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Let's Talk About CBT

Cognitive Behavioural Therapy: what it is, what it's not and how it can be useful.


May 16, 2019

Maggie's flat was so full that the council threatened to clear it out themselves. CBT helped her understand the reasons behind her hoarding disorder and start to let go of some of her possessions. 

Maggie and Dr Victoria Bream speak to Dr Lucy Maddox.


Show Notes and Transcript

Want to know more? Some useful resources are included here. 


For more about BABCP check out:

To find an accredited therapist:

Hoarding UK's website has resources including support group listings:

Centre for Anxiety Disorders and Trauma website:


Overcoming Hoarding by by Satwant Singh (Author), Margaret Hooper (Author), Colin Jones (Author)



Lucy: Hello, and welcome to Let's Talk about CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT. What it is, what it's not and how it can be useful.  

In this episode, we're going to find out about hoarding disorder. I speak to someone who has experienced hoarding and the treatment for it and a clinical psychologist who specialises in CBT for hoarding disorder.  

Maggie: My name's Maggie and I've been fortunate to have received therapy in a group and individual therapy. So, I would like to be able to share some of my experience that I hope will be of help to people.  

Lucy: Could you say a little bit about how things were for you before therapy? 

Maggie: Hoarding is how I coped with life because it kept people out and it kept me in, where I didn't have to deal with the outside world. Being alone has always been my comfort zone.  

Lucy: So, it kind of kept you from having...  

Maggie: Kept things at bay. I saw the outside world and people as the other. The enemy. That's what I've had to deal with. There was a lot of pressure from the borough where I live with the fire risk that hoarding causes.  

Lucy: So, you were quite unsure about it to start with? 

Maggie: I wasn't happy because I was being challenged and I felt threatened. I had a way of life that suited me.  

Lucy: Is it okay to ask what your house was like? 

Maggie: It's a council flat that I've had for 18 years, now. It just built up and up. I just didn't try and stop it. I have always seen books as my best friend. I always felt books would be the solution to my problems.  

When I retired 13 years ago, I was able to indulge in a lifestyle that I'd always wanted, where I'd just ride around on buses and read what books I want. Go deep into things and study what my hobbies are.  

Lucy: It sounds quite nice, actually.  

Maggie: Well, it is. It's a selfish life. But family life didn't mean happiness to me and relationships didn't spell happiness. My comfort zone was living life vicariously. Learning about life and people through biographies, books, magazines, rather than going straight in to the physical reality. Which suited me.  

Lucy: I'm sure a lot of people can recognise that. There's something very nice about that, isn't there? But it sounds like it was really getting in the way.  

Maggie: Well, it doesn't give you deep, ultimate satisfaction. You're always on guard, in a way. When I first started individual therapy, it seemed very threatening. But it isn't threatening, now. It's almost like I can feel creative more instead of not moving beyond that defensive position.  

Lucy: We'll hear more about Maggie and her reasons for hoarding later. But first, here's Dr Victoria Bream, clinical psychologist at the Centre for Anxiety Disorders and Trauma and the Maudsley hospital.  

Victoria: Hoarding is characterised by a large volume of possessions in the home. Things can sometimes be somewhat organised but generally are in disarray. It can be a mixture of items, often paper, books. Also, food, clothes, bric-a-brac. Things inherited from other people.  

All these items are of such a volume that someone's home is difficult for them to use in the way for which the home was designed. So, the bathroom... The bath may be full of clothes. In the kitchen, there might be books all over the worktops. We'd characterise it as hoarding disorder when someone's life is actually impaired and they're experiencing a certain amount of distress from this.  

I think everybody has the capacity to form a strong attachment to any item. People with hoarding difficulties, for various reasons some of which we understand and some of which I think we don't form that level of attachment to a greater number of objects.  

Lucy: Has it made you think about your relationship with possessions differently, doing this work? 

Victoria: Oh, constantly. I think that might be one of the things that draws me to it. I really get it, with understanding how possessions can mean so much. My home is far from immaculate and I hang on to all sorts of things for sentimental reasons.  

If my children give me a picture that says, "I love you Mummy" on it, in that one second they give it to me, I feel very attached to it. I can't let it go. There's no way I could rip it up and put it in the bin.  

I think it's made me think about how we're all kind of battling with these beliefs about possessions. What is it that then tips it over into being something where it becomes a problem that takes on a life of its own.  

Lucy: What's CBT for hoarding disorder like? What does it look like? 

Victoria: At the moment, the main work we do is based on the work of Gail Steketee and Randy Frost and colleagues in the States. They've been working on things in the last 20, 30 years or so to come up with a CBT model.  

They have identified the main beliefs that people have about possessions. So, having an emotional attachment to possessions. Seeing the utility of an object far more so than other people might. So, everything would have a purpose. A yoghurt pot, once the yoghurt has gone, isn't just a container. It could be a plant pot. Also, the intrinsic beauty and aesthetic properties of objects. These things seem to be particularly potent belief systems in people with hoarding problems.  

The Steketee and Frost model also acknowledges the influence of past experiences, early experiences, whether there's a familial history of hoarding problems, whether people have experienced a trauma or other kind of life event that might precipitate hoarding in some way.  

Also, there's a component of information processing differences. So, that's much more tricky to investigate. There are a couple of papers that do look into that but there's a lot more we need to learn about the way that people handle information and how it affects their ability to order the items they do have, make decisions about the things that they do have in terms of discarding, and then how to carry that plan out.  

Lucy: That's really interesting. If I were sitting working at a desk that's really cluttered, say for example... (Laughter) I'm thinking of my desk, which is quite cluttered! That could have an impact on how our attention is? 

Victoria: When we're working with people trying to make decisions in their home, sometimes just the volume of stuff around them makes the decision process difficult. Peoples' attentions flip from object to object.  

We quite often get people to bring bags of things to the office and say, "You can take it all back home again if you want. But let's try and sort through it while we're here." People are usually quite effective at doing that. Not everybody. But we get people to stick things in the recycling and the bin or take them straight to a charity shop.  

Lucy: You mentioned about early experiences sometimes having an effect or an impact, or perhaps it being more likely for someone to have a hoarding disorder. Could you say a tiny bit more about that? 

Victoria: Yeah. What's in the literature so far is that, if people have had some family history of hoarding, that might be associated with hoarding themselves. They've just grown up not knowing another way of doing things but to have a lot of clutter. And then often inherit those items into their own home, as well. So, have two houses' worth of stuff in one go.  

Sometimes if people have come from very impoverished backgrounds where they haven't had enough when they were growing up, then when they have had the means to buy things and acquire things, it's felt very loaded to keep those items. It would be extremely wasteful to get rid of everything. Then it's working with people to update those beliefs and think, "Is that a helpful idea to have around at the moment?" 

Lucy: So, how did Maggie find CBT? 

Maggie: We looked at why I was doing this. First of all, the big change for me was being unconditionally accepted because I'd never had that from my parents. It was an emotionally cold upbringing, like some people have.  

I think the common element in hoarding is some sort of, I feel, very primal trauma. Where you're not given unconditional love and acceptance, for whatever specific reason. I think that is the basic that you have to feel because every baby really does need unconditional acceptance, otherwise it won't feel love. It's about replacing fear with love. It sounds simple but it's not easy.  

Lucy: No. I was going to say, how does that happen? What would I have seen if I was in your therapy sessions? What kinds of things did you do or talk about? 

Maggie: Well, we reviewed the week and set an agenda through how things had developed. And looked at what I had or hadn't done. I found it particularly helpful because it helped to ground me. Because I tend to be a bit above it all and beyond it all. I've had to look at those issues. To look at why I don't really want to be here.  

I think you have to face your fears realistically and see what can be done about them. I think the only way to deal with them is to deal with things in small amounts. Take a few steps at a time.  

Lucy: As part of the therapy, did you have to throw things away? Was that part of it? 

Maggie: Yes. Discarding. Which I did resist. I still haven't got rid of all my books and I think, "Yes, I must read this. I must read that." It's working to a system of priorities.  

It's quite surprising that things don't always have the effect you think they will. You don't know, until you've done it, whether you've done the right thing or not. I found it quite easy to discard clothes. As I got rid of a lot of books, I found I didn't really miss them.  

My clutter was really quite bad. It was all mixed up with clothes, books and food. I've just gradually and slowly had to learn to separate different classes of items. Paperwork... I don't like dealing with paperwork. If you don't get the mundane sorted out so it doesn't support you then that's going to make things even worse. Because you spend so many hours looking for things.  

Lucy: Is that what you found was going on before? 

Maggie: Yes. Very much. I was being hounded by my housing officer, as well.  

Lucy: So, discarding is one of the things that you worked on in the individual work. Were there thoughts that you talked about, as well? 

Maggie: Learning to come into... I keep saying, "The outside world" because that is the biggie, with me. That's the bottom line, for me. I belong to several social groups for retired people and I've joined a committee there that I would never have done a year or so ago.  

And, for the first time ever, I feel that I would like to help other people. That is a new one, for me. Because I never saw outside myself. Gradually, with the very good therapy I got, I realised that people are more important than books.  

Lucy: Victoria told me a bit more about CBT for hoarding.  

Victoria: It's often tempting to think that people need a practical solution to the problem. That someone like a support worker will come in and just say, "Right, where do we start?" For a lot of people, it's about unravelling quite a lot of distress and upset. Only then can you actually approach making some decisions to discard the items.  

Lucy: I guess because people might just then fill up again with other items? 

Victoria: Yes. I think, anecdotally, that's what... I work with the local councils around here. They've all said that they've done that. They call them, "Blitz cleans". They go in. They take everything out. Chuck it all in a skip. Scrub everything. The person whose home it is, if they haven't consented to that, is obviously really upset and unlikely to engage with services in the future, and reaccumulates possessions.  

We advise the councils around here to try and encourage a very understanding and psychologically minded attitude towards hoarding problems. As well as going through possessions with people and thinking about, "Do I really need it? Or do I want it?" Trying to get the distinction between the need and the want. This can be really tricky. So, trying to disentangle that very strong emotional attachment to a lot of things.  

Also, spending lots of time talking about whether the possessions do actually fulfil the function that people hope that they do. Objects connecting people to their pasts. Do the objects actually do that? Or do they hold someone back from getting on with their life and actually make them feel miserable, sad and less able to take new opportunities?  

Lucy: As well as individual cognitive behavioural therapy, Victoria is involved in a really exciting project set up by the local fire brigade, who were worried about local residents who were hoarding and wanted to help. 

Victoria holds group sessions at the local fire station using CBT principles. 60 people have attended over the last year. There's often about 15 people in the group.  

Victoria: It's been amazing to see the actual support nature of the group. The magic that's worked between the participants of... Someone admitted a couple of weeks ago that they'd blocked their front door. This was a very well-presented person who you wouldn't imagine would be in those circumstances. The other people in the group were so moved that he could say that.  

It then made other people sort of say, "Well, actually I've got to the point now where I can't use my bath." This kind of thing. Acknowledging the extent of the difficulty. Just being part of that process of people moving towards thinking, "Well, I'm going to have to face up to this problem."  

And describing the possessions that they're keeping to each other in the group. Saying, "Well, can't you give them away?" She was like, "Oh, no. They're too rubbish to give away." The penny dropping then about, "Oh, I can't give them away. And why am I keeping something rubbish for myself?"  

Trying to facilitate that group so that people then go home and take action off the back of these insights. Then, when they come back to the group maybe next week or a few weeks later, people take great pleasure in reporting back and saying, "Actually, I did manage to do this."  

Lucy: Maggie has attended the group.  

Maggie: It's fun.  

Lucy: It's fun? Really? 

Maggie: I had such a laugh at the last session. It was like, "Carry On Hoarding". (Laughter) 

Lucy: It sounds like it's really supportive and light-hearted, in some ways.  

Maggie: Yeah. Because I do think you need a sense of humour. If you can laugh at yourself a bit, it puts things more in perspective. There is hope out there.  

Lucy: What would you say, if someone is listening to this and they think they might have a bit of a difficulty with hanging on to things for too long or if they're experiencinglike you didsomebody telling them that they need to work on that? What sort of advice would you give? 

Maggie: I would say don't listen to people who don't understand what you're going through. It seems to be that one of the problems is other people find it incomprehensible. They don't understand. I think it's a silent neurosis. It's anti-social but it's hidden.  

It's very good to meet people who think similarly because there's an instant, unconditional acceptance. You've got the group support. People will listen to you and they will give you advice that will help you because they're in a similar position.  

It has changed, albeit slowly. Sometimes it's two steps forward, one step back. What I've learned is that I have to be compassionate to myself and realise it will take time.  

Lucy: I asked Victoria about the evidence base for CBT for hoarding.  

Victoria: Well, it's still the only treatment, really, that's recommended for hoarding problems. The way I always try and explain it when I'm talking to people in the wider public is... In the Centre for Anxieties and Trauma here, if someone came in with a phobia, a panic problem, OCD or PTSD, we'd be pretty confident at the beginning that someone would walk away with quite significant change in their distress and their symptoms. And, with any luck, actually losing the diagnosis entirely or certainly to be well along the road to that. Whereas with hoarding problems, we're definitely not in that position.  

Even the really wonderful studies that have taken place Gail Steketee, Randy Frost and colleagues are still looking at 50-70% of people reporting some improvement. But not radical improvement either, necessarily.  

Studies are coming out a lot at the moment, since the reclassification as a separate disorder. I think there's going to be some nice updates to the literature continuing in the next year or two.  

Lucy: It's a field that's still quite exciting, actually, isn't it? It's quite emerging and ongoing.  

Victoria: Yeah. And that is what I would say to anybody who has got an interest in hoarding. It's still something that a lot of services don't offer treatment for. It is in the DSM, now, as a separate disorder. It does cause people a lot of distress and upset. It perpetuates all sorts of other problems.  

We know from epidemiological data that people with hoarding problems are more likely to have a physical problem, like heart condition or diabetes. So, there's this big public health disaster, in a way, associated with hoarding problems. But it's still a problem that everybody is preferring not to talk about.  

What I think we don't understand at the moment is what's normal behaviour. What do most people do, in terms of keeping possessions? How do people decide how to have a clear-out and how do they do it? I'm hoping, if we could shed some light on those processes amongst people who don't have a problem with an accumulation of possessions, it might help us to further understand what happens when people do have difficulties discarding.  

Lucy: Are you doing research into that at the moment? 

Victoria: We're just working out a research question on that at the moment, which we think would be quite an interesting and a fun one to do. In terms of just being able to get it out there in the general population and say, "Well, how do you do it?" Like you say, it is sort of in the public eye at the moment. How we cope with our possessions.  

What we know is that, even within people who acquire a lot of things and who enjoy shopping, not all of them keep all those possessions. So, quite a big percentage of people who acquire a lot will then take those items back, sell them on or give them away or whatever.  

Whereas we know for hoarding... And it's a distinct thing. Also, people aren't always buying things, they're picking stuff up from the street. Picking stuff up out of bins. They are very good at knowing where free things are and accumulating things in that way.  

Lucy: I spoke to Maggie about how she thinks hoarding and decluttering is talked about in the media.  

Maggie: What I've noticed on television programmes, probably for entertainment purposes, is they tend to choose people with a fair amount of space. Probably because it's not so boring watching it. I don't know. It's the same with their financial problem programmes. They'll always have people who are on a middle-class income. "How to cut down."  

But they never deal with the grass-roots people on benefits or people in small places who are finding it difficult to cope. So, I feel those of us who come from that sort of background have a less visible impact.  

Lucy: And actually, it's really important, isn't it? There should be more about that. Thank you so much.  

Maggie: Good luck, everybody.  

Lucy: That's great. Is there anything else you'd want to say to people? 

Maggie: Just don't be afraid to ask for help. Because there is hope out there.  

Lucy: If you'd like more information on CBT for hoarding, have a look at the show notes. For more on CBT in general, and for our register of accredited therapists, check out And have a listen to our other podcast episodes for more on different types of CBT and the problems it can help with.