Testing alternative outcomes of discarding through image rewriting shows promise as a treatment strategy for people who hoard, a study by UNSW psychology researchers has shown.
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 getting rid of their possessions. Many avoid treatment.
People who hoard also experience more frequent, intrusive and distressing mental images in their daily lives, says Isaac Sabel of the Grisham Research Lab, an experimental clinical psychology research group at UNSW Sydney.
“Negative memories and feared outcomes, such as an item rotting in a landfill, a catastrophic regret, or the disappointment of a loved one, can induce anxiety and block the discard process. Our best evidence-based treatments are not getting the results we would like,” says the psychologist and PhD candidate at UNSW.
“While one in three people who accumulate may experience symptom improvement, less than a third of people experience clinically significant changes. Additionally, there are high rates of treatment dropout and refusal.”
Imagery rewriting is an experiential technique, often used in cognitive behavioral therapy (CBT), where participants input positive or benign information to “rewrite” the results of negative mental images, in this case, the worst ones. discard scenarios.
“It is typically used to reduce distress associated with negative memories; however, it has been successful with other disorders characterized by mental imagery focused on the future, such as generalized anxiety and obsessive-compulsive disorder (OCD),” Sabel says.
This study in 176 people aimed to determine whether rewriting a future-focused negative discard narrative helped people high in hoarding traits to discard. Participants participated in an online intervention using an item that they had had difficulty discarding. They wrote down the imagined outcome of throwing it and then completed an exercise based on one of four treatments.
The response to image rewriting was compared to cognitive restructuring (learning to identify and ignore irrational and harmful thoughts); imaginal exposure (engaging with anxiety-provoking images/narratives to reduce their impact over time); and focusing on positive mental images to improve your mood (as a control). Participants were then asked to discard their article.
The study found that participants who rewrote images were happier, more motivated, and more likely to discard their items. Imagery rewriting 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.
The study found that a participant’s ability to visualize impacted how well image rewriting worked. Rewrite participants completed the Visual Imagery Vividness Questionnaire (VVIQ), self-assessing the vividness of elements within prescribed scenarios, such as a rising sun or a rainbow. Greater creative visualization ability was associated with greater willingness and motivation to discard.
These results have been replicated in a second therapist-led study, yet to be published, that compares image rewriting with thought listing, a technique that has been found effective in facilitating discarding in people with hoarding problems.
Preliminary findings show that rewriting outperformed list thinking in key areas, with participants more motivated to discard and more positive about the discard experience. These findings will now be tested in a clinical trial.
The High Costs and Challenges of Hoarding Treatment
Hoarding disorder affects 2.5 per cent of the working-age population, around 715,000 Australians. People who hoard usually have a very poor quality of life. The associated psychological distress and social impairment are considered equivalent to living with schizophrenia.
This condition can lead to unhealthy and unsafe living conditions, social isolation, health problems, and inability to work. Hoarding can also contribute to fires, housing, pestilence, falls and other hazards. The cost of returning homes to a livable state is estimated at more than $87,000 per hoarding household.
Clutter can make it difficult to do things most of us take for granted, like eating at the table or sleeping in bed, says Professor Jessica Grisham, director of the Grisham Research Laboratory.
“In the most serious cases, the houses are completely unhealthy, either because it is impossible to clean them or because the person keeps the garbage. The strain on families can be extreme.”
The associated stigma can prevent hoarders and their families from seeking support. Hoarding is often not addressed until the condition is well established. Additionally, people who hoard have difficulty regulating and tolerating negative emotions, which can reduce engagement in exposure therapy and increase dropout rates from it, he says.
“There is so much pressure and often interpersonal conflict for people to get rid of things, that clients who hoard can feel quite upset. They may or may not have much motivation or knowledge and feel really stressed and reactive,” says.
“In this preliminary study, image rewriting appears to reduce some of that reactivity. Instead of a direct approach, [asking] What stops you from throwing this away… and exploring and challenging those beliefs: It has a more creative and emotional style that has great potential to accumulate clients.”
Anecdotal evidence suggests that people who hoard may have greater creative tendencies. “We know that images act as emotional amplifiers. They allow us to access people’s emotions, [and engage with] the neural characteristics responsible for processing memories and emotions within the brain,” he says.
“Image rewriting emphasizes rich, sensory details to create an emotionally evocative and immersive experience. And we think that’s partly responsible for the results we’ve seen.”
Ultra-brief online delivery of the study also has potential as part of treatment in rural and remote areas where access is an issue and as an early intervention, he says.
Why do people hoard?
Collecting excessive amounts of objects, many of them worthless by objective standards, can seem difficult to understand, says Professor 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 attachment to objects, as well as an over-reliance on possessions and difficulty be away from them.”
While research has shown that genetics play a role, hoarding is more likely caused by a variety 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, difficulties connecting with others, and traumatic childhood experiences. They may end up believing that people are unreliable or trustworthy, and that it is better to rely on objects for comfort and security,” he says.
Their experiences have taught them that their self-identity is entangled in what they possess; that if they give up their possessions, they will lose themselves, he says.
Hoarding disorder is also associated with high rates of attention deficit and hyperactivity disorder. Difficulties with planning, decision-making and categorization can make it difficult to organize and get rid of possessions, says Professor Grisham. “The person ends up avoiding these tasks, which leads to unmanageable levels of clutter.”
Imagery rewriting is particularly interesting because of its potential to address both the core traumas that inform our future-focused narratives (an area of research interest for the lab) and to address distressing and intrusive mental images that interfere with discarding in the present. she says.
“Images can link our past, present and future. Rewriting memories that may have triggered hoarding (going back and meeting those needs) can open the door to better treatment outcomes and a greater positive impact on clients’ lives.”