On television, a cluttered house is often portrayed as a
problem quickly solved with a professional cleaning crew
— but the realities of hoarding disorder and
its treatments are more complex, and people living with
the condition in rural areas may face additional
Hoarding disorder is a relatively new condition in the
Diagnostic and Statistical Manual of Mental Disorders
(DSM), having been officially added to the manual in
2013. But many people with the diagnosis have struggled
for much longer than that to declutter their homes, with
their challenges compounding over time, experts say.
Left untreated, the disorder can lead to health risks and
a hazardous home environment, and may exacerbate other
conditions such as depression and anxiety. In rural
settings, identifying and reaching people struggling to
part with their possessions can be extra difficult
— and for those who do seek help, resources are
often not as readily available as they might be in urban
There are still those same underlying urges to save items
and difficulty getting rid of things, but the motivating
factors that lead someone to seek out treatment are going
to be very different.
“There are still those same underlying urges to
save items and difficulty getting rid of things, but the
motivating factors that lead someone to seek out
treatment are going to be very different,” said
Mary Dozier, PhD, a professor of clinical psychology at
Mississippi State University who studies hoarding
disorder in rural populations.
Aging in a Cluttered Place
Hoarding disorder is
defined in the DSM as “persistent
difficulty discarding or parting with possessions,
regardless of their actual value…due to a perceived need
to save the items and to the distress associated with
discarding them.” This difficulty
“causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning,” the manual states,
“including maintaining a safe environment for
oneself or others.”
“It's not that [people with hoarding disorder]
are lazy, and it's not that they're messy
even,” said Tara Ferrante, LMHC, a private
practice counselor specializing in the treatment of
hoarding disorder in Amherst, Massachusetts.
“It's really an attachment to things. A lot of
times, they want their homes to look better, too. They
just don't quite know how to get there.”
…[people with hoarding disorder] want their homes to look
better, too. They just don't quite know how to get there.
About 2% percent of the general population experiences
hoarding disorder. Among older adults over 55, the
prevalence rate jumps
up to more than 6%, making people increasingly
vulnerable to the disorder as they age.
“Hoarding disorder is something we need to pay
attention to with the aging process because, besides
dementia, it's the only disorder that we know to increase
in prevalence and severity” as people get
older, said Catherine Ayers, PhD, a professor of
psychiatry at the University of California San Diego.
Ayers, who has studied hoarding tendencies in older
adults for the past two decades, said she first became
interested in the topic after noticing a “trend
of older people suffering from having too many
possessions and not being able to use their space in the
way they intended.”
“A lot of people were not able to age in place,
which is a very important thing in the aging
process,” Ayers said. “People's free
will to choose where to live was being compromised due to
A few different factors may contribute
to these increases in the prevalence and severity of
hoarding disorder later in life, according to Ayers and
Dozier, including some natural consequences of aging.
As we get older, there's a natural accumulation of stuff.
“As we get older, there's a natural
accumulation of stuff,” Dozier said.
“Think about every time you bring a pile of
mail into your home, or you get a Christmas present from
your aunt and you say, ‘Oh, I don't really like
this clock, but my aunt gave it to me so I'm just going
to put it in the closet.’” For
someone who isn't in the habit of decluttering,
“things will just keep piling on.”
Aging brings “normal decreases in executive
functioning,” Dozier noted, making it more
difficult to make decisions about which items to discard.
Age-related changes in strength and flexibility also make
it harder to physically move things around.
“Somebody who maybe always had a little bit of
clutter might suddenly really struggle to make those
decisions,” Dozier said. “They come
home with a stack of papers from the doctor and say,
‘I don't know if I'm supposed to keep this or
not,’ or they aren't able to move objects off
their bed to sleep on it. There's an increase in the
dysfunction of what used to be a tolerable level of
Among older adults, especially those in rural areas,
Dozier said she also sees a hesitation to let go of
family heirlooms or other items with sentimental value.
“Culturally, I think we have more folks [in
rural areas] that have lived for generations in the same
area and might have more items of sentimental value
around the home,” Dozier said. “Here
in Mississippi, a lot of folks will say things like,
‘I can't ever get rid of this fancy china
because my kids don't want it, but it needs to stay in
the family, so I'm going to hold onto
The health risks associated with excessive clutter
— including an increased risk of falling, fire
hazards, food contamination, poor sanitary and hygienic
conditions, trouble keeping track of medications, and
infestations of mold, insects, or rodents — are
well-documented. But some medical problems may also
contribute to hoarding tendencies.
co-authored by Ayers found that older adults with
hoarding disorder reported “significantly
more” health conditions than their peers
without hoarding disorder, with 9 out of 10 people with
hoarding disorder reporting at least one medical
condition compared to half of those without the disorder.
Head injuries, arthritic conditions, diabetes, seizures,
lung conditions, hematological conditions, and sleep
apnea were especially common among the hoarding disorder
group, the study found.
Figuring out the reasons for this relationship between
hoarding disorder and medical conditions will require
further study, Ayers and her co-authors concluded. But
they had a few ideas about why the correlation might
exist: For one, the study notes, people with hoarding
disorder tend to be less likely to visit their primary
care doctor regularly. And in some cases, medical
conditions might make it more difficult for people to
physically declutter their homes.
“Even if somebody is in treatment and able to
make decisions about discarding and letting those
possessions go, physically sometimes people are not able
to do those things,” Ayers said.
These instances often require outside help to physically
assist with the decluttering process. In places without
hoarding-specific resources available, this might mean
seeking help from a local church, or even from a mail
delivery person, Ayers said.
We do need to get creative, and we have gotten creative
in many cases.
“We do need to get creative, and we have gotten
creative in many cases,” Ayers said.
An ‘Unseen’ Disorder
In rural areas, getting someone into treatment in the
first place can be a challenge, as hoarding disorder is
often less visible in less populated settings. Ayers
describes the disorder as often
“unseen” in rural environments:
“It's not bothering other people, because
there's so much space,” she explained.
“They don't have a neighbor that is having
roaches or bedbugs come over, so there's no urgency
A cluttered house far from neighbors is less likely to
attract attention than a cluttered city apartment, Dozier
noted. In a study
of eight older adults with hoarding disorder living in
rural areas, Dozier found that half of the
participants had experienced at least one intervention
from family members, with just one participant having
experienced an intervention from a property manager or
There isn't the same impetus to seek out treatment that
you might have in a larger city.
“There isn't the same impetus to seek out
treatment that you might have in a larger city, where
your neighbor is knocking on your door or calling the
police on you, or your property manager is trying to
intervene because of issues with fire hazards,”
Dozier said. “You're going to be less likely to
be noticed by the people who would do forced
interventions than you would in an urban area.”
Rural homes and properties are often larger than in
cities, Dozier added, meaning that excessive clutter
might not always be as apparent to visitors.
“You might walk into a home and it doesn't
immediately seem like there's an issue with clutter, but
then you turn a corner and find that a whole wing of the
house is cluttered up, or the barn outside is cluttered
to a point where they can't use it anymore,”
To identify and treat hoarding disorder early on, Ayers
recommends that primary care providers ask all of their
patients a few simple, non-stigmatizing questions, such
as, “Does the number of possessions you have in
your home make it difficult to use the rooms in the way
they're intended?” or “Have friends
and family members complained that you have too many
items in your home?”
For friends and family members of people with undiagnosed
hoarding disorder — including those who may not
visit their primary care provider regularly —
she suggests inviting yourself over to the person's home.
…what I recommend for those remote or rural areas is
truly reaching out, connecting, and trying to just be
present in the living space.
“When you know that somebody's coming over,
what do we all do? We run around and we pick things
up,” Ayers said. “And in those
moments, for a person with hoarding disorder, it brings
awareness that there's an issue here because you know
that somebody else is going to see it. So what I
recommend for those remote or rural areas is truly
reaching out, connecting, and trying to just be present
in the living space.”
These visits can start an important conversation, Ayers
“Going over to a person's home naturally
creates space for discussions,” she said.
“‘It looks like you have a number of
these things. Are you having difficulty getting rid of
them, or is there some way I could help you?’
You want to open up the conversation in a way that
normalizes hoarding, because it is quite prominent and
prevalent, and then talk about it in a very nonjudgmental
way. Finally, offer to provide some support around
getting a person into treatment, because that is the
While larger cities often have task forces and other
resources specifically for people with hoarding disorder,
hoarding-specific resources tend to be fewer and farther
between in rural areas. Ideally, Dozier says, a provider
will be able to visit with a patient in the patient's
home to better help them sort through and discuss their
clutter, whether through in-person visits or via
Ferrante says the growing popularity of telehealth
post-2020 has made it easier for mental health providers
in her region to connect with rural clients. The local
mental health agency Ferrante previously worked for
hadn't allowed for home visits, requiring patients with
hoarding disorder to bring their possessions from home
into the office to talk through with their provider.
Before the pandemic, no one from the [rural] Berkshires
[region] was coming in to get this [hoarding disorder]
treatment, and now they are.
“If people were living in rural areas and they
didn't have access to public transportation, or they
didn't have access to their own vehicle, they just
weren't able to get the support,” Ferrante
said. “Now that we have telehealth as an
option, we're able to be in people's homes. Before the
pandemic, no one from the [rural] Berkshires [region] was
coming in to get this [hoarding disorder] treatment, and
now they are.”
While Ferrante describes the support for people with
hoarding disorder in her region as a “work in
progress,” largely-rural Western Massachusetts
has more resources available than most non-urban areas.
ServiceNet, the local nonprofit mental health agency,
offers hoarding disorder treatment services, and a
private consulting team made up of two people with lived
experience with hoarding disorder provides in-home
support to people going through treatment.
To better coordinate the resources available, Ferrante
and others formed the Western Mass Hoarding Disorder
Resource Network, a group of volunteers from various
local agencies that meets once a month.
“It's a place people can come and say,
‘Hey, I just encountered this individual with
too much stuff in their home and they're facing eviction.
What are the resources we can
provide?’” Ferrante said.
“And we do some brainstorming
The Network also hosts conferences and trainings, shares
informational videos about hoarding disorder on social
media, and has organized free, grant-funded workshops for
local people with hoarding disorder. The Buried in
Treasures Workshop, based on a book with the same name,
lasts 16 weeks and is a curriculum-based support group
where participants discuss, and learn new strategies for,
their hoarding disorder treatment journey. After the 16
weeks have ended, participants have the option of
continuing their own peer-led support group, called the
Finders Keepers Group.
While the workshops used to be held in person, since 2020
they've been held over Zoom — a shift that has
also made it easier for people in farther-flung rural
communities to participate, Ferrante said.
“It helps to hold people accountable and helps
them identify how to start to practice applying what
they're learning,” Ferrante said.