusional thinking. “They are convinced that they are helping the animals, that they are loving them,” Stargell says. These individuals may even believe that this is their calling in life — to help animals that would not have a good life without them (or so they think), she adds.

Hoarding affects not only the individual with the problematic behavior but also his or her loved ones and the community, Kress says. “The unsanitary condition of their homes presents a hazard to surrounding homes in the form of increased rodent populations, bug infestations and fire hazards,” she explains. “Cluttered living spaces present significant challenges to medical first responders in reacting to emergency situations, which may be more likely to occur due to the fire hazards and chronic health conditions that are associated with HD.”

Treatment challenges

Because HD is more treatment resistant than many other mental health disorders, treatment is slow, sometimes taking as long as three to five years, Stargell says. Part of the problem is that those who hoard are rarely motivated to change.

“Hoarders are traditionally in … denial about their own conditions and, when confronted, usually become very defensive, even verbally attacking, toward those who want to help them,” Kahl says. “The longer the condition has gone on, the more in denial and defensive the hoarder will be.”

Kahl likens hoarding to addiction in that both involve denial and a strong sense of shame. Another similarity is that, as with addiction, those living with the person who hoards may reinforce the hoarding behaviors and their attendant emotional distress, she says.

“There is a synergy between hoarders and those who live with them which can go a couple of different ways,” Kahl explains. “Many roomies [or family members] respond by trying to intentionally shame or embarrass the hoarder into cleaning up their act. This further solidifies the hoarding behavior by intensifying the hoarder’s defensiveness. The other common response to the hoarder is to avoid confronting them because of their [negative] behavior when confronted. As with addictions, this serves to enable further hoarding.”

“Occasionally, partners or housemates of hoarders gradually acclimate to their hoarded surroundings, developing their own ‘clutter blindness,’ and they become hoarders as well,” she adds.

Although those close to someone who hoards may enable or exacerbate the condition (even if unintentionally), they are also often the key to the person finally getting help. In another similarity to addiction cases, those who hoard often refuse to seek treatment until family members or other loved ones force the issue, say the counselors interviewed for this article.

Treatment suggestions

Even so, clients with HD may initially present in a counselor’s office with other issues such as depression or attention-deficit/hyperactive disorder, both of which are frequently comorbid with HD, say Kress and Stargell.

Stargell says clues to the underlying HD often turn up in clients’ descriptions of their families, social relationships and daily lives. For instance, clients might mention not socializing much because of their reluctance to let friends into their house or discuss family members refusing to visit because of the condition of their home. If clients bring up losing a job or being “forced” into therapy by family, counselors should be sure to explore all of the underlying factors because problems related to hoarding may be involved, Stargell says.

“Oftentimes, people with hoarding disorder have poor overall physical health,” says Stargell, citing another red flag for which counselors should be on the lookout. Indicators of hoarding might be hidden in the underlying causes of the client’s bad health, such as not going to the doctor because the person is avoiding the world or being unable to eat properly because the kitchen or eating areas are inaccessible, she explains.

Clients who hoard may also incur frequent injuries because they regularly trip and fall over accumulated clutter, Chidley says, or they may have respiratory problems caused by exposure to mold or toxic substances in their homes.

For treatment to be successful, clients with HD will eventually need in-home support, if not with a counselor, then with case managers or others trained in working with those who hoard, Kress says. However, it is possible to begin treatment in the counseling office. Kress and Stargell say that cognitive behavior therapy techniques such as thought stopping and cognitive restructuring have been shown to be effective when treating HD.

Counselors also need to help these clients understand the thinking that forms the foundations of their behavior. This might involve asking them to maintain a “thought journal” that tracks what they collect and why, Stargell suggests. For instance, clients might note that yesterday they went to a fast-food restaurant, purchased a drink and saved the cup and straw for future use. Counselors then encourage clients to consider the reasons why they might not need to save the cup and straw, such as “I already have 700 cups and straws,” or “I will only ever use five cups and straws,” Stargell explains.

Even speaking hypothetically about disposing of items can be extremely stressful for these clients, Kress points out. For that reason, it can be helpful for counselors to introduce emotional regulation and distress tolerance skills.

“Clients with hoarding disorder often have difficulties generalizing skills learned in sessions to real-life situations,” Kress says. “Practicing coping skills during hypothetical discussions may reinforce learning and the appropriate application of skills.”

Once clients start to understand the thoughts and feelings that underlie their hoarding behavior, counselors can then work on helping them restructure irrational thoughts into more logical and factual beliefs, Kress says. “For example, a client may work to replace the thought ‘If I throw away this newspaper, I may find out that it is of value and lose out on a fortune’ with ‘It is unlikely that if I throw away this newspaper, I will lose out on a fortune,’” she explains.

Counselors should move slowly with those who hoard in order to gain their trust. Because people with hoarding disorder are often experiencing shame and embarrassment and are typically sensitive to what they may perceive as rejection or judgment, they need to feel a strong sense of acceptance from the counselor, Kress says.

People who hoard typically lack self-awareness and insight. They are unable to accurately see and assess the destructive effect that hoarding has on their lives, Kahl says. For this reason, counselors must help these clients make the connection between their hoarding and its myriad unhealthy consequences.

“As with addiction, the best way to achieve this is by helping them see the consequences of their hoarding,” Kahl says. “In one case, a hoarder was … desiring [of] help because she realized her adult children had refused to enter her home for years. Now that she had grandchildren, she needed to clean out her home if she ever hoped to have them over to visit or come for family events like Thanksgiving dinners.”

Adds Kress, “Threats of eviction, loss of independent living, legal action and social isolation are some of the consequences that these clients face as a result of their behaviors. Because impaired insight is a facet of this disorder, interventions that focus specifically upon enhancing motivations, such as motivational interviewing, may be a helpful adjunct to other treatment approaches for this disorder.”

Once clients feel comfortable and open to change, it is important to incorporate family and other loved ones into treatment — with the client’s permission — so that they can help provide support and encouragement, Kress says.

Kress also suggests using exposure therapy to help clients. This process involves “practicing” disposing of items by discussing it hypothetically, either in the counseling office or in the client’s home. Once clients are ready to let go and discard, counselors can enlist the help of professional organizers or cleanup crews to remove discarded items, she says. But in some circumstances — such as impending eviction — counselors will not have enough time to slowly integrate exposure therapy.

“In this case, counselors should do their best to support the client and process mass cleanup events as a traumatic experience before working toward continued insight,” Kress says. “In situations that require immediate action, counselors should be prepared for the client to experience extreme emotional distress and may wish to include assessment for suicidal ideation.”

Because HD affects all aspects of these clients’ lives, practitioners should be prepared to provide referrals to other professionals such as physicians as well as to community resources such as vocational services, Kress notes. Although counseling those with HD does not require special training, Kress suggests that practitioners educate themselves by staying up to date on the literature and, if possible, attending training sessions.

Kress reiterates the challenges of working with clients who have HD. “They are deeply entrenched in their ideas and the importance of holding on to their items,” she says. “Also, they often don’t want to change. It is almost always someone else who is pushing them to make changes. Their ambivalence to change can be a real treatment barrier, so I like to focus on enhancing their motivation to want to change, because without that, you have nothing to work with.”




If you’d like to learn more, ACA offers a Practice Brief on hoarding disorder, written by Nicole A. Adamson, Chelsey A. Zoldan and Victoria E. Kress, at counseling.org/knowledge-center/practice-briefs.

In addition, Kress, Nicole Stargell, Zoldan and Matthew J. Paylo wrote an article titled “Hoarding Disorder: Diagnosis, Assessment and Treatment” for the January 2016 Journal of Counseling & Development.

Stargell and Kress will be presenting an Education Session on hoarding disorder on April 1 at the ACA Conference & Expo in Montréal.




Contact the following counselors interviewed for this article:




Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org