UNDERSTANDING AND TREATING HOARDING DISORDER:
AN EXCESSIVE ATTACHMENT TO OBJECTS
Interview with Melissa Norberg
Melissa Norberg is President of the Australian Association for Cognitive and Behaviour Therapy. She is also an Associate Professor in the Department of Psychology at Macquarie University (Australia) and the Deputy Director for the Centre for Emotional Health. She is a clinical researcher whose chief interest is in discovering what general and specific factors and processes contribute to the aetiology and maintenance of anxiety, obsessive-compulsive and related disorders, and substance use problems. Her research curriculum highlights more than 90 scientific publications focused on obsessive-compulsive disorder, hoarding disorder, specific phobias, and drug abuse.
The following interview has been conducted by Ana Isabel Rosa-Alcázar (Professor of Clinical Psychology at the University of Murcia, Spain, and main researcher of group focused on Obsessive-Compulsive Disorder and related)
AIRA: Firstly, Dr. Norberg, on behalf of the organization, I thank you for accepting the invitation to participate as relevant speaker in the XIII International Congress of Clinical Psychology that will take place on November 11-14 in Santiago de Compostela (Spain). It is an honor to count on your collaboration as we are aware of your busy schedule.
We will now start the interview, you were born in Nebraska, completed your undergraduate education at the University of Nebraska-Lincoln, your Master's degree and PhD in Clinical Psychology at the University of Wisconsin-Milwaukee, and are currently working in Australia. Have you found relevant differences in Clinical Psychology in the US compared to Australia?
MN: Yes, the most obvious difference is that in the United States you must obtain a PhD to be a clinical psychologist, but Australia only requires a master’s degree. The PhD training programs in the USA tack on another two-three years of training, which allows students to obtain more training in statistics and research methods, as well as in the biological, developmental, social, and cognitive/affective bases of behaviour.
AIRA: You are currently the President of the Australian Association for Cognitive and Behaviour Therapy. What are this association´s goals? What is your vision for the Association and more broadly for the field of clinical psychology?
MN: The objectives of the Australian Association for Cognitive and Behaviour Therapy are to 1) provide high quality professional development; 2) publish and disseminate evidence-based practice; 3) increase the use of behavioural and cognitive therapies in Australia; and 4) partner with the international community.
Personally, I would like to see a greater focus placed on the science of clinical psychology. There has been a disconnect between theory and clinical practice, such that we have been focused on what works rather than why it works. This has led to a proliferation in the number of treatments disseminated. Because we also haven’t been concerned enough with ensuring that new treatments work better than what currently exists, therapists are stretched, becoming a jack of all trades, rather than experts in a few key treatments. Thus, I’d like to see more of a focus on linking models of psychopathology to treatment processes. Many models overlap (e.g., avoidance is a key feature in models of anxiety and depression), and we need to figure out which treatment techniques target these overlapping features the best, and then work on disseminating and training clinicians to deliver these techniques to the best of their abilities. Likewise, if psychopathology models or particular tenets of models do not have scientific support, we should not be using them to guide treatment. Inherent in this process is ensuring clinicians are capable of interpreting research findings so that they can figure out which models and interventions have enough support to warrant their attention.
AIRA: We have found that your field of research is wide, but focuses heavily on OCD and related disorders. As you know, in 2013, a new classification of the disorder emerged, forming a new grouping together with “related disorders”, what is your opinion of this change?
MN: My interpretation of research findings is that OCD and body dysmorphic disorder are similar, whereas trichotillomania and skin picking are similar to each other. Hoarding disorder seems to differ quite a bit from OCD. Individuals who meet criteria for hoarding disorder tend to enjoy possessions. They collect them because it makes sense to them, what is difficult is parting with them. Saving is the absence of a behaviour (i.e., discarding), which to me is different from the compulsive behaviour associated with OCD. But what is similar is the fear produced by thoughts associated with each disorder and a profound belief that distress cannot be tolerated. With all of the OCRDs, clinicians need to help individuals realise that they can tolerate distress. After all, they do it every day.
AIRA: One of your lines of research is to discover what factors and processes contribute to the aetiology and maintenance of anxiety, obsessive-compulsive and related disorders, and substance use problems. In addition, you are interested in the role of both general and disorder-specific factors, would we be talking about looking for factors common to these disorders? Would this fall within the so-called "trandiagnostic or transtreatment"?
MN: Yes, this falls in line with researching transdiagnostic factors. Emotion dysregulation appears to be a problem underlying many disorders. This entails becoming overly distressed by certain cues and the perception that one cannot tolerate distress. Transdiagnostic treatment, like the one developed by Prof Peter Norton and colleagues, can help individuals suffering from excessive anxiety regulate their emotions, regardless of which cues trigger their anxiety and belief that anxiety cannot be tolerated. My own research has highlighted that emotion dysregulation and poor interpersonal functioning underlies hoarding disorder.
AIRA: One interest in your research is hoarding disorder. You have published numerous papers on attachment style, including a systematic review. What conclusions have you reached in regard to attachment style and hoarding disorder?
MN: It seems likely that hoarding disorder develops, at least in part, because individuals rely on possessions for emotional support. This may happen when individuals have not learned how to emotionally support themselves or others. According to attachment theory, when primary caregivers inconsistently respond to their infant’s needs and emotional states, children do not learn how to support their own emotional needs or the emotional needs of others. As a result, these infants grow up looking for signs of rejection, which may heighten their negative emotion and lead to engagement in strategies meant to gain support and love, but which often fuel interpersonal problems because they are carried out with resentment and anger. This style of interpersonal functioning is referred to as an anxious attachment style. Much of my research has shown a link between an anxious attachment style, emotion dysregulation, poor interpersonal functioning, and hoarding disorder. As a result, I believe that treatment for hoarding disorder must target these factors.
AIRA: Your conference in the Congress is titled: "Understanding and Treating Hoarding Disorder", could you tell us what would be the main elements to take into account when designing a treatment for hoarding disorder?
MN: During my keynote, you’ll learn that I think modules targeting emotion dysregulation and interpersonal functioning are missing from current treatment for hoarding disorder. These two facets seem to underlie many people’s excessive attachment to objects, and we need to reduce object attachment if we want people to be able to part with their possessions.
AIRA: Focusing on the effectiveness of OCD in children and adolescents, and taking into account your training as a clinical researcher, what ingredients should treatment for resistant cases have or whose relapses are frequent in the short and medium terms?
MN: Basic research has taught us that extinction learning is context dependent. Thus, we must realise that exposure and response prevention is not a cure for OCD. We need to use treatment strategies that help reduce context-dependent relapse (e.g., the passage of time, being in different environments) and inform clients of this up front. This way we can help reduce the chance of relapse and teach our clients how they can help in this regard. As for treatment resistant cases, we need to be looking into how we can enhance exposure and response prevention. For example, we know that sexual and harm obsessions are more difficult to treat. Research also has indicated that sexual and harm obsessions trigger shame, in addition to anxiety, but research has not explored whether ERP reduces shame. If exposure to feared events does not reduce shame, we need to figure out which strategy does.
AIRA: Finally, and focusing on this moment in time during the COVID-19 Pandemic, how do you think this virus is affecting OCD and related disorders? Will it have more of an effect on patients with symptoms of contamination?
MN: It seems that COVID-19 has had variable effects. Some, even those with contamination concerns, haven’t been too concerned with contracting COVID-19. For others, COVID-19 has supported their belief that they should be overly concerned with contamination. This highlights the idiosyncratic nature of OCD and the need to fully understand each person’s underlying beliefs and how those beliefs fuel avoidance.
AIRA: What about hoarding disorder during the COVID-19?
MN: The same goes for hoarding disorder. It really depends on an individual’s circumstances. Discarding is always hard and COVID hasn’t changed this. For some, the only impact has been that charity organisations are closed and not accepting goods. For others, the lockdowns have reinforced their beliefs that they need to save to always be prepared. And yet for others, they are using the pandemic to directly challenge their beliefs that they need possessions to manage loneliness and are now discarding more possessions.
AIRA: I reiterate my gratitude for your participation in this congress and your continuing to disseminate knowledge, an aspect that is so relevant to you throughout your career.
MN: Thank you very much. It is a pleasure