Motivating hoarders to let go – and be happy about it

Hoarding disorder is debilitating, and current treatments aren’t that effective. A new study found that modifying distressing mental images into more positive ones was an effective way of motivating people with the condition to discard their unneeded objects.

People with hoarding disorder have persistent difficulty parting with possessions, regardless of how valuable they are, because they perceive a need to save them and attempts to discard them cause considerable distress. This leads to an accumulation of clutter that reduces the ability to use living spaces and can negatively affect relationships and social and work activities. In severe cases of hoarding, there is a risk of fire, injuries from falling, pest infestations and medical illness.

Cognitive behavioral therapy, or CBT, is the gold-standard treatment for hoarding disorder but has relatively low success rates. So, researchers at the University of New South Wales Sydney (UNSW Sydney) adapted regular CBT to improve its potential as a treatment strategy for people with hoarding disorder. Their study’s results were recently published.

“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,” explained Isaac Sabel, a psychologist and PhD candidate at UNSW and the study’s lead and corresponding author. “Our best evidence-based treatments aren’t getting the outcomes we’d like.”

Although CBT, which aims to restructure a person’s maladaptive beliefs about their possessions, is the gold-standard treatment for hoarding disorder, it leads to clinically significant change in only 24% to 43% of cases. In addition, many people with hoarding disorder refuse CBT or drop out prematurely, likely because of its emphasis on decluttering, which they find overly upsetting. The researchers looked at whether incorporating mental imagery would make the treatment more effective.

There’s evidence that people who hoard tend to experience more frequent, intrusive, and distressing mental images than other members of the community, resulting in avoidance behavior and more life-interference. These images often correspond to memories of early life events or reflect hoarding-specific concerns, like distressing images of clutter, and their presence feeds the problem. An intervention that directly addresses problematic mental imagery is imagery rescripting (ImRs). During ImRs, a distressing or unpleasant image is retrieved from the memory and imagery is used to modify it to conform with a more desirable one. It can be used to modify unpleasant memories (‘flashbacks’) or upsetting future imaginings (‘flashforwards’). Addressing the latter is relevant to treating hoarding disorder.

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

Here’s an example of ImRs being used to ‘rescript’ imagined future events, although not in the context of hoarding. When an individual has an image of experiencing a debilitating panic attack on an upcoming plane trip, to rescript it, they picture themselves entering the image as a strong and wise person, to coach their fearful self through managing their anxiety. So, instead of actively avoiding these sorts of images, ImRs involves engaging with them so that, seen from a new and different perspective, they’re less threatening.

The researchers recruited 176 people with ‘high’ hoarding behavior who were asked to imagine a negative outcome from discarding an object they were still attached to and had difficulty discarding. They were then randomized into one of four conditions and presented with a discarding task. In addition to ImRs, the other three techniques used were cognitive restructuring, which involves learning to identify and disregard irrational, harmful thoughts; imaginal exposure, engaging with anxiety-provoking images and/or narrative to reduce their impact over time; and positive imagery control, or dwelling on positive images to improve mood.

Compared to other conditions, ImRs was associated with increased readiness and motivation to discard objects and increased frequency of discarding. It also reduced negative emotions (anxiety, sadness, anger) and increased positive emotions happiness and relaxation) relating to exposure to and restructuring of the mental image.

The results were replicated in a second, yet-to-be-published study that compared ImRs with a technique called thought listing, which involves retrospectively listing all thoughts that come to mind during image exposure and has been found to be effective in treating hoarding disorder. Preliminary findings showed that ImRs outperformed thought listing in key areas, with study participants more positive and more willing to discard objects after undergoing rescripting.

The researchers say rescripting has great potential as a treatment for hoarding disorder because it can address both the past traumas that inform future-focused narratives and the distressing mental images that interfere with someone’s ability to discard objects in the present.

“Images can link our past, present and future,” said Professor Jessica Grisham, who runs the Grisham Research Lab at UNSW Sydney and was the study’s senior author. “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.”

The study was published in the Journal of Psychopathology and Behavioral Assessment.

Source: UNSW Sydney