Hoarding

Estimates for HD in the general population range from 2-6%, with pooled prevalence across meta-analyses at about 2.5% (1,25,29-32). In the UK, the Southeast London Community Health study reported a prevalence of 1.5%, with higher rates in urban and socioeconomically deprived areas, likely reflecting increased stress, isolation and reduced access to services (31). Despite these figures, HD remains under-recognised and under-reported, with many people identified only through family or community referrals and relatively few actively seeking professional help (33).

Hoarding behaviours usually begin in adolescence, most commonly between ages 11-15, with around 75% of individuals reporting onset between 10 and 25 years (34). Symptoms typically cause significant impairment by the mid-20s, with many individuals meeting diagnostic criteria by their 30s. Difficulties often become more entrenched with age, as discarding proves increasingly difficult. Older adults (55+) are nearly three times more likely to display severe symptoms, compounded by physical health problems, cognitive decline and reduced social support (30,35,36). Comorbidities are common and include depression, anxiety disorders, OCD, ADHD and Autism, all of which can contribute to organisational and decision-making difficulties and should be considered in treatment (37).

Although HD is formally diagnosed in adulthood, hoarding behaviours can emerge much earlier, with retrospective studies highlighting that symptomatic behaviours often start to emerge in adolescence (18). Studies suggest 2-5% of children and adolescents show clinically significant hoarding symptoms, often linked to family history, anxiety and OCD and associated with academic and social difficulties (38-40). Gender differences also appear across study designs: community surveys suggest slightly higher prevalence in men, particularly with comorbid OCD, while clinical samples are predominantly female, with women more likely to present with excessive acquisition behaviours (41). Familial clustering is pronounced, with up to 50% reporting a first-degree relative who also hoards, highlighting potential of both genetic and environmental contributions (42).

Higher prevalence has been identified in certain groups, including veterans (18), and individuals with OCD (18,43) or ADHD  (29,31), with emerging evidence suggesting elevated rates among ethnically diverse and under-researched populations (18,19,29).  However, prevalence estimates remain difficult to interpret because of inconsistent methodology, heavy reliance on self-report measures, and limited use of clinical interviews or in-home assessments. As a result, true rates may be underestimated or distorted (44). Reviews emphasise the need for larger, representative studies using rigorous diagnostic methods to provide accurate prevalence data and guide service planning (45).

This information is intended for commissioners, service managers, trainers and healthcare practitioners in Scotland who are considering the evidence base for the delivery of psychological interventions for individuals with HD. It is also designed as a resource for individuals diagnosed with HD, their families and carers, to promote understanding of available treatments and care pathways. This topic overview summarises the current evidence for psychological interventions used to treat HD in children, young people (CYP), adults and older adults (OA). It also outlines the psychological practice and service settings in which these interventions may be delivered across health and social care systems in Scotland.

This topic does not cover pharmacological interventions or interventions which are not informed by psychological theory. It may be helpful to refer to The Matrix pages on OCD and NICE OCD guidelines if there are comorbid OCD symptoms. There are a wider range of non-psychological interventions and supports that are beyond the scope of this topic and further guidance can be found on NHS Inform, from charities supporting people affected by hoarding (e.g. Iriss – https://www.iriss.org.uk/projects-day-day-dignity/supporting-people-who-hoard, Hoarding Disorders UK, Hoarding UK, Mind, and SAMH. Practical support and advice can be provided from Citizen’s Advice Scotland https://www.citizensadvice.org.uk/scotland/ and Local Authority Environmental Health or Housing Services.

Children and Young People (CYP)

The current evidence base for hoarding in CYP is extremely limited. Due to its reclassification in 2013, only a very small number of studies exist, and these have largely been conducted within specialist OCD clinic populations rather than through hoarding-specific randomised controlled trials (RCTs) (38,39). Research in this area has typically examined hoarding as a symptom dimension of OCD rather than as a distinct diagnosis (40). This reflects the fact that HD was only recently reclassified as a separate disorder in DSM-5, meaning that much of the earlier literature conceptualised it within the OCD spectrum.

Systematic reviews suggest that hoarding symptoms can emerge in early childhood, but treatment efficacy has not been established (40).

At present, there is no RCT-level evidence for the application of psychological therapies or interventions specifically for CYP with hoarding. Interventions described in the adult table may be considered with appropriate adaptation, in line with guidance on delivering effective psychological therapies and interventions to younger populations. As there is considerable overlap with other presentations, particularly OCD and GAD, please refer to other Matrix evidence summaries as appropriate (e.g., OCD Matrix, GAD Matrix).

Overview of evidence for adults

Across trials, hoarding severity has been assessed using a small set of standardised measures that capture changes in clutter volume and in the individual’s ability to manage clutter. However, there are limitations in these methods, including reliance on self-report, inconsistent assessment of functional impairment and limited use of in-home observations, which restrict the ability to capture the full impact of hoarding on health, safety and quality of life.

The evidence for psychological therapies in adults with HD has been reviewed in numerous randomised controlled trials (RCTs) and synthesised in systematic reviews and meta-analyses, with the highest quality evidence summarised here.  

A recent review and meta-analysis of psychological interventions for HD included 41 studies (of which 8 were randomised control trials) and found a large reduction in HD symptomatology at end of treatment with similar findings across different psychological interventions and types of delivery (e.g. individual, group, with or without home visits). However, although symptom improvements are reported, many participants remain within the clinical range following intervention. The review also highlights the need to increase participant diversity and drop-out rates in trials, emphasising the importance of addressing motivational challenges in HD treatment. Long-term outcomes and relapse also remain under-studied (40,46,47). It is also important to recognise that HD remains under-recognised, and many individuals do not seek psychological help, or are not ready to engage with it. Identification and professional involvement often occur through housing or environmental health routes rather than mental health services. As a result, the contexts in which psychological therapies, such as CBT, have been examined in clinical trials may not reflect the service responses most experienced in routine practice, where access to structured psychological therapy is often limited.

Cognitive behavioural therapy (CBT) adapted for hoarding is the most studied psychological intervention across individual and group delivery formats. Other approaches with emerging or more modest evidence include therapist-supported self-help (e.g., Buried in Treasures programmes), peer-facilitated groups (46,47) and multi-component models such as Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST). These alternatives have been examined in studies, including contexts where access to individual therapy is limited.

Individual CBT

The evidence for individual CBT is summarised in three meta-analyses (24,48,49) which demonstrated substantial improvements (large effect sizes) in hoarding symptoms. Research focusing on CBT for HD developed steadily since the first manualised programme was introduced by Steketee and Frost (14). Their 20-26 session model (typically delivered in 60–90-minute weekly appointments) was created in response to the limited impact of traditional OCD-based CBT on hoarding symptoms (24,50). It is the psychological treatment most frequently examined in clinical trials for HD.  The Steketee & Frost model (14), subsequently tested in controlled trials (51,52), sets out a structured, multi-component programme that includes: psychoeducation, motivational interviewing strategies, cognitive restructuring, skills training, behavioural experiments and exposure tasks, homework assignments, and relapse prevention. There are also optional home visits, where therapists provide live coaching in the client’s environment, helping them practise decision-making on their own possessions.

The CBT protocol was associated with reductions of distress and increased ability to discard possessions compared with a waitlist control, although clutter was slower to change and full remission remained rare (51). This trial reported changes in hoarding symptoms following delivery of hoarding-specific CBT. Similarly, Tolin et al. (24) reported reductions in hoarding severity across emotional, cognitive and behavioural domains. Gilliam et al. (25) tested a shorter version of the programme and reported changes in discarding and reduced acquiring, although effects were smaller than those achieved with the full protocol. Some adaptations have incorporated home visits, enabling clients to practise skills directly in their living environment. Muroff et al. (52) also reported changes in organisation and decision-making, although a later meta-analysis concluded that home visits are not essential for positive outcomes overall (48).

Systematic reviews by Williams and Viscusi, and Thomson et al. (53,54) reported reductions in hoarding symptoms following individual CBT in relation to discarding, acquiring control and distress.  These reviews also note limitations including small sample sizes, high dropout and challenges in maintaining progress. Follow-up data presented by O’Brien and Laws (55) across more than forty studies indicated that hoarding scores at 6-12 months post-treatment were comparable to those observed at the end of intervention.  Across reviews, clutter is consistently identified as the symptom least likely to change, reflecting both the volume of accumulated possessions and their emotional significance.

In clinical studies, CBT has most commonly been delivered in moderate to severe or more complex presentations, particularly where symptoms are associated with significant distress, functional impairment, or safety risks. Most clinical trials have recruited participants scoring above established clinical cut-offs on standardised measures such as the Saving Inventory–Revised (SI-R; (21) and the Hoarding Rating Scale-Interview (HRS-I; (18). However, the presentation and functional impact of HD vary considerably across individuals. Accordingly, individual CBT should not be conceptualised as limited to a fixed severity threshold, but rather as an intervention that can be flexibly adapted across a range of presentations in line with individual clinical need.

Group CBT

Group CBT adapts the hoarding-specific model for delivery in a shared setting, usually across 13-20 weekly sessions lasting around two hours. These programmes are manualised, based on the structured treatment first developed by Steketee and Frost (14) and include the same core components as individual therapy. The group format includes peer support, shared problem-solving and discussion of experiences, which participants describe as motivating and reassuring (49,52).

Evidence from clinical trials (24,25,52,56) and systematic reviews (48,49) demonstrates that group CBT is effective in reducing hoarding severity. Some trials have described smaller changes compared to individual CBT (24) but a recent review (55) indicated no difference in effect between individual and group CBT.

Rodgers et al. (48) found no consistent advantage of adding home visits to the treatment format but noted that group formats allow delivery to multiple participants for services with limited resources.  Group delivery allows intervention to be delivered to multiple participants and includes peer interaction.  Reviews highlight peer support and reduced isolation as commonly reported features of the group format (49). Group CBT has been described in the literature within stepped-care frameworks, where group therapy may precede individual interventions in some service contexts (48). This format also allows delivery to multiple participants simultaneously and includes shared discussion, peer interaction and accountability within the group setting, which studies describe as relevant for services aiming to reach larger numbers of people and for individuals who report benefiting from shared experience (48,49,52).

Self-help and peer-facilitated programmes

Self-help approaches represent a lower-intensity form of intervention and draw on the same CBT principles as therapist-led interventions. The best-known example is the Buried in Treasures (BiT) programme, a structured workbook course delivered over 12-15 sessions. The programme includes psychoeducation about hoarding, cognitive techniques for challenging unhelpful beliefs and stepwise decluttering exercises. Homework tasks, such as discarding a set number of items per week are intended to support learning and build tolerance of anxiety. Programmes also emphasise decision-making and resisting acquiring, encouraging participants to test predictions about changing behaviour (25,37).

Evidence suggests that these programmes are associated with changes in hoarding symptoms. Williams and Viscusi (53) and Wheaton (50) reported changes particularly in excessive acquiring and motivation to discard, while clutter change was limited. Peer-led versions of BiT have also been evaluated in North American studies, where trained peers deliver structured support in North America (25,37).However, there remain significant evidence gaps in understanding adverse outcomes and longer-term effectiveness of these approaches.

Other psychological approaches

Alternative therapies for HD have been explored, but the current evidence for these approaches remains limited. Acceptance and Commitment Therapy (ACT) has been trialled in three small studies showing symptom reductions but with no control groups and short follow-up (55,57). Compassion-Focused Therapy (CFT) has been piloted in an uncontrolled cohort, targeting shame and self-criticism, with preliminary findings reported (55). Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST) has been examined in controlled and community studies. In an RCT with 37 older adults, Ayers et al. (58) reported greater reductions in hoarding severity and improved functioning compared with case management, and a community study also reported changes in clutter reduction and housing stability (59).

Systematic reviews describe these alternative models as having been delivered in small studies, with the evidence remaining preliminary and of low quality (50,55). Trials of approaches such as rational-emotive therapy, peer-led groups, social-cognition training, and virtual reality are limited to small studies or case reports and have shown mixed and limited findings (48,55,60). While these approaches may inform future developments, the current evidence is limited to small or uncontrolled studies and not established enough to include as a recommendation at this time.

Learning disabilities

In the absence of specific evidence for psychological therapies for adults with learning disabilities, the guidance for adults applies. Clinicians are advised that there are differences in presentation of psychological problems in people with learning disabilities and to consult Delivering Effective Psychological Therapies and Interventions for People with Learning Disabilities for further information on factors relevant to practice.

Older adults

Research on psychological therapies for older adults (OA) remains limited. Studies report reductions in hoarding severity and changes in anxiety, depression and daily functioning, but methodological limitations include small samples, limited controls and short follow-up. Standard hoarding-specific CBT has been tested in this group, and studies report symptom reductions and improvements in decision-making, however, outcomes are less consistent than in younger adult populations, dropout rates are higher, and the overall evidence base remains too limited to draw firm conclusions.

One intervention tested in this age group is Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST). It was developed in recognition that older adults with HD frequently experience impairments in executive functioning, planning, memory and attention, which impact on delivery of CBT for HD (61,62). CREST integrates CBT components such as psychoeducation, motivational interviewing, cognitive restructuring and graded discarding with cognitive rehabilitation exercises. In a randomised controlled trial, Ayers et al. (58) reported greater reductions in hoarding severity and improvements in daily functioning compared with case management and hoarding scores at follow-up were comparable to those recorded post-intervention. A community-based adaptation also reported changes n clutter and housing stability, with participants at lower risk of eviction after treatment (59). Both studies described good participant engagement and noted that the cognitive rehabilitation elements were relevant to participation in the intervention compared with standard CBT.

Other approaches tested in older adults include group CBT and therapist-supported self-help. Studies of these formats report smaller changes in hoarding severity compared to individual CBT or CREST. Overall, outcomes in older adults are similar to those in the wider HD literature: some show partial improvement, with clutter remaining the symptom less likely to change. Age-tailored adaptations such as CREST are associated with participant engagement and greater reductions in hoarding severity compared with standard CBT (58,59).

Overview of Evidence for Harms and Adverse Effects

Like all treatments, psychological therapies for HD can cause adverse effects, though these are rarely monitored or reported systematically in clinical trials (see information relating to safety in the delivery of psychological therapies). Reported therapy-related harms most commonly involve transient increases in distress during exposure-based tasks such as sorting, organising or discarding possessions. When not appropriately paced or supported, such tasks may lead to short-term anxiety, emotional dysregulation, or temporary worsening of hoarding behaviours, particularly among individuals with low insight, cognitive impairment or high levels of comorbid distress (63). Importantly, there is limited high-quality evidence regarding the prevalence, severity, or duration of adverse effects associated specifically with psychological therapies for HD, and few studies include formal monitoring of negative outcomes or dropout-related harms. As a result, the risk profile for hoarding-specific psychological therapies remains unclear.

Distinct from therapy-related effects are the harms associated with non-therapeutic and coercive interventions, most notably forced or coerced clearouts conducted in response to housing, fire, or public health concerns. Qualitative studies consistently report that such interventions can result in profound distress, loss of trust in services, increased attachment to possessions, disengagement from future support, and, in some cases, significant psychological deterioration (64,65). These harms arise not as side effects of psychological treatment but as consequences of system-level responses to unmanaged risk.

Alongside psychological therapies, multi-agency harm-reduction approaches are frequently employed to address immediate safety concerns such as fire risk, eviction, or severe sanitation issues. These approaches typically involve coordinated input from housing services, fire and rescue services, social care, and health providers, and may include case management, tenancy-preservation schemes, and home safety interventions. A recent review by Twigger et al. (28) reported consistent improvements in housing-related outcomes, including reduced eviction risk and enhanced safety, although the evidence base largely comprises service evaluations rather than randomised controlled trials. Reviews consistently conclude that multi-agency harm-reduction approaches play a critical role in managing risk and maintaining housing stability, particularly for individuals who are unwilling or unable to engage in psychological therapy. However, these approaches address safety rather than the underlying psychological drivers of hoarding and should not be considered substitutes for therapeutic intervention. Future research should prioritise systematic monitoring of both therapeutic and system-level harms, alongside outcomes that reflect quality of life, trust in services, and long-term housing stability.

See adult table for recommendations with age-appropriate adjustments in line with guidance on delivering effective psychological therapies and interventions to children and young people.

 

Recommendation	Who for?	List of Interventions	Type of psychological practice	Evidence	Efficacy
First Line	Adults presenting with moderate to severe HD (meeting diagnostic cut-off; significant distress/functional impairment)	Hoarding-specific individual CBT (face-to-face, 2-26 sessions, with homework and optional home visits) (55)	Specialist	A	Medium-high
First Line	Adults presenting with moderate HD, or in cases where individual therapy is not accessible, may be appropriately offered group CBT as an alternative or first-line intervention	Group CBT (Manualised, 13-20 sessions, face-to-face, with in-session sorting and structured homework) (55)	Enhanced/Specialist	A	Medium-high
First Line	Older adults with moderate to severe HD	CREST. Individual, face-to-face, 20+ sessions; integrates CBT with cognitive rehabilitation (planning, attention, memory) and live sorting/discarding tasks (58)	Specialist	B	Medium
Alternative (evidence less established)	Adults with mild HD or those reluctant/unable to commit to intensive therapy	elf-help programmes (e.g., Buried in Treasures workbook, 12-15 sessions; therapist-supported or guided self-help where available) (55)	skilled	B	Low–medium

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