Hoarding disorder: ‘Sensory CBT’ treatment strategy shows promise

Hoarding disorder is a highly debilitating condition that worsens with age. People who hoard form intense emotional attachments to objects, accumulate excessive clutter, and have difficulty discarding possessions. Many avoid treatment.

People who hoard also experience more frequent, intrusive and distressing mental images in their daily lives, says Mr Isaac Sabel from the Grisham Research Lab, an experimental clinical psychology research group at UNSW Sydney.

“Negative memories and feared outcomes, such as an item rotting in landfill, catastrophic regret or the disappointment of a loved one, can induce anxiety and block the discarding process. Our best evidence-based treatments aren’t getting the outcomes we’d like,” says the psychologist and PhD candidate at UNSW.

“While one in three people who hoard may experience symptom improvement, less than a third of people experience clinically meaningful change. Additionally, there are high rates of dropout and treatment refusal.”

Imagery rescripting is an experiential technique, often used in cognitive behavioural therapy (CBT), where participants introduce positive or benign information to ‘rescript’ the outcomes of negative mental imagery, in this instance worst-case scenarios of discarding.

“It’s typically used to reduce distress associated with negative memories, however, it’s had success with other disorders characterised by future-focused mental imagery, such as generalised anxiety and obsessive-compulsive disorder (OCD),” Mr Sabel says.

This study in 176 people aimed to determine whether rescripting a negative future-focused narrative of discarding helped people with high hoarding traits discard. Participants took part in an online intervention using an item they’d had difficulty discarding. They wrote down their imagined outcome of throwing it away and then completed an exercise based on one of four treatments.

The response to imagery rescripting was compared with cognitive restructuring (learning to identify and disregard irrational, harmful thoughts); imaginal exposure (engaging with anxiety-provoking images/narratives to reduce their impact over time); and dwelling on positive mental imagery to improve their mood (as a control). Participants were then asked to discard their item.

The study found that participants who engaged in imagery rescripting were happier, more motivated and more likely to discard their items. Imagery rescripting was also more effective at reducing anxiety, sadness and anger and increasing feelings of happiness and relaxation around discarding, relative to imaginal exposure and cognitive restructuring.

A participant’s ability to visualise impacted how well imagery rescripting worked, the study found. Rescripting participants completed the Vividness of Visual Imagery Questionnaire (VVIQ), self-rating the vividness of elements within prescribed scenarios, such as a rising sun or a rainbow. Higher creative visualisation abilities were associated with greater readiness and motivation to discard.

These results have been replicated in a second therapist-led study, yet to be published, that compares imagery rescripting with thought listing, a technique found to be effective in facilitating discarding in people with hoarding problems.

Preliminary findings show rescripting outperformed thought listing in key areas, with participants more motivated to discard and more positive about the discarding experience. These findings will now be tested in a clinical trial.

The high costs and treatment challenges of hoarding

Hoarding disorder affects 2.5 per cent of the working-age population, around 715,000 Australians. People who hoard often have a very poor quality of life. The associated psychological distress and social impairment are considered equivalent to living with schizophrenia.

The condition can lead to unsanitary and unsafe living conditions, social isolation, health problems and the inability to work. Hoarding can also contribute to fire, housing, pestilence, falling and other hazards. The cost of returning homes to a liveable state is estimated at more than $87K per hoarding household.

Clutter can make it hard to do things most of us take for granted, such as eating at the table or sleeping in bed, says Professor Jessica Grisham who leads the Grisham Research Lab.

“In the gravest cases, homes are completely unsanitary, either because it has become impossible to clean or because the person saves garbage. The strain on families can be extreme.”

Associated stigma can prevent people who hoard and their families from seeking support. Often hoarding is not addressed until the condition is well established. Additionally, people who hoard have difficulty regulating and tolerating negative emotions, which may reduce engagement with and increase dropout rates from exposure therapy, she says.

“There’s so much pressure and often interpersonal conflict for people to get rid of things, hoarding clients can feel quite badgered. They may or may not have a lot of motivation or insight and they feel really stressed and reactive,” she says.

“In this preliminary study, imagery rescripting seems to reduce some of that reactivity. Rather than a direct approach — [asking] what’s keeping you from throwing this away … and exploring and challenging those beliefs — it has more of a creative, emotional style that has a lot of potential for hoarding clients.”

Anecdotal evidence suggests people who hoard may have greater creative tendencies. “We know that imagery acts as emotional amplifier. It enables us to access people’s emotions, [and engage with] the neural features responsible for processing memories and emotions within the brain,” she says.

“Imagery rescripting emphasises sensory-rich details to create an emotionally evocative and immersive experience. And we think that’s in part responsible for the results we’ve seen.”

The study’s ultra-brief online delivery also has potential as a part of treatment in rural and remote areas where access is an issue and as an early intervention, she says.

Why do people hoard?

Collecting excessive amounts of objects, many worthless by objective standards, may seem difficult to understand, says Prof. Grisham. “However, most of us become attached to at least a few possessions. Perhaps we love the way they look, or they trigger fond memories. Hoarding involves this same type of object attachment, as well over-reliance on possessions and difficulty being away from them.”

While research has shown genetics play a part, hoarding is more likely caused by a range of psychological, neurobiological and social factors. Hoarding disorder has been linked to early trauma, life stress and emotional deprivation.

“People who hoard often report excessively cold parenting, difficulty connecting with others, and traumatic childhood experiences. They may end up believing people are unreliable and untrustworthy, and that it’s better to rely on objects for comfort and safety,” she says.

Their experiences have taught them their self-identity is tangled up in what they own; that if they part with their possessions, they will lose themselves, she says.

Hoarding disorder is also associated with high rates of attention deficit and hyperactivity disorder. Difficulties with planning, decision-making and categorising can make it hard to organise and discard possessions, says Prof. Grisham. “The person ends up avoiding these tasks, which leads to unmanageable levels of clutter.”

Imagery rescripting is particularly exciting because of its potential to address both the foundational traumas that inform our future-focused narratives — an area of research interest for the lab — as well as tackling intrusive distressing mental images that interfere with discarding in the present, she says.

“Images can link our past, present and future. Rescripting memories that may have triggered hoarding — going back and meeting those needs — may open up the doorway for greater treatment outcomes and greater positive impact on clients’ lives.”