Hoarding disorder (HD) can be difficult to treat. Some have suggested that this is because people with HD don’t recognize or acknowledge the problem, and even for those who do, motivation and compliance with treatment are often low. The initial stages of CBT for HD are designed to help people gain some recognition of the impairment caused by HD and to develop the motivation to change.
By the time most people with HD come for treatment, they have endured years of criticism and complaint from family and friends. To cope with this, many develop ways to deflect the criticism by denying or minimizing the problem. When this happens, it might appear that the person does not recognize that they have a problem, when in fact their reaction is merely a defense against criticism and pressure to discard from other people. Not surprisingly, if therapists begin treatment with efforts to convince them to discard possessions, clients are likely to experience this as yet more pressure, further increasing their defensiveness and reducing their motivation to change.
For this reason, CBT for HD utilizes a motivational interviewing (MI) approach whenever clients express ambivalence. MI seeks to develop a positive therapist-patient relationship that reduces defensiveness and motivates efforts to change. MI is a person-centered method for increasing motivation to change behavior by directing clients to identify and explore their own ambivalence.
Most people with HD, even those with limited insight, have some degree of ambivalence about their hoarding behavior and the environment it creates. On the one hand, they cannot bear to part with cherished possessions, but on the other hand, they recognize that their way of life is not merely different, but also problematic. The MI process explores this ambivalence of wanting to keep possessions, while also wanting to achieve the goals and values they’ve outlined. MI is especially helpful to clients to maintain their motivation during difficult non-acquiring and discarding exercises.
MI has two primary goals: (1) to increase the importance of changing behavior and (2) to increase the confidence that one can do so. The first goal refers to the discrepancy between a person’s current situation and how they would like to live. For change to occur, clients must experience such a discrepancy in order to feel motivated to reduce it. MI creates this discrepancy by exploring the individual’s life goals and values while also taking a realistic look at his or her life experience in the cluttered home. Frequently, HD clients’ basic values have been pushed aside by the chaos that has enveloped them. Discussions about what they value most in life set the stage for later determination of the real value of individual possessions in the broader context of how they want to live.
A second goal of MI is to increase the person’s confidence that they can change. This requires careful and dedicated work to evaluate the true value of possessions and to experiment with different ways of using, caring for, or discarding objects. Helping clients talk about and make plans for change are significant parts of the MI process.