Contemp Fam Ther (2012) 34:566581

DOI 10.1007/s10591-012-9214-6

ORIGINAL PAPER

An Evaluation of an Ambiguous Loss Based

Psychoeducational Support Group for Family
Members of Persons Who Hoard: A Pilot Study

Jennifer M. Sampson Janet R. Yeats Steven M. Harris

Published online: 16 October 2012

 Springer Science+Business Media New York 2012

Abstract The current study is a pilot evaluation of a six-week psychoeducational-support

group based in an ambiguous loss framework for family members of people who hoard.
Findings suggest that participants who completed the six-week intervention group (N = 8)
indicated positive results at the two-month follow up interview, reporting an increased
understanding of family members hoarding behaviors and their own experiences related to
the hoarding behavior and its impact on the family system. Participants also reported that
having personal and professional support from others who understand hoarding behavior
was helpful to them in lowering psychological distress and improving interactions with
their family members.

Keywords Hoarding
Psychoeducation
Support group
Hoarding behavior

Family
Ambiguous loss

Hoarding disorder, a mental health issue marked by excessive acquisition, difficulty dis-
carding belongings, significant amounts of clutter, and personal distress (Frost and Hartl
1996), and an estimated 25 % of the population hoard is the United States alone (Ier-
volino et al. 2009; Samuels et al. 2008). Increasing awareness of the prevalence and
severity of hoarding has sparked research on therapeutic techniques to assist individual
who hoard (cite research, or summary article). The impact of hoarding on an even larger
population, family members of people who hoard (Tolin et al. 2007), has received rela-
tively little attention.
We are just beginning to understand the potent impact of hoarding on family members
and their perception and attitude toward hoarding family members (Sampson 2012; Tolin
et al. 2007; Wilbram et al. 2008). Despite increased techniques for therapeutically assisting
people who hoard, therapy models for family members of hoarders have not been explored.
Research that further identifies the impact of hoarding on family members, history and

J. M. Sampson (&)
J. R. Yeats
S. M. Harris

The Hoarding Project, Marriage and Family Therapy Program, Family Social Science Department,
University of Minnesota, 290 McNeal Hall, 1985 Buford Ave, St. Paul, MN 55108, USA
e-mail: samps138@umn.edu

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systems, and assist families in achieving greater psychological health is clearly indicated.
The current pilot study aims to embark on this goal by identifying family members
psychological needs and psychotherapeutic techniques that uniquely address these.
Hoarding likely has systemic effects, not only on family members who live with someone
who hoards but also with those who do not live with them (Sampson 2012). Understanding
these systemic effects (Sampson 2012) and testing interventions that could reduce them
drive the current study. Of particular interest is the use of psychoeducational groups, an
intervention that would seem effective for addressing ambiguous loss, which is an expected
effect of hoarding on family members of hoarding individuals.
The current study reports on evaluation data collected from a psychoeducational support
group designed specifically for individuals who have a family member who hoards. Pre-
vious research has suggested that family members could benefit from education and
support to understand and cope with their situation, and understand more about the impact
of hoarding on relationships and its tendency to marginalize loved ones (Sampson 2012;
Wilbram et al. 2008). Additionally, the curriculum was guided by ambiguous loss theory
(Boss 1999). The goal of this analysis was to determine if the psychoeducational group
format provided a helpful structure for the participants, and also to determine if a theo-
retical framework, informed by Ambiguous Loss theory (Boss 2006), would be appropriate
to apply to the lived experiences of these individuals. The authors are hopeful that iden-
tifying a suitable theoretical framework from which to view these individuals lives will
promote empirical research and scholarship on these families, not merely sensationalism
around the life of the person who hoards.

Literature Review

Background

Ambiguous Loss Framework

Ambiguous loss is loss that does not have definition or clarity, and can be experienced as
psychological or physical (Boss 2006). For persons experiencing ambiguous losses, grief
becomes complicated, as their losses are not identified as legitimate. As opposed to more
typical losses (i.e., when a family member dies and their deceased body serves as a visual
reinforcement of the loss) ambiguous losses do not have visual or other tangible cues to
confirm the legitimacy of the loss. Without those cues, the person suffering the loss
experiences confusion during the grieving process and can become emotionally and psy-
chologically stuck without resolution of the grief, or even the ability to begin the
grieving process. Without the ability to grieve, the individual does not know how to make
meaning of their loss. Ambiguous loss theory offers guidelines for living with ambiguity
which can help families name their psychological and relational losses due to the pre-
cipitating events or actions of others, find meaning in those losses, and work toward
healthier ways of being, maintaining relationships, and coping with behaviors that threaten
those relationships (Boss 2006).

Hoarding and the Family

While some research has examined the genetic linkages of hoarding disorder among
families (e.g. Mathews et al. 2007), current literature has generally overlooked how

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hoarding behavior emotionally affects the family. Currently, there are just three studies to
date on the impact on families. Tolin et al. (2007) first examined the burden of hoarding on
family members of persons who hoard in a retrospective, self-report Internet survey of 665
individuals reporting to have family members with hoarding problems. The study found
that living in a severely cluttered environment as a child is associated with increased levels
of childhood distress, which included less happiness, more difficulty making friends,
reduced social contact in the home, increased intra-familial strain, and embarrassment
about the condition of the home. It was also found that family members feelings of
rejection toward the person who hoards are associated with the severity of the hoarding
behavior and lack of insight about the hoarding behavior displayed by the persons who
hoard.
Another study qualitatively examined the perspectives of caretakers of persons who
compulsively hoard (Wilbram et al. 2008). Ten people who served as a caretaker for a
hoarding family member were interviewed, and the major themes that emerged included
loss of normal family life, the need for understanding, coping with the situation,
impact on relationships, and marginalization. They found that family members strug-
gled to cope with both the environmental and interpersonal aspects of hoarding; due to lack
of treatment and networks of support, education and support were recommended for
information and treatment options.
In a preliminary study to the current research, Sampson (2012) qualitatively explored
the lived experiences of 12 non-caretaking family members of persons who hoard in order
to better understand their experiences of their interactions with their loved ones who hoard.
It was found that participants reported a lack of understanding of hoarding behavior, which
resulted in a significant amount of personal psychological distress when dealing with or
thinking about their loved ones hoarding behavior. Further, they also reported a hesitancy
to seek out social support from others around their problem due to perceived feelings of
judgment associated with the hoarding behavior, despite wishing for support in order not to
feel so alone.
In the above study, Sampson (2012) proposed the application of ambiguous loss theory
(Boss 1999) to the experiences of family members of people who hoard. The ambiguous
characteristics of hoarding disorder- including the general lack of societal knowledge and
definition, lack of definite time of onset, chronicity and intensification of the disorder over
time, high co-morbidity with other mental health disorders- may all contribute to the
family members struggles with definition, interpretation, and attribution of the ascribed
etiology of hoarding behavior, interfering with their ability to secure information and
access appropriate resources. Because of the lack of clarity or ambiguity involved in
hoarding situations, the family often cannot understand the problem; and with the inability
to understand the problem at hand, the family is immobilized (See Boss 1999, 2006).
Trying to understand and live with a loved ones hoarding behavior is stressful and often
typified by a host of losses, for example, being unable to visit the family home, thereby
creating distance or even a break in the family relationship. However, based on the level of
understanding that the family member has about the hoarding disorder, the behavior itself
may be experienced differently. If a family member lacks a general understanding of the
disorder, and is unable to discuss or label the disorder with their family member, he or she
may experience their loved one as psychologically present but physically absent because
they have cut off interactions with their family due to the hoarding behaviors. This lack of
understanding can block coping and decision-making processes (Boss 1999, 2006). In
contrast, ambiguous loss theory offers guidelines for living with ambiguity which can help
families name the problem. Knowing that the problem is ambiguous loss, and not just

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hoarding, family members can better understand the losses they feel. Having more
understanding of the relational context of hoarding and its systemic effects helps them find
meaning in their relational loss.

Psychoeducational-Support Group Format

Psychoeducational-support groups have demonstrated effectiveness for family members of

individuals with various mental health concerns. Chien and Norman (2009) provided a
review of 25 different studies on the effectiveness of support groups for family members of
people with mental health disorders. In the current study, the researchers were able to find
consistent evidence of short-term positive effects of the support group for family members.
The benefits included: increased knowledge about the illness, reduced caregiving burden,
and enhanced coping and social support. Schultz et al. (2002) also provided a review of the
literature on the effectiveness of interventions for caregivers of people who suffer from
dementia. This review found that support groups, along with psychoeducational and
psychotherapeutic interventions, had positive outcomes for caregivers, including higher
quality of life, mood changes, and reduced feelings of burden.
The provision of an environment that allows for mutual support among group members
has also been shown to be effective in terms of providing benefits for participants. In a
study of 114 adult children of alcoholics, Kingree and Thompson (2000) found that, over a
four-month time period, the mutual support groups had a positive effect on the participants
well being and were able to help reduce depression symptoms and substance abuse among
group members.
Other research also provides support that six-session, manual-driven, multi-family
psychoeducation groups for family members of childhood mood disorders were effective in
both participant satisfaction as well as improvement in family climate following partici-
pation in the program (Fristad et al. 1998). The use of psychoeducational support groups to
help family members cope with a variety of mental health problems is well established.
The findings of each of the previously described studies demonstrate the need for further
clinical and empirical attention to people whose family members engage in hoarding
behavior. A psychoeducational group would seem to be an appropriate intervention for
family members of people who hoard. The group would be expected to clarify experiences
shared by members of the group thereby decreasing marginalization, along with associated
loneliness, isolation and embarrassment, anticipated in social interactions. Education about
common features of families with hoarding members could decrease the ambiguity of their
stress and loss and provide clearer constructs to guide choices and interpretation of
experiences. All of this is expected to decrease stress and encourage less frustrating family
interactions.
The current study reports on data collected from participants in a psychoeducational
support group for family members of persons who hoard. The aim of the group was to
provide education from an Ambiguous Loss perspective as well as a venue for professional
and peer support for family members of people who hoard.

Methods

In the pilot project, the researchers applied a qualitative approach in order to evaluate and
more deeply understand participants experience of the ambiguous presence and absence of
their loved one who hoards.

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Participants

Participants in this pilot project (N = 8) were adult family members of people who hoard,
representing five different families. Two of the participants were a married couple, three
were siblings with other participants, and the three others represented the remaining three
families. All but one of the participants were children of a parent who hoards. The other
participant was the spouse of a person who hoards. All participants were Caucasian,
between the ages of 2665, with one male and seven females. Two of the participants had
received a graduate school education, three had earned a college degree, two had attended
at least some college, and one had received a high school diploma. All but one of the
participants were married; the other was single.

Recruitment and Screening

Subjects were recruited on a voluntary basis through referrals from a mass mailing to area
professionals, such as professional organizers or mental health professionals. Participation
was open to all adults who have an immediate family member (i.e. parent, sibling, child,
etc.) who meets the criteria for hoarding disorder, as determined by the Hoarding Rating
Scale-Interview (HRS-I; Tolin et al. 2010).
The Hoarding Rating Scale-Interview (HRS-I; Tolin et al. 2010) has been used in the
past for the diagnosis and ranking the severity of hoarding. Using a self-report version of
the HRS-SR, participants rated on an 8-point Likert scale, from 0 (none) to 8 (extreme), the
severity of the family members hoarding behavior. Items measured on the scale were
clutter, difficulty discarding, excessive acquisition, distress and impairment caused by
hoarding. The HRS-I has shown high internal consistency (a = 0.97), testretest reliability
(range 0.850.94), and correlated strongly with other measures of hoarding, and reliability
discriminated hoarding from non-hoarding participants (Tolin et al. 2010). Severity of
hoarding was determined by calculating the mean of all 5 items, with 0 = no hoarding
symptoms, 2 = mild symptoms, 4 = moderate, 6 = severe, and 8 = extreme hoarding.
The participants family member who exhibited hoarding behavior was considered to meet
diagnostic hoarding criteria if the participants mean score was described as moderate (4)
or higher.

Procedures

The psychoeducational support group met for six, 2-h sessions at a midwestern university
campus. The authors met with the group each week, provided psychoeducation to the
participants, and facilitated conversations about the weekly content. Each session began
with check-in time and offered education regarding hoarding behaviors and tools for living
with ambiguity (see Appendix 1; also, Boss 2006). One tool for living with ambiguity
was introduced each week and discussion and interaction took place regarding imple-
mentation and integration between participant experiences and the ambiguous loss
framework. Five participants attended all support group sessions, two participants missed
one session, and one participant missed another session. Two months following the last
session, the participants were contacted and asked to attend a follow-up interview. Since
two of the eight members declined the request, only six interviews were conducted, and
two of these related participants were interviewed together.
The interviews, which were semi-structured, conducted by the investigator and audio-
recorded, explored participants impression of the group (see Appendix 1 for interview

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schedule). Each interview, which ranged from 45 to 90 min in length, was designed to be a
free-flowing discussion. The interviews, led to a degree by the participants, included their
interests, concerns, and experiences. The interviewer encouraged descriptive, in depth and
detailed responses about the participants experiences, perceptions, and feelings about their
psychoeducational-support group experience. The investigator analyzed the interviews in
the form of verbatim transcriptions provided by project research assistants.

Analysis

The studys evaluation design was prospective and observational, using qualitative follow-
up participant interviews as well as post hoc observations of the support group sessions.
Verbatim transcriptions of the interviews were coded and analyzed using a content analysis
for principal categories, with independent peer review of categorization. Group activity
data were also collected by merging notes taken from transcripts of the weekly group along
with descriptive weekly data from both of the groups co-facilitators. The qualitative
software package NVIVO 9.0 was used in the coding of qualitative data.

Results

The primary categories that emerged from an analysis of the data are as follows: (1)
participant evaluation of group intervention; (2) appropriateness of an ambiguous loss
framework; and (3) recommendations for future group structure. Each of these categories
included sub-themes also generated from the data. Primary categories and sub themes are
presented below. Additionally, group members brought up other topics of interest but due
to the limited number of people in the sample we are reluctant to include them as bona fide
categories. However, we present them here as areas of interest for further exploration.

Participant Evaluation of Group Intervention

Overall, participants described significant emotional support and knowledge gains from the
intervention and peer group experience. Each participant clarified that both the psycho-
education and support pieces of the group were important and necessary components
for why they felt the group was beneficial to them.

Psychoeducation

For the Psychoeducational portion of each group session, the participants reported benefits
including having an increased knowledge about the content material (i.e. hoarding and
ambiguous loss). One group member described the education on hoarding and ambiguous
loss as being vital to why the group was helpful to me.
The participants each stated in the follow-up interviews that the research-based infor-
mation on hoarding helped ease their psychological distress around not understanding
[their family members] hoarding behaviors. Participants discussed how their perspective
on hoarding behavior changed as a result of attending the group. In general, the partici-
pants negative feelings about their family member and their hoarding behavior seemed to
soften after learning more about hoarding and hearing other group members stories. One
group member stated,

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My feelings have definitely changed towards hoardingand understanding the

whole process and the issues and what might be behind it. I cant say that Im less
angry about the whole situation because I still just want [my mother who hoards] to
feel better and want to fix it but understanding that she might not ever be able to, is a
big piece for me. (Daughter of a person who hoards)
Participants also acknowledged that the education around ambiguous loss helped to give
[them] a way to talk about things they had experienced in relation to their family member
who hoards. In the process of acknowledging ambiguous loss, participants reported
experiencing compassion and empathy to their family member who hoards rather than the
negativity they had been previously experiencing. Participants described a shift that
occurred in considering how their loved ones hoarding had affected them. Several of the
group members described moving from thinking that hoarding was a result of their family
members laziness or unwillingness to get rid of things, to seeing the behavior as a
mental illness or a coping mechanism. Participants described that through the process of
the group, it became less important to them to get their loved ones home cleaned up,
and instead, focused more on the hopefulness that their relationship with them could be
repaired.

Support

The participants also acknowledged the support component of the group as contributing to
an enhanced level of coping and reduced feelings of burden related to their family
members hoarding behaviors. One of the main areas that was discussed by participants at
the two-month follow-up interview involved their valuing the social support that the group
offered. Multiple group members discussed the feeling of camaraderie with other
individuals in the group, saying it was helpful to be able to talk to other people, who have
similar experiencesmade me feel goodto have something in common and not be
alone.
Participants reflected that the group meetings gave them a place to explore their
experiences that are not easily understood by families who do not experience hoarding
behaviors. In the interviews, one group member said:
We need this place to voice those things; we need a place to share our stories. We
dont have that and to just selflessly vent and have it received with NO judgment, no
bewilderment, just - like - understanding. Its a really safe place to share. (Daughter
of mother who hoards)
Not only were group members able to talk in-group about their experiences, but they also
began to talk about them with their families at home. At the two-month follow-up, some of
the participants had initiated therapy with their family members who hoard, which had
been encouraged by some of the other group participants during the six-week intervention.
According to the participants, engaging with their loved ones in these new ways seemed to
contribute to an increase in positive relationships with their family member who hoards.
The final way that several of the participants described the group as helpful was by
feeling supported in their secret fear that they themselves may turn into a hoarder.
Participants in the group identified this fear as a continual concern for them personally and
for others in their families, including their own children, and being able to talk about these
feelings with others who also experience them, reportedly felt very freeing to many of
the participants.

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Appropriateness of the Ambiguous Loss Framework

Group participants reported that the ambiguous loss theoretical framework was appropriate
for the six-week intervention. Participants stated that learning about ambiguous loss at each
group meeting helped them acknowledge the losses they have experienced due to family
members hoarding behaviors. Losses which were discussed during the group sessions
included: Lack of or interruption to relationship with family members who hoard, the loss
of the childhood home, limited time spent with family, loss of normal family experiences,
and loss of childhood experiences.

Interruption of Family Relationships

A consistent theme throughout the six-week group meetings was the participants wish to
maintain a relationship with their loved one who hoards. Participants spoke of confusion in
knowing how to maintain relationships with their loved ones who hoard while also holding
feelings of anger, frustration, shame and guilt toward that person. Family members
understood their wish to stay in relationship with their loved one increased the confusion as
they will continue to experience inner discomfort with this relationship both from a past
and present perspective. This desire to maintain relationship is tricky particularly as
making necessary adjustments in their thinking and actions is difficult to accomplish.
Participants were in agreement that they hoped change would be possible within the
relationships they had with their loved one who hoards. Participants perspective about
their ability to control hoarding behaviors shifted throughout the six-week meetings from a
requirement that their loved one change to an understanding that they could only change
themselves and their perspectives. Although I dont like her hoarding, I have a better
understanding about why she hoards. That helps me not get so angry with her (Daughter).
It seems that the shift in perspective may be what allowed the participants to feel more
familiar with hoarding, if they did not feel more comfortable with their loved ones
behaviors.

Loss of Childhood Home

A second theme that emerged from the meetings was the loss of a home in which to return.
Many of the participants expressed both a desire to return to the home in which they grew
up and grief related to not being welcomed back by a parent who hoards. Participants
spoke of their discomfort about the family home due to the clutter in the home, as well as
the lack of control they feel regarding the desire to change the hoarding behaviors. They
reflected on their fears for the physical safety of their loved ones, in addition to their guilt
and shame about the behaviors, and the dilemma of wanting to force a clean-out because of
their own fears and discomfort with respecting their family members wishes to have their
home remain in a hoarded state:
I mean it would be nice - but the house doesnt have to be immaculate, but if there
was just an aisle, you could put the stuff on the sides, but theres an aisle and the
couches were cleared off, and it would be more safe, and you could come in and visit.
(Son-in-law of woman who hoards)

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Limited Time Spent with Family

A common topic discussed among the participants in the support group, as well as in
individual interviews, was of the impact hoarding behaviors have on family time together.
The adult children of people who hoard spoke of their disappointment that their children
were limited in the ways in the time they spent with their grandparents.
And then they [grandkids] come in town, like Thanksgiving, we - all of them were
here, and all these kids had this plan, were gonna go over there and well bake with
her, and you know, it just seem like - bake with her? You couldnt even get through
the front door.
Participants also spoke of their frustration and disappointment at not having access to their
parents home due to safety concerns and not knowing how to raise the subject with them.
An adult child stated:
I just want to clean and make it safe, so its a safe thing, where she can get in and out
the door. But yet, would she- if I move it downstairs - would she just put something
else there? But yet its not a safe, its not a safe environment to begin with. So how
do you do that? Do you talk? Do you talk to her about it?

Loss of Normal Family Experiences

Participants experienced frustration at not having what they termed normal family
experiences due to the hoarding behaviors of a family member. The participants referred to
ways in which the hoarding behaviors kept them from new experiences, which reflected of
sense of moving on as a family. The adult child of a parent who hoards realized she had
unacknowledged grief about the dissonance between wanting to preserve a room exactly
as it was when the rest of the house is so full that theres no room to make happy
memories.
Participants who are adult children of a parent discussed the sense of responsibility they
felt toward the parent in terms of a role reversal. One participant spoke of the internal
conflict for her and her sister of not letting their mother continue hoarding behaviors
because she is aging and living alone in her home. As mentioned earlier, concerns for the
safety of an aging parent living in a hoarded home were frequently mentioned in the group
sessions. Though issues of physical safety are a concern for aging parents in general,
hoarding behaviors compound this concern due to the safety hazards created by the excess
amount of clutter in the home, specifically increased risk of falling and lack of accessibility
for emergency personnel in the event of a medical crisis.

Recommendations for Future Group Intervention

Participants were supportive of the format of the group and the co-facilitation of the group.
(See Appendix 1) The facilitators were encouraged to continue the provide handouts
regarding hoarding and ambiguous loss, they were a life preserver I have informa-
tion! (Daughter of a father who hoards) Comments from group members indicated that
the structure of the psychoeducational- support group was helpful and they would not
change the process, however, they suggested setting a limit on the number of family
member participants from one family. This was somewhat expected in that three members
of the group came from the same family. Because of this, their particular story tended to be

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discussed more often than others. Suggestions to avoid this from happening were to limit
the number of participants from any given family to two.
Participants agreed that the six-week timeframe was an appropriate amount of time for
presenting pscyhoeducational information regarding hoarding and ambiguous loss. As well,
meeting once a week provided time to better process things in small chunks. (Spouse of a
person who hoards) However, the members of the current study requested the authors to
continue the support group beyond the six-week intervention, as they felt an ongoing group
would offer support needed for maintaining relationships with family members who hoard.
The support group in the current study included adult children of people who hoard as
well as a spouse. Participants in this current study felt keeping the groups together rather
than separate was also helpful. In future studies with a larger number of group members, it
may be helpful to divide the groups between children of people who hoard and partners of
people who hoard in order to better understand issues specific to their situations, e.g., the
differences between living outside the hoarded home (children) and living in the hoarded
home (partner).

Discussion

Participants reported having an increased understanding of both their family members

hoarding behavior and their own experiences of ambiguous loss related to the hoarding
behavior and its impact on their family relationships. The findings indicated that ambig-
uous loss theory (Boss 1999) is a useful framework for helping family members understand
how they have been affected by their family members hoarding behaviors, supporting the
findings of Sampson (2012). Participants seemed to agree that ambiguous loss is present in
their lived experiences of their relationship with a family member who hoards. Through the
tools for living with ambiguity (see Boss 2006, and Appendix 2), ambiguous loss theory
provided a framework for family members of people who hoard to remain in relationship
with the person who hoards while also lowering their own negative emotions caused by the
hoarding behaviors. In turn, this understanding shifted their focus away from merely
wanting to clean out the cluttered home to repairing and enhancing their relationship
with the person who hoards. Though an ambiguous loss framework has been suggested in
previous research (Sampson 2012) and is supported by the current study, future research is
necessary to further validate the application of this framework to the experience of family
members of people who hoard.
Of particular importance is the reported benefit of the psychoeducational and support
sections of the group format. Participants reported that having the support of other individ-
uals, both professional and non-professional, who have had and/or understood similar
experiences, was emotionally helpful to them. This report supports previous findings in the
research (Sampson 2012; Wilbram et al. 2008), resulting in lower reported levels of psy-
chological distress and improved interactions with their loved one who hoards. Further, the
participants of the group reported benefits including having an increased knowledge about the
content material (i.e. hoarding and ambiguous loss), a benefit found in other clinical studies
(e.g. Chein and Norman 2009; Schultz et al. 2002). Participants also acknowledged the
support component of the group as contributing to an enhanced level of coping and reduced
feelings of burden related to their family members hoarding behaviors. Each participant
clarified that both pieces of the group- psychoeducation and support- were important and
necessary components for why they felt the group was beneficial to them. Since the current
group was specifically developed for this population based on the findings that family

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members of people who hoard experienced a lack of understanding about their loved ones
hoarding behavior, feelings of grief and loss, and lack of support (Sampson 2012), these
participant reports support the helpfulness of the current intervention.
In addition to the evaluation of the intervention group, participants also provided further
considerations for future research and clinical work, including the relationships between
unresolved trauma and loss, attachment representations, and hoarding disorder. Throughout
the course of the group and also in the interviews, participants discussed the presence of
unresolved trauma and loss as a part of the lived experience for the person who hoards.
Though this theme has also been found in previous family member research (Sampson
2012; Kellett et al. 2010), more in-depth examination is required to fully understand the
relationship between unresolved trauma and hoarding behavior. Issues of attachment were
also indicated by family members as possible contributors to their loved ones hoarding
behaviors. Past research has briefly examined self-related constructs, including uncertainty
about oneself and others, as vulnerability factors for the development of OCD and cog-
nitions related to hoarding behavior (Frost et al. 2007), however, further investigation is
also needed on how attachment representations may contribute to hoarding behavior.
Currently, the authors are conducting research that will serve to further examine the
connection between unresolved grief and loss, attachment, and hoarding behavior in both
people who hoard and their family members. It is clear that future directions for research
and clinical work must be aimed at further developing a systemic view to both research and
treatment for hoarding disorder within the family system.

Limitations

The findings of the current study suggest that the ambiguous loss framed psychoeduca-
tional-support group may be beneficial to family members of people who hoard. However,
the study was subject to limitations and further evaluation is required to conclude this. This
study has three significant limitations: lack of a control group; ability to generalize find-
ings; and lack of a quantitative focus. In order to conclude that the psycho-educational
support group model is effective it would be necessary to compare it with a group of family
members receiving no treatment and/or a group receiving a different treatment. Partici-
pants would need to be randomly assigned in order to ensure that any group biases are
evenly distributed.
Although findings from this study can inform a treatment intervention, they cannot be
generalized to a larger population due to the small sample size and recruitment limitations;
therefore, a study which involves a larger sample size from a broadened referral base is
needed. The current study utilized a large professional referral base for recruiting partic-
ipants for the project who are in contact with professionals who serve people who hoard.
Considering that only a minority of family members of people who hoard are affiliated
with professional help specific to their experience of having someone who hoards in their
family, our sample may represent a small proportion of family members of people who
hoard, and may not relate to other family members who have not sought out professional
help. A study that expands a recruitment method to include participants who are not
connected with professional services should be attempted to increase the probability of
involvement and to address the experiences of these individuals.
Lastly, due to the small sample size and the impact of the attrition of two participants in
the final interview, this study lacked the ability to utilize any quantitative assessments to
measure efficacy of the intervention on variables such as psychological distress, family
conflict, or attitudes toward the family member who hoards. Increasing the sample size in

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future replication studies will allow for the use of quantitative measures to be considered to
assess specific benefits of the intervention.

Clinical Implications

The clinical and research implications for this pilot project are quite significant. Currently, the
state of clinical and research on the treatment of hoarding is conducted with the main focus on
the individual to exclusion of the family members, despite the fact that the current study and
past research has supported that there is a significant amount of family burden associated with
hoarding (e.g. Sampson 2012; Tolin et al. 2007; Wilbram et al. 2008). While some studies and
approaches do acknowledge that family members experience emotional distress relating to
their loved ones hoarding, current practices generally do not include a family-focus for
treatment (e.g. Steketee and Frost 2007). Clinicians may be advised to simply coach family
members to be more effective members of the team, and at times may be encouraged not to
engage in treatment with family, as they may create difficulties in the individual work. Some
published works geared toward family members of people who hoard do acknowledge their
frustration related to hoarding behaviors in their family, but in the end, offer the advice of
letting go of their anger and forgiving their loved one (e.g. Tompkins and Hartl 2009) in
order to move toward the overall goal of helping their loved one. The findings from the current
study provide support that family members of people who hoard may benefit from education
and treatment focused directly toward their experience in order to develop compassion
toward their loved one who hoards. By helping the participants to process their own emotions
and frustrations, not only were they able to personally benefit from decreased levels of
emotional distress, they were also able to serve as a more helpful part of the treatment process
for their family members who hoard.
The importance of developing positive family support has been well established in the
literature as a powerful protective factor against individual maladaptive behaviors. Adequacy
of social support from family relationships has been found to be directly related to the reported
severity of psychological and physical symptoms and/or acts as a buffer between stressful life
events and associated symptoms (e.g. Andrews et al. 1978; Schaefer et al. 1981; Wills 1990).
Feminists stress the role of environmental factors, such as blaming the victim and social
isolation, in exacerbating the effects of a traumatic experience (Root 1991). In studies of other
clinical samples, there is evidence that low social support leads to avoidant coping, while
positive support decreases avoidant behaviors (Runtz and Schallow 1997; Ullman 1996).
Being that studies have shown that lack of family member support due to rejection and critical,
hostile, or other negative emotional patterns of interaction can lead to poor response to
treatment or relapse following successful treatment (Chambless and Steketee 1999; Leonard
et al. 1993), it is particularly important to provide the necessary education and support for
family members in order to foster positive relationships and family support with their loved
one who hoards in order to increase the possibility for treatment success.
Given that there is substantial literature supporting the efficacy of augmenting indi-
vidual treatments for various forms of psychopathology with family interventions (e.g.
Fruzzetti 1996; Fruzzetti and Boulanger 2005), there seems to be adequate support for the
argument that family members of people who hoard not only must be included in the
treatment process for hoarding behavior, but may also require specific therapeutic attention
of their own. Given the strong influence that family members may have in the effectiveness
of hoarding treatment through their level of support, it is imperative that clinicians and
researchers begin to consider how to augment current treatment approaches to include,
support, and focus on the family relationships.

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Future Research Implications

In addition to replication of the current study, on the basis of this pilot project, the research
suggests issues for further study, including an examination of the relationships between
attachment, unresolved, trauma, and hoarding behavior. Participants responses to inter-
view questions elicited a need to further study issues of trauma and attachment and how
they are affected by hoarding behaviors. Participants identified that family members who
hoard had experienced trauma and losses in their backgrounds which they believed
impacted not only the person who hoards but also negatively influenced the relationships
with their children, spouses, and other family members. They reported that their hoarding
relatives had all sustained significant relational traumas- such as death, divorce, infidelity,
and poor relationships with their parents- in their pasts, and that these traumas were still
very much alive to their loved ones. Research that examines past relational trauma could
be helpful to further understanding present relationships and hoarding behaviors. Most
participants had deduced that their family members hoarding was their way of dealing
with the emotional toll that these past events had taken on them. An adult child speaking
about her mother who hoards said:
Like since she was a child, its the way her parents treated her so awfully, as she
claims. And when my dad left her, which was 28 years ago and shes still bitter
and angry about it, and you know, thats a problem and she talks about it to people
she hardly knows. And, yeah, I dont, its just, you know, beyond my grasp of
explanation, like I dont know. Its always someone elses deal. You know when my
dad left, and I was in sixth grade, she never got counseling for anyone of us, She got
it for herself, but not for us. And, I just dont think she thinks that it wouldve
affected us. I dont know. I dont know why.
The concerns raised by the family members bear further study to explore how issues of
trauma, attachment and hoarding behaviors may be related.

Conclusion

In conclusion, these findings suggest that the psychoeducational-support group intervention

based in an ambiguous loss framework may be an effective means of support for family
members of people who hoard. Family members who completed the six-week group
experienced positive gains afterwards that were maintained 2 months later. Future research
will aim to address some of the limitations associated with the present study such as the
ability to generalize from this sample, the lack of a control group, the small sample size,
and the attrition rate. However, these preliminary results suggest that the ambiguous loss
framed psychoeducational-support group for family members of people who hoard is a
promising development in providing support for this group of people.

Appendix 1: Interview Schedule

Can you tell us your feelings about how effective attending the group was for you?
After attending this group, how have your ideas about hoarding changed?
How have your attitudes toward your family member changed?

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Have you noticed a change in the way you interact with your family member who
hoards? (Thinking/feelings/actions) If so, what?
Have you noticed a change in your feelings toward yourself? If so, what?
How was the education on hoarding behavior helpful to you?
Did you learn anything new from the information given?
If you learned anything, how was that helpful?
How was the education on Ambiguous Loss helpful to you?
Did you learn anything new from the information given?
If you learned anything, how was that helpful?
How was the support piece helpful to you? What about it was helpful?
Tell us about your experience with the structure of the group.
Location
Time limit
Group setting
People in the group
Etc.
What could have made this experience better for you?
If we were to do this group again, what suggestions would you have for us?

Appendix 2: Psychoeducational-Support Group Outline

Week One Introduction to Project/Group Introductions/Check-In

Hoarding Information Sheet
Ambiguous Loss Definition/Effects
Tool for Living with Ambiguity: Finding Meaning
Break
Support Group Facilitation
Week Two Check-In
Hoarding and the Family
Tool for Living with Ambiguity: Tempering Mastery
Break
Support Group Facilitation
Week Three Check-In
Hoarding and the Cleaning Process
Tool for Living with Ambiguity: Reconstructing Identity
Break
Support Group Facilitation
Week Four Check-In
Hoarding Information
Tool for Living with Ambiguity: Normalizing Ambivalence
Break
Support Group Facilitation

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Week Five Check-In

Hoarding and Family Caregivers
Tool for Living with Ambiguity: Revising Attachment
Break
Support Group Facilitation
Week Six Check-In
Hoarding Information Resources
Tool for Living with Ambiguity: Discovering Hope
Break
Support Group Facilitation

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