The holiday season brings joy, connection, and celebration for many families—but for individuals living with hoarding disorder and their loved ones, it can be a time of overwhelming stress, shame, and isolation. As occupational therapists specializing in home safety and accessibility, we have a unique opportunity to support this often-marginalized population through trauma-informed, occupation-based interventions that respect client autonomy while addressing genuine safety concerns.
Understanding Hoarding as an Occupation
Hoarding disorder affects an estimated 2.3% to 4.6% of the population and is characterized by persistent difficulty discarding possessions due to a perceived need to save items, coupled with significant distress when forced to part with them (American Psychiatric Association, 2013; Clarke, 2019). The incidence of hoarding disorder increases to 6% in the population over 65 years of age. Unlike the stereotypes often portrayed in media, hoarding is not simply about laziness or poor housekeeping—it is a complex condition that involves cognitive, emotional, and behavioral components that structure a person’s daily life and identity.
From an occupational therapy perspective, hoarding can be understood as a daily occupation that provides value, purpose, and meaning to the individual who engages in it (Clarke, 2019). The activities of acquiring, sorting, and organizing collected items fill the person’s waking hours and become deeply intertwined with their sense of self. While this occupation may be viewed as “nonsanctioned” by dominant sociocultural standards, it remains a meaningful activity for the person who hoards and therefore falls within the scope of occupational therapy practice (Clarke, 2019).
Why the Holidays Intensify Hoarding-Related Stress
The holiday season creates unique challenges for individuals with hoarding disorder that can exacerbate existing difficulties. Family members may expect to visit or stay overnight, creating intense pressure to make the home “presentable” according to conventional standards. The inability to host gatherings in cluttered spaces can trigger profound feelings of shame, embarrassment, and social isolation—emotions that are particularly acute during a season centered on togetherness and hospitality.
Research shows that hoarding disorder significantly impairs the social, physical, and emotional functioning of both individuals who hoard and their family members (Onyeka et al., 2023). Family relationships often become strained when relatives cannot comprehend the person’s attachment to possessions or their refusal to remove items from the home. This friction can lead to marginalization and social rejection, with individuals who hoard becoming increasingly isolated to avoid judgment (Clarke, 2019; Onyeka et al., 2023).
The holiday season also typically involves increased acquisition through gift-giving and shopping, which can trigger or worsen hoarding behaviors. For someone already struggling with decision-making about possessions, the influx of new items—combined with the emotional significance attached to gifts from loved ones—can create additional distress.
The Limitations of Traditional Interventions
Historically, interventions for hoarding have been dominated by psychological approaches, primarily cognitive behavioral therapy (CBT) aimed at changing thought patterns and behaviors, often accompanied by forced decluttering (Clarke, 2019). While these approaches may seem logical from an outsider’s perspective, research reveals significant limitations.
Forced decluttering—whether initiated by family members, landlords, or public health authorities—fails to address the underlying causes of hoarding and often results in increased emotional distress, reduced trust in healthcare providers, and rapid reaccumulation of items (Clarke, 2019; Rodriguez et al., 2012). When possessions that hold intrinsic, instrumental, and sentimental value are removed against a person’s will, the process essentially strips away objects that define their identity and sense of home. Compliance with CBT interventions is poor, with only 20% of cases typically receiving this treatment, and outcomes show limited effectiveness (Brakoulias & Milicevic, 2015).
Importantly, these traditional approaches tend to be done “to” the person rather than “with” them, failing to honor their autonomy and occupational rights (Clarke, 2019).
Occupational Therapy’s Unique Contribution
Occupational therapy offers an alternative framework that views hoarding through the lens of occupation, daily functioning, and person-centered goal setting rather than pathology requiring remediation. Our profession’s core values—supporting health and wellbeing through meaningful occupation, respecting client autonomy, and addressing barriers to occupational performance—position us uniquely to work with individuals who hoard.
Trauma-Informed Assessment: Rather than focusing solely on clutter removal, occupational therapists conduct comprehensive assessments of how hoarding impacts activities of daily living, instrumental activities of daily living, safety, and social participation. We explore the roles, routines, and habits embedded in hoarding behavior and understand their relationship to the person’s identity and life purpose (Clarke, 2019).
Safety-Focused Modifications: During the holiday season, our priority shifts to ensuring basic safety while respecting the person’s attachment to possessions. This might include creating clear pathways to essential areas (kitchen, bathroom, exits), ensuring functional smoke detectors and adequate egress in case of emergency, and addressing sanitation issues that pose immediate health risks—all while involving the person in decision-making about which areas to address first.
Skill Development: Occupational therapists can support development of decision-making skills, organizational strategies, emotional regulation techniques, and non-acquiring behaviors through collaborative, gradual approaches (Clarke, 2019). These interventions focus on supporting occupational choice and engagement in activities with more positive health outcomes rather than simply stopping hoarding behavior.
Practical Strategies for the Holiday Season
For therapists working with clients who hoard during the holidays, consider these occupation-based approaches:
Collaborative Goal Setting: Work with the client to identify their personal goals for the holiday season. Perhaps they want to be able to sit at the table with one family member, or create a safe path to the guest bathroom. Starting with small, client-identified goals builds trust and demonstrates respect for their autonomy.
Functional Space Creation: Rather than wholesale decluttering, focus on creating functional spaces for specific holiday activities. Can we clear enough space in the kitchen for meal preparation? Can we ensure the bathroom is accessible and hygienic for a short visit?
Alternative Hosting Options: Help clients problem-solve alternatives to traditional home hosting. Could they meet family at a restaurant? Host a small outdoor gathering if weather permits? Participate in a potluck where others provide the venue?
Family Education: Educate family members about hoarding disorder as a recognized condition, not a character flaw. Help them understand that judgment and forced cleanouts damage relationships and worsen outcomes. Provide guidance on supportive communication that maintains connection without enabling unsafe conditions.
Connection to Resources: Link clients with hoarding-specific support groups, peer mentorship programs, and specialized mental health providers who use evidence-based approaches for hoarding disorder. The holiday season, despite its challenges, can be a motivating time for individuals to seek support.
Building Your Expertise in This Emerging Practice Area
Hoarding represents an underserved area within occupational therapy practice, with limited published research on OT-specific interventions despite clear recognition of the profession’s potential contribution (Clarke, 2019). As home modification specialists, we are particularly well-positioned to address the environmental and functional implications of hoarding while maintaining our commitment to client-centered, occupation-based practice. The Home Accessibility Therapist LLC offers a 5 hour AOTA approved continuing education course focused on developing skills to provide evidenced based occupational therapy.
Understanding hoarding through an occupational lens—recognizing it as a meaningful but potentially health-compromising occupation—allows us to offer interventions that support occupational choice, address genuine safety barriers, and promote engagement in health-sustaining activities without resorting to reductionist approaches that strip away the person’s autonomy and identity.
This holiday season, consider how your skills in home safety assessment, environmental modification, and functional goal setting might serve individuals and families affected by hoarding disorder. By bringing compassion, occupational expertise, and respect for client autonomy to this complex challenge, we can make a meaningful difference in the lives of a marginalized and underserved population.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.
Brakoulias, V., & Milicevic, D. (2015). Managing hoarding disorder. Australian Prescriber, 38(6), 194-197.
Clarke, C. (2019). Can occupational therapy address the occupational implications of hoarding? Occupational Therapy International, 2019, Article 5347403. https://doi.org/10.1155/2019/5347403
Onyeka, T. C., Ibeh, C. C., & Ibe, B. C. (2023). The impact of hoarding disorder on family members: A case report. Cureus, 15(10), e47246. https://doi.org/10.7759/cureus.47246
Rodriguez, C. I., Herman, D., Alcon, J., Chen, S., Tannen, A., Essock, S., & Simpson, H. B. (2012). Prevalence of hoarding disorder in individuals at potential risk of eviction in New York City: A pilot study. The Journal of Nervous and Mental Disease, 200(1), 91-94.
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