Using Motivational Interviewing to Treat Hoarding Symptoms in a Rural-Dwelling Older Adult: A Case Study

Abstract

IntroductionHoarding disorder is one of the few psychological disorders that increases in severity and prevalence in older adulthood. It is marked by maladaptive cognitions (e.g., distress parting with items others would discard) and behavioral patterns (e.g., avoidance of sorting/discarding items) that result in the problematic accumulation of items, typically referred to as clutter. Due to its various consequences for both the individual and society, hoarding disorder is a critical area of research for treatment development and refinement. MethodsThis is a case report of an older adult living in rural Mississippi who participated in a pilot study of a brief in-home intervention for hoarding disorder. Ms. T is a 61-year-old White woman with a psychiatric history of hoarding disorder and several psychiatric and medical comorbidities, including high blood pressure, diabetes, asthma, arthritis, obesity, and sleep apnea. She also reported an extensive history of head trauma, both in childhood and as an adult. At baseline, she reported high levels of distress during a sorting task and discarded 23% of items sorted. She also completed the NIH Toolbox Cognition Battery. She performed in the mildly to moderately impaired range on measures of working memory, processing speed, memory, and overall fluid intelligence. However, she performed in the average to above average range on measures of vocabulary, cognitive flexibility, oral reading, and overall crystallized intelligence. Ms. T received six one-hour long sessions of treatment using motivational interviewing (MI), a treatment approach that facilitates behavioral change through a focus on the patient's values and exploring discrepancy between their current behaviors and their desired goals (Miller & Rollnick, 2013). Session one involved an assessment of strengths, values, and goals. Ms. T then engaged in sorting practice, which involved sorting items from her home into keep and discard piles. Sessions 2-6 involved checking in on progress and engaging in sorting practice while using MI skills to facilitate motivation for behavioral change. Each week, she recorded number of days and average time spent sorting. ResultsFollowing treatment, Ms. T reported increased frequency and duration of sorting/discarding clutter independently between sessions. She also demonstrated decreases in reported sadness and somatic arousal associated with fear. Despite the brief nature of the intervention, Ms. T also indicated a slight decrease in overall negative affect and a slight increase in social satisfaction. Expanding on her self-identified strength of surviving and being resilient, Ms. T was able to overcome her feeling of being overwhelmed at initiating sorting and avoidance behaviors to consistently engage in sorting practice for the majority of each session. At post-assessment, she reported low to medium levels of distress during the sorting task and was able to discard 48% of items sorted, an increase of 25% from baseline. Ms. T consistently reported increased motivation driven by her desire to gain a fresh start after her traumatic past and provided her treatment progress with unique momentum that protected against attrition and encouraged continued compliance. ConclusionsMs. T presented externally as a typical hoarding disorder case; however, the psychosocial factors of the case created a unique set of barriers and protective factors. This case report discusses the interplay between the effectiveness of MI and the impact of external psychosocial factors (i.e., resilience within negative lifetime experiences, relational stress, and physical limitations) as they relate to Ms. T's treatment for her hoarding symptoms. Here, we illustrate the need for a more comprehensive approach to case conceptualization for older adults diagnosed with hoarding disorder.