The November BABCP Article of the Month is from Behavioural and Cognitive Psychotherapy and is entitled ”A more human approach … I haven’t found that really’: experiences of hoarding difficulties and seeking help” by Megan McGrath, Amy M. Russell and Ciara Masterson.

Hoarding behaviours can have a significant negative impact on an individual’s life, yet many people seem to find it difficult to engage with treatment or support (Frost, Tolin & Maltby, 2010).  Meg had experienced this struggle several times when working with people who were facing eviction, experiencing enforced house clearances and estrangement from family, but still maintaining that their hoarding was not an issue. This sparked an interest that we agreed to explore together. But how could we begin to try and understand the experiences of a group of people who we anticipated would be reluctant to characterise themselves as demonstrating hoarding behaviours?  This led to us recruiting individuals who accessed help through support groups or hoarding charities.

We interviewed eight people who self-identified as seeking help for their hoarding behaviours. They described complicated help-seeking journeys, with a sense that none of the support they had come across was the correct ‘fit’ for them. One of the themes illustrated the complex, and often seemingly contradictory, nature of hoarding: participants appeared to view their items as problematic, but also protective. They also seemed to be experiencing an ongoing struggle with identifying whether their behaviour was an issue, often prioritizing seeking support for other problems, such as grief.  They described fearing being judged by others and struggling to trust anyone. Yet for most people accessing a support group of peers with similar difficulties “opened up a whole new world”. Participants described falling between gaps within services – that they were deemed ‘too complex’ for some services but did not meet the thresholds for others.  Finally, they described that support focused on their items, rather than them as an individual. They expressed how they felt pressured to clear their belongings and were overwhelmed by the task, and that they were reluctant to focus on clearance while they were still driven to collect. This disconnect between the aims of treatment and their own priorities meant they grew disillusioned with treatment and continued the struggle.

We had hoped to conduct in-person interviews, however data collection in the context of the Covid-19 pandemic prevented this. With hindsight we think that remote interviewing may have supported people to engage with the research without the fear of judgement they identified as a barrier to accessing support.  

Several people described the impact of their race and culture on their hoarding behaviours. Regrettably we did not collect information on participants’ ethnicity and further exploration of this would be valuable to research.

Our findings suggest that even those actively seeking help for hoarding behaviours continue to struggle to identify the behaviour as being problematic. This offers some understanding around difficulties engaging with treatment. We were struck by how disillusioned and trapped people felt in a mental health system they perceived as not suitable for their needs. Our hope is that this study provides insight into the systemic barriers people face in accessing support for their hoarding and encourages practitioners to carefully and compassionately negotiate treatment goals with people who hoard.

Frost, R.O., Tolin, D.F., & Maltby, N. (2010). Insight-Related Challenges in the Treatment of Hoarding. Cognitive and Behavioral Practice, 17, 404-413.

From Paul Salkovskis, the Editor-in-Chief of BCP: Why I chose this article 

Hoarding is not a new problem, but with the relatively recent addition of “Hoarding Disorder” as a specific Disorder in both US Classification (DSM 5) and WHO International Classification (ICD 11) there has been something of a welcome increase in clinical research in this field. Our article of the month represents one such “in depth” report of high-quality research on Hoarding, and is an excellent example of the way in which qualitative research enhances our understanding of complex problems. In addition to the excellent treatment of issues specific to hoarding, the article also brings to the fore broader issues in terms of how we conceptualise the problems experienced by those we seek to help.

This article specifically highlights the reality of a number of themes currently emerging in the literature including the sense of those with hoarding issues that they were not well supported by those around them and Mental Health services. The value of peer support systems in groups also comes through clearly, and as CBT professionals it would be important for us to consider how we can facilitate this without hijacking it. The link between Hoarding and Homelessness is also mentioned and is a neglected and important area of research. It is helpful to have such a clear insight into the issues with engagement, linked to potentially modifiable factors including but not confined to stigma, both internal and public. The article also highlights the need for therapists to be person centred rather than “stuff” centred, a timely reminder.

This article also links to an important more general perspective on problems such as hoarding, which is that we need to use a different conceptual model to that typically used in mental health problems such as anxiety or depression. Hoarding is now defined not as a psychological problem, but rather in terms of a behavioural outcome (clutter rendering the person’s home inaccessible). This means that Hoarding can be seen as occurring as the “final common pathway”, representing the convergence of a range of different psychological, social and environmental influences. Similar considerations apply to other behaviourally defined problems we work with, including suicidality, substance misuse, homelessness and so on. We will, I think see more consideration of this way of considering the problems where we as CBT therapists seek to help.

Author Bio:

Dr Meg McGrath works as a clinical psychologist, having trained at the University of Leeds. Prior to this her clinical background was in mental health nursing, receiving her nursing degree from the University of Hull. She currently works in Hull and the East Riding, and throughout her academic studies has had a research interest in hoarding presentations.

Dr Ciara Masterson is Academic Director on the Clinical Psychology Programme at the University of Leeds.  Her research interests centre on clients’ experiences of psychological therapy.

Dr Amy M. Russell is a Senior Research Fellow at the University of Leeds. Her research focuses on addressing health inequalities in health services and in the exclusion of under-served groups from health research.