1. A Pilot Study of Contingency Management for Hoarding Disorder
Blaise Worden, Ph.D. & David F. Tolin, Ph.D.
Anxiety Disorders Center/Center for Cognitive-Behavioral Therapy
Hartford Hospital/Institute of Living, Hartford, CT

2. Background
There are few empirically-supported treatments for hoarding disorder (HD).
CBT has resulted in only moderate improvement
High rates of ongoing functional impairment post-treatment
Majority continue to meet the diagnosis at post-treatment
Rates of clinically significant change around 24-43% (Tolin, Frost, Steketee, & Muroff, 2014)
Problems
Low treatment compliance
Psychological reactivity
Overvalued ideation

3. Why Try Contingency Management for HD?
Contingency management is an empirically supported treatment for substance use disorders
Has also been used with successfully with health maintenance behaviors, weight loss, etc.
Likely capitalizes on a pre-existing high drive for material reward, and high loss aversion
Provides additional incentive to complete “risky” behavioral experiments
Does not rely on good insight

5. Myths about Contingency Management
CM “bribes” the patient--it relies on external motivation and will thereby decrease internal motivation for change.
CM doesn’t provide lasting skills. Once you remove the contingencies, you’re back to square one.
The cost and resource burden of CM is too high to be worthwhile.

6. Study Aims Gauge preliminary efficacy of CM for HD
Compare effect sizes to existing treatments for HD
Gauge patient interest and satisfaction
Retention and refusal rates
Patient feedback
Examine tolerability

7. Method CM was administered in the context of 16-session group CBT
Contingency payments based on results of in-home assessments
Two successive group cohorts; n = 14; 8 completers
2 dropped from both study and group
2 dropped from study only, citing that the intervention made them feel too anxious and pressured to change

8. Contingencies Group 1 Group 2
$30 per 1-point reduction in mean CIR rating
Total amount earned: $660; mean per person = $132
Payment for each goal completed
8 goals per month collaboratively set with in-home evaluator; were discarding-focused
Escalating payments; $3, 5, 7, 10
Also received $40 bonus payment for each 1-point CIR reduction
Total amount earned: $730; mean per person = $123

9. Measures Clutter Image Rating (CIR) Saving Inventory Revised (SI-R)
Hoarding Rating Scale (HRS)
Clinical Global Improvement Ratings (CGI-S; CGI-I)

10. Results: Saving Inventory-R
ITT results (n = 10); red = group 1; blue = group 2
C = (60%)
F(2, 8) = 4.74, p = .04; d = 1.18

11. Results: Clutter Image Rating-IE
Mean IE-rated CIR score dropped from 4.3 to 3.2

12. Results: SIR Subscales

13. Results: CGI-I

14. Conclusions
Size of mean percent SI-R reduction (32%) was larger than any prior psychosocial intervention for HD
Briefer than existing treatments
Large effect sizes
High patient interest and retention
Results are promising and suggest additional research on CM for HD is indicated

15. Conclusions Limitations Future Directions
Difficult to decide what to reinforce; reinforcing decreases in clutter required home visits
Two patients dropped, citing anxiety
No follow-up
Relatively higher functioning sample
Future Directions
Determine who is most likely to benefit from CM
Determine ideal reinforcement system
Obtain follow-up data