CFT and Hoarding

Releasing Hoarding Tendency with a Compassionate Mind Approach

Chia-Ying Chou, PhD

The San Francisco Center for Compassion-Focused Therapies

When we think of the word, hoarding, what often comes to our mind may be a mental image of piles and piles of stuff congesting someone’s living space – like what we see on TV. However, stuff is not, and should not be the focal point of understanding or treating hoarding.

What is hoarding? Who experiences it?

Hoarding Disorder (HD) is currently defined as the following: (a) Persistent difficulty discarding, (b) linked with psychological distress of doing so, (c) such difficulty results in a clinically significant level of clutter and (d) functional impairments, (e) these phenomena cannot be better explained by other psychiatric or (f) medical conditions (DSM-5, APA, 2013).

HD has a lifetime prevalence of 2-5% in the adult population based on studies in Europe, America, and a number of Asian countries (Best-Lavigniac, 2006; Grisham et al., 2009; Kessler et al., 2005; Kim et al., 2001). This rate is at least twice of that of Obsessive Compulsive Disorder (OCD). We may have an impression that hoarding is associated with aging. Yes, the older the surveyed populations go, the higher the prevalence rates are: Among people aged 65+, the rate for HD is greater than 5% (one out of twenty). However, hoarding is not something that only happens when people get older.

compassion and hoarding

Part of the reason why we see a higher rate amount the elderly population is related to the current diagnostic criteria. As described above, the criterion C, which is about the level of clutter, rules out people who experience psychological difficulties related to hoarding, but just don’t have severe enough clutter issues (yet). Our study (Chou et al., 2018) interviewed over 300 people in California diagnosed with HD. Among these individuals, whose average age was over 60 years, 44% recalled the beginning of their hoarding behaviors to be before age 18. Other studies (Ayers et al., 2010; Dozier et al., 2016) also showed that for about half of the people, hoarding appeared before adulthood. Without recognition or intervention, it slowly gets more and more severe. On the other hand, another half of the people reported that they did not ever experience hoarding related difficulties until a major loss, life change, or trauma happened. For both camps, trauma is found to be associated with hoarding symptom severity.

Why a Compassion Focused Therapy (CFT) Approach?

Following the previous section, we can hopefully see that the accumulation of stuff is an external expression or result of complex and intertwining psychological and cognitive factors. These factors include emotional attachment to possessions (for sentimental or reasons pertaining to a sense of security); behavioral avoidance due to severe emotional distress associated with discarding; attention and executive functioning issues that further challenge the letting-go process; and certain kinds beliefs about possessions, such as perfectionist or catastrophizing thinking (Frost & Hartl, 1996). And if we peel the onion further down, we will find deeper issues related to the self, such as shame, ambivalence about self-worth, self-hatred and self-criticism; intolerance of uncertainty and distress; complicated grief, trauma, loss, and other adverse life experiences; isolation and interpersonal difficulties (e.g., Castriotta et al., 2019; Chou et al., 2018; Fontenelle et al., 2021; Yap et al., 2023).

Most of the exiting clinical treatment, peer-support, and self-help resources for hoarding are based on Cognitive Behavioral Therapy (CBT; Steketee & Frost, 2014; Tolin et al., 2014). Evidence has suggested the effectiveness of CBT in reducing hoarding symptoms. However, the percentage of individuals, who have obtained clinically significant changes in their symptom severity after receiving CBT, is less that 50% (Bodryzlova et al., 2019; Tolin et al., 2015). This suggests that while CBT is hitting some treatment targets of HD, there may be more targets that need to be attended to or more effectively addressed.

CFT - Addressing Shame in Hoarding

Our team began to consider Compassion Focused Therapy (CFT) as an alternative approach to treating HD in 2015 because of its emphasis on addressing shame, which is one of the most painful self-related factors almost every individual experiencing hoarding would endorse. Shame in this population is not only about the difficulty in letting-go or having too much stuff. It is perhaps even more about this fundamental feeling of ‘I am unworthy or bad.’ This creates great discomfort for one when they try to relate to the self, or do something with or for the self, such as working with one’s emotional distress! It also plays a role in the tendency to keep or savage possessions that are not serving the individual – out of a ‘need’ to feel better about self by owning certain things, or a tendency to prioritize the ‘well-being’ of items over their own. By targeting the affective system around these self-related issues and supporting the process with mindfulness and somatic approaches, CFT works with shame and other self-related issues from the bottom up. This is different from the focus of CBT, which is on replacing one ‘unhelpful’ thought with another, and addresses one of its main limitations of clients experiencing situations where they report “I know the right things to think, but I don’t feel it.”

Stemming from evolutionary psychology, CFT humanizes challenging emotions and behaviors by providing psycho-education on how the human brain and emotional systems have evolved to be. With this philosophy, CFT cares more about the psychological underpinning of the hoarding challenges, rather than seeing things through the lens of a diagnosis. CFT also introduces the lens of compassion from Buddhist philosophy, which focuses on seeing and understanding how suffering occurs, and being willing to help. These backgrounds have tremendous impacts on turning one’s attitudes from shame and stigma to compassionate courage and actions. Building on this, CFT connects the tendency to acquiring excessively and holding onto possessions with emotion regulation challenges. It provides a theoretical framework – the three circle model – to help building emotional awareness, and a set of compassion-based cognitive and behavioral methods to help individuals regulate emotions.

Growing literature has suggested that challenges and adverse experiences in human relationships and loneliness may contribute to a stronger tendency to seek comfort and a sense of safety in possessions (Yap et al., 2023). Besides cultivating a more compassionate and effective self-to-self relationship, CFT also has a strong focus on giving compassion to and receiving compassion from others – in a trauma-sensitive manner. Most people experience varying degrees of fears, resistance, and blocks of compassion (Steindl et al., 2023), which can lead to feelings of loneliness and disconnection (Best et al., 2021). With the evidence in improving these roadblocks, CFT has great potential in addressing hoarding or difficulties letting go through cultivating courage, wisdom, and resilience in human connections.

Compassion-Focused Therapy for HD (CFT-HD; Chou & DuFrene, 2022) tailors key frameworks and techniques of CFT (Gilbert, 2010). Since 2016, CFT-HD has been offered as a treatment option for hoarding in individual and group therapy formats through a clinical trial and as a clinical service at my private practice: San Francisco Center for Compassion Focused Therapies. Evidence on group therapy has suggested positive effects, such as reducing HD symptom severity to the threshold of clinical significance among those who remained significantly symptomatic after receiving CBT (Chou et al., 2018), and yielding clinically significant symptom reduction for those who receive CFT as a standalone treatment for HD (manuscript in preparation). Besides individual and group therapy, our practice also offers online Compassionate Mind Training workshops tailored for hoarding. This allows us to share the benefit of the compassionate mind approach more broadly to people all over the world. We invite you to connect with us on social media @sfcompassion @bettertreatmentforhoarding to be informed of the most up-to-date hoarding and compassion related resources we offer.

About the author

Chia-Ying Chou, PhD., is founder and director of the San Francisco Center for Compassion Focused Therapies (@SFCompassion)- a group psychotherapy practice and training hub for Compassion Focused Therapy (CFT). Dr. Chou obtained her PhD from University College London with a focus on trauma. She spent her postdoc years at University of California, San Francisco working with individuals experiencing hoarding, which she considers to be a relatable human experience and a form of difficulty letting-go. Dr. Chou’s interest focuses on the connection between trauma and the blocks and fears of letting-go and letting-in. She provides training and consultation for clinicians on CFT and hoarding worldwide. Her team found the Better Treatment for Hoarding (@bettertreatmentforhoarding) program, which brings forth compassion-based public education, support, and research about hoarding. You can access more CFT and hoarding related resources on Dr. Chia-Ying Chou’s YouTube channel.

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