Hoarding Disorder

Dr. Laura Roberts (00:16):

Hi, I'm Dr. Laura Roberts, Editor-in-Chief for the Books Portfolio of the American Psychiatric Association. And welcome to the APA Books podcast.

Dr. Laura Roberts (00:30):

So welcome everybody to, Unbound. I'm thrilled that we're here together. And on this episode we're going to talk about a fascinating topic, namely hoarding. And we're going to talk with fascinating people, namely Dr. Carolyn Rodriguez and Dr. Randy Frost. Really thrilled that we could be together, and especially that you all put this wonderful book together for APA Publishing.

Dr. Laura Roberts (00:53):

I think hoarding has been recognized through human history and in literature and has been recognized in popular culture. But it took us a while with the American Psychiatric Association to recognize hoarding as a disorder. It wasn't until the publication of DSM-5 in 2013, as I've come to learn from Dr. Rodriguez and Dr. Frost, that there was really this shift in understanding of hoarding as its own disorder. And not just a symptom say, of obsessive-compulsive disorder, or obsessive-compulsive personality disorder, or another nature mental disorder. It was a condition in its own right.

Dr. Laura Roberts (01:35) 

And so it's for this reason that I think this book is really a landmark or a milestone book, and it has many strengths, which I'll talk about in just a little bit. Dr. Carolyn Rodriguez, is Associate Chair and Professor in the Department of Psychiatry and Behavioral Sciences at Stanford University, and my colleague. And she's the Director of the Translational Therapeutics Laboratory in our department.

Dr. Laura Roberts (02:00):

And Randy Frost, is the Harold Edward and Elsa Siipola Israel Professor Emeritus, that's a kind of a tongue twister there, Randy, in the Department of Psychology at Smith College in Northampton Massachusetts, where one of my children attend.

Dr. Laura Roberts (02:18):

Welcome to Unbound. And thank you so much for doing this wonderful book and thank you for being here today. So I always start with the question, why did the world need this book? Why was this of sufficient value that you would give so much of your time and thought to it? And maybe Carolyn, I could turn to you first to help us understand the significance of this area and the need for attention to it.

Dr. Carolyn Rodriguez (02:43):

Absolutely. Well, what an honor to have the opportunity to write this book and really just want to thank you for encouraging us to fill this gap. It was really a gap and big need in the field. When I was training as a psychiatry resident, I started my career doing OCD research and often we would get called by individuals who were struggling with clutter, struggling with eviction, in desperate need of help.

Dr. Carolyn Rodriguez (03:18):

And at the time, hoarding symptoms were actually considered part of OCD. And so that's why I was on the front lines of getting these calls. And it got to the point where a lot of these individuals were excluded from the OCD studies because researchers recognized for a long time that these were two separate disorders.

Dr. Carolyn Rodriguez (03:42):

And it got to the point where I wanted to find resources and help. And through just a little bit of digging, it became clear that my colleague, Randy Frost was the pioneer. He uncovered this area, has studied it for a long time, and I basically just invited him to come and give a talk. And it was the beginning of a beautiful mentorship and then colleague interface over many, many years. And this book is really a reflection of that dialogue.

Dr. Randy Frost (04:17):

Yeah, Carolyn. It is a strange phenomena where we know now that this is a very prevalent problem. It looks like this is more prevalent than OCD, but yet 25, 30 years ago, we do virtually nothing about it. And it didn't... started this really by accident. I was teaching a class a seminar, senior seminar in obsessive-compulsive disorder, and one of the students asked about hoarding because when she was growing up, she grew up in New York City and her mother used to tell her, "If you don't clean your room, you're going to end up like the Collier brothers."

Dr. Randy Frost (04:58):

Now, the Collier Brothers were the famous case back in the '40s in New York City. It made the newspapers for two straight weeks with these two gentlemen who both died in their home. And when they discovered them, they discovered the house was absolutely packed with stuff.

Dr. Randy Frost (05:16):

And so the student said she wanted to do her term project on hoarding, and we looked, and lo and behold, we found nothing. There were a few comments about hoarding, relating it to OCD, but no case studies and no real scientific study of hoarding disorder. So we decided we would try to find somebody to interview and we were hoping to put an ad in the paper and find a person who, in the ad we described it as someone who considered themselves a pack rat or chronic saver.

Dr. Randy Frost (05:53):

And lo and behold, we got a hundred telephone calls out of the small community of Northampton Massachusetts. And so we went out and visited these folks in their home and discovered really quite remarkable living conditions. And that really set off our research. We did a couple of studies using these folks as our participants and were just really surprised by the seriousness of this and the extent to which this interfered with their lives.

Dr. Randy Frost (06:25): 

Not only their ability to live in their home and do the basic activities of daily living people need to do at home, but also the relationship with family members. And after that, we published that paper and a couple more, and then the whole field became like a runaway train with lots of people starting to say, "Hey, what is this?" And finally, in 2013, there was enough evidence to support this as a separate disorder in the DSM.

Dr. Laura Roberts (06:58):

Can you tell us just a little bit more, Randy, about the natural history of the condition? So what do you see in childhood, in adolescence transition into adulthood and independence and maybe separate living quarters and then throughout the life story?

Dr. Randy Frost (07:14):

It's a good question because it is a little confusing. When people come to us with hoarding problems, they typically are a little bit older than the folks we see with OCD, for instance. But when we start to look at these cases, what we find is that the hoarding behavior starts pretty early, somewhere between 15 and 20 years of age.

Dr. Randy Frost (07:40):

We see the beginning of difficulties with possessions. But interestingly, that difficulty doesn't become impairing until decades later. So this behavior seems to start pretty early. And by about the fourth decade in life is where there's sort of a cut-off point where the seriousness starts to ramp up. And maybe that's because that's a time in which people have enough resources to collect a lot of things. It's beginning the time where their parents pass away and leave them with suddenly a lot of new possessions and so forth.

Dr. Randy Frost (08:21):

But for whatever reason, there's some tipping point where the symptoms become more extreme. And the interesting thing is when we talk about these symptoms, the core symptoms in the diagnostic code, the core symptom is difficulty discarding possessions regardless of their value.

Dr. Randy Frost (08:37):

Now, one of the stereotypes of people with hoarding is that they have difficulty throwing away things that are worthless and worn out. But what we know from our research now is that it's not that they save worthless and worn out things, it's that they save virtually everything. And we've had cases with houses full of brand new stuff, clothes with the tags still on them, unopened boxes that have been ordered or purchased. So it's this core feature.

Dr. Randy Frost (09:12):

But one of the other things that's kind of interesting is that acquisition, excessive levels of acquisition, are present in about 90 to 95% of people with hoarding disorder. But yet, when trying to put together the diagnostic criteria, it looked... we weren't exactly sure whether if we included that as one of the core features, the acquisition is a core feature, we might exclude some cases that should be included.

Dr. Randy Frost (09:43):

So instead of being a core feature, excessive levels of acquisition as a problem behavior became a specifier that to that's used once the diagnosis of hoarding disorder is made. Now, it looks like acquisition may start a little bit later than difficulty discarding life with the developmental trajectory, but that probably has to do with the extent to which the individual has an opportunity to acquire more. So in childhood the kids don't often have their own resources at an early age.

Dr. Laura Roberts (10:16):

Right. Yeah, no, it is fascinating. You can see where you'd get drawn into it, such interesting cases. Carolyn, can you comment a little bit on the status of research in this area? What we understand about psychosocial predisposition, or biological predisposition, or prior experience how that might shape it, or just family experience, how it might shape the manifestation of hoarding disorder?

Dr. Carolyn Rodriguez (10:45):

Absolutely. So in writing this book with Randy, it was really a tremendous opportunity not only to give clinicians, peer professionals, social workers, insight into what hoarding disorder is, how to recognize it, how to do risk assessment and give people tools to really lean into that, recognizing it and diagnosing it and getting people to referrals.

Dr. Carolyn Rodriguez (11:14):

But it also gave us a moment to pause and reflect and get a really nice overview and up-to-date of where we are in the research. Not surprisingly, Randy has been at the forefront of this for many years. So a lot of what we know about the phenomenology of hoarding disorder was really pioneered by him and he and his longtime partner, Gail Steketee, had started out with a series of really beautiful papers and then extending to partnership with David Tolan, looking at cognitive behavioral therapy as a treatment for hoarding disorder.

Dr. Carolyn Rodriguez (11:54):

There have been many people, Jordana Muroff, Kiara Timpano, Christiana Bratiotis, and others who have taken this on, expanded this research and looking at differences between communities and populations. And also Randy himself, hopefully he'll talk a little bit about how their principles of CBT can be used in facilitated group support that can actually facilitate more implementation into the community, not relying on clinicians to lead those groups, but the really peer professionals.

Dr. Carolyn Rodriguez (12:28):

And the results of that look like CBT is helpful for boarding disorder. That's the great news. And that the peer professional groups that are very easier to implement into a larger range look to be about as efficacious. So that's really exciting news. I'm definitely a glass half full person, but my research is glass half empty. So I really focus on those people who are not helped by those treatments and seeing if we can push the edge of what is possible.

Dr. Carolyn Rodriguez (13:02):

We recently published a paper, Hannah Riley was the first author looking at virtual reality uncluttering. So for those homes where it's unsafe to do the uncluttering practice and skills-based things, can we start to move away from in virtual reality environments, being able to have people scan the items of their home and practice over and over discarding an object as opposed to when you discard it in real life, it actually goes away.

Dr. Carolyn Rodriguez (13:30):

So those are more things for the future. One thing that is very still... hits my heart deeply is that we're nowhere near medication for hoarding disorder. There is to date, no FDA approved medications for hoarding disorder. The evidence that we have is very low numbers in open label studies, but these kind of large randomized studies to look at medications is a big need in the field.

Dr. Laura Roberts (14:06):

Great, thank you. So I'm really intrigued by what you're saying and I'm especially intrigued by this tipping point. It's like a little bit of collecting of things might be usual experience for people, but this idea that it gets to a certain point where the tipping point is where it becomes a disability or it's disabling either in some sphere of life that's important.

Dr. Laura Roberts (14:31): 

And so I'm wondering if there are interventions looking at basically prevention before the tipping point and then interventions that can be implemented and are known to be efficacious after people have some years of time where they're engaged in hoarding that is actually disabling? So I don't know if you talk about before the tipping point and then after the tipping point, Randy.

Dr. Randy Frost (14:55): 

Well, I don't know of any studies of this point that have focused on treating people below that tipping point. And part of it I think is because people don't show up until the problem gets serious. I had lots of people call and once they learn something about it, say, "I've always been this way, but I didn't have a name for it. I didn't know what it was."

Dr. Randy Frost (15:25):

And so I think the problem we've got in doing this research is being able to identify people below that tipping point because they tend not to show up. And I think that's one of the reasons why this disorder was so hard to find because people didn't show up at clinics until it was really a pretty serious problem.

Dr. Laura Roberts (15:49):

And so then after the tipping point, we know that CBT is helpful or adaptive CBT is helpful.

Dr. Randy Frost (15:56):

Right. After that tipping point, what we have is a treatment that is based on what we knew at the time with respect to this. And it looks like the treatment involves the challenging of one's beliefs and attachments to possessions.

Dr. Randy Frost (16:19):

Now there's a lot of things that lead to the development of the disorder, but the real crux of the matter is in order for us to treat people, we've got to focus on these attachments they have to these objects, because that's what's getting in their way of throwing things away. We ask someone with this disorder, "Throw something away." They give us lots and lots of reasons why they can't throw it away. And in their view, they shouldn't throw it away.

Dr. Randy Frost (16:42):

So it's these attachments that people have for possessions that are the core focus of cognitive behavior therapy and involves challenging them in some way. And that's tied a little bit to what we know about the development of this disorder. For instance, we know that people with hoarding disorder have difficulties with emotion regulation.

Dr. Randy Frost (17:10):

And what that seems to lead to here is an avoidance of negative emotional experiences. And what happens when someone tries to throw something away seems to be an immediate and a very intense negative emotional state. I can't tell you how many people when they're beginning treatment, the first thing they say when you ask them to try and experiment and throw something away, when they take something out of their house and put it in some kind of trash receptacle or recycling receptacle, they frequently say, "I just feel like I want to die."

Dr. Randy Frost (17:46):

Is that really, really intense emotion. And so that sort of ties in with this emotion regulation problem. And it is a negative reinforcing event for the saving behavior that we see here. So one of the things we have to deal with is this avoidance or escape behavior that people are trying to avoid this emotional reaction.

Dr. Randy Frost (18:11):

And so one of the things we do is we ask them to engage in experiments, where they're testing their ability to tolerate this negative emotional state without doing something about it. Now, this is very similar to what we do with OCD with respect to exposing people to fear and stimuli. It's kind of like that in this context.

Dr. Randy Frost (18:32):

On the other hand, we have the other piece of this hoarding puzzle where we need to somehow get people to control their acquisition because if we got them to control discarding and discarding more, it may not make a difference because of the volume of stuff coming into the home. So we typically do two things in treatment when we're dealing with acquisition. The first is to try to introduce the life context into the decision about acquiring because what we know from studying these folks is that they tend to acquire impulsively.

Dr. Randy Frost (19:10):

So when they see something that they want to pick up for free, or to buy, or whatever, what happens is their focus of attention is so narrow. It is focused on what a wonderful thing it would be to have this possession and all the things I could do with it, all the avenues and opportunities it would open up for me and so forth.

Dr. Randy Frost (19:31):

But what's absent in the consideration is the context of the person's life. Do I have space for this? Do I have money for this? Do I already have something that's exactly like this and so forth? So that information doesn't seem to be available to them when they're making the decision to acquire something. So what we do is we ask people to come up with a set of questions they think they should ask themselves before they acquire something. That's when we're in the clinic and they're not in an acquiring episode.

Dr. Randy Frost (19:59):

And then we have them carry that list with them and challenge themselves by asking those questions and then making the decision about whether to acquire something. So that's the one leg of this treatment for acquiring. The other has to do with helping them learn how to tolerate the discomfort that's associated with losing the opportunities that are available because of that possession or that potential possession.

Dr. Randy Frost (20:31):

And we treat that just like a physical fitness routine where we ask them to create sort of a hierarchy of places where there's an urge to acquire and then we have them go to those circumstances, engage that urge and walk away without acquiring something. And have them build up their strength or tolerance for that urge so you get a sense of the way in which treatment works.

Dr. Laura Roberts (20:56):

No, it's great. Carolyn, led a session with high school students in one of our programs in the department and being a chair of a department, I feel like I'm a little vacuum cleaner. I go around and I pick up little things everywhere and I hold them dear and I hold closely to them. But anyways, one of the things I learned from Carolyn in this session with high school students is identifying an object that people attach value to and it isn't getting rid of it's actually giving it to someone.

Dr. Laura Roberts (21:22):

No, it's great. Carolyn, led a session with high school students in one of our programs in the department and being a chair of a department, I feel like I'm a little vacuum cleaner. I go around and I pick up little things everywhere and I hold them dear and I hold closely to them. But anyways, one of the things I learned from Carolyn in this session with high school students is identifying an object that people attach value to and it isn't getting rid of it's actually giving it to someone.

Dr. Laura Roberts (21:52):

No, it's great. Carolyn, led a session with high school students in one of our programs in the department and being a chair of a department, I feel like I'm a little vacuum cleaner. I go around and I pick up little things everywhere and I hold them dear and I hold closely to them. But anyways, one of the things I learned from Carolyn in this session with high school students is identifying an object that people attach value to and it isn't getting rid of it's actually giving it to someone.

Dr. Laura Roberts (22:22): 

It sounds like the person who's accumulated a lot of stuff and has a hard time giving up the stuff, actually feels like having that stuff is right and good. So when you think about how to move people into motivation for change, how do you get people there and who's uncomfortable? And as a therapist, are you the one who's uncomfortable, right? So help me with that.

Dr. Carolyn Rodriguez (22:46):

Well, I'm happy to start and hopefully Randy will tag team this one, there's a lot to say about this topic and thank you for raising it, it's so rich. I think when I first started learning about hoarding disorder and I started doing home visits, the wisdom of Randy and Leesher, who's a peer professional, really shifted how I approached individuals.

Dr. Carolyn Rodriguez (23:13):

I think individuals with hoarding disorder are used to people making expressions on their faces or being overwhelmed by the amount of things that are in the home. And so approaching as if it is a museum of valuable items and asking individuals to tell you about the stories and items is a really beautiful way to connect with people, and helps you as somebody who is coming in to be helpful, focus on an item and the joy that the person experiences in the item and really help you have empathy.

Dr. Carolyn Rodriguez (23:50):

For if that one item, maybe it's a bottle cap and they love how the light shines on it and they're speaking about it, you can't help but be captivated by the joy and the memories that come up for that person. So I think that hoarding disorder is unique in that it touches the individual, it touches their family. It also touches the larger community.

Dr. Carolyn Rodriguez (24:18):

If you're living in New York and you have an apartment that is full and you have other extenuating circumstances where you can't clean now because it is too full, there's a potential for pest infestations, for fire hazards that can impact the whole building.

Dr. Carolyn Rodriguez (24:37): 

And in fact, we've seen the ramifications of firefighters who have lost comrades because it is quite dangerous for them to go into a building and be sometimes lost and disoriented in a maze and the hazard of having items fall on them. So it isn't just a one person effect like a lot of mental illness, but unlike a lot of mental illness, there's the physical aspect of the items impinging on neighbor's homes. Randy?

Dr. Randy Frost (25:11):

And I think one of the things we learned pretty early on is that by the time folks get to us with pretty serious hoarding problems, they've faced decades worth of criticism and advice from family, friends and so forth. And that advice is usually, "Throw that away, that's worthless." Or "Throw that away, you don't need it." So we know if we approach them in that way, what's going to happen is their motivation's going to shut down because that's the way they've been treated.

Dr. Randy Frost (25:43):

And there's an implied criticism there that we are telling them what they need to do and we can't really tell people what to do or what to think about these possessions because then we're on the wrong side. We have to somehow get them to start making the arguments for why they need to change. And the best way we do that I think is using motivational interviewing strategies, but trying to help them identify what they value in life.

Dr. Randy Frost (26:16):

And that starts with a general discussion about what their life is like and what things are important to them. And most of the time what people report are the things that all of us would report. The things that are important is family, friends, community, being able to attach with people and so forth. And these are pretty universal values that people have.

Dr. Randy Frost (26:43):

And what we try to do is to draw those out and then get them to think about how the way they're living now prevents them from following those values or attaining those kinds of goals that they have for themselves. And the last thing we want to do is say, "This is something that's worthless," because we know for them it's not worthless. There is value. And as Carolyn was saying, we want to get in there and understand the value that they have placed on these objects.

Dr. Randy Frost (27:18):

Because if we're not there with them in doing that, then we're going to be viewed as somewhat suspiciously and maybe we're just like everyone else and you're trying to get me to throw my stuff out. So it's a delicate process and one that takes some time and some openness on the part of the therapist, or the person running the group to listen and really comprehend in a deep way what it is these people get out of these possessions. And then help them figure out, well, is that really what they want in life and how not having this possession might get them a step closer to what they want their life to be like.

Dr. Laura Roberts (28:06):

Right. So thank you for all of that. So just thinking from the point of view of a psychiatrist in practice, or a psychiatric training person, and I think in psychology training, just a clinical setting, how do we do a better job of recognizing this? Especially earlier, earlier on, what kinds of questions might people ask? How do they keep it top of mind to understand that it might be even the reason that the person's presenting, or a contributing factor when there's presence say of two diagnoses that need to be attended to? So Carolyn, did you want to...?

Dr. Carolyn Rodriguez (28:46): 

Yeah, I have to start off. So I think one thing that we were very mindful in getting the book together is how to give a practical tool. And so in the last pages of the book, there is something called, The Clutter Image Rating Scale, and actually a lot of different rating scales that is in the vein of the phrase, a picture is worth a thousand words. So Randy and his colleagues have designed, they basically have three different rooms in the home and each of them have different levels of clutter. Where an individual can very quickly, it takes less than a minute to administer, say "My room is, from level one to nine, it is a four. It is a five. It looks like this."

Dr. Carolyn Rodriguez (29:33):

And so normalizing it, having a quick tool that a clinician can do it, and actually it's anything that's a four or above would make you suspicious to then take a little bit more effort in terms of a self rating scale, which again is very easy to administer because its self rated.

Dr. Carolyn Rodriguez (29:56):

But the key is asking the question. So if you have a tool, you have something just sitting at your desk or something that you have a PDF on that you can flash if you're doing a virtual session, "Tell me what your home looks like." That's really important not only for the individual or the community, and also we haven't touched on this yet, is that individuals can have children that live in the home and they're very impacted by this.

Dr. Carolyn Rodriguez (30:22):

And it is a situation that you want to make sure that you recognize that there's children being impacted and also get them the help and support. Sometimes we see people who really have deep scars and are impacted their whole lives. And so we want to make sure that this isn't something that falls by the wayside. You're treating somebody for one state of diagnosis, but actually people with hoarding disorder have very high, 50% comorbidity with major depression.

Dr. Carolyn Rodriguez (30:54): 

And so those clinicians were treating people with depression, especially if they have a lot of falls reported, maybe they're falling or tripping on their things. It's really important for clinicians to really think about what the home looks like, what's the environment, who's living in there? But in a more intentional way with these instruments.

Dr. Randy Frost (31:12): 

There are some clues that people can look for. And one of the things we know is that people with hoarding disorder frequently have problems with organizing time as well as possessions. And so someone who's coming in for the treatment of depression, or anxiety, or some such thing will often be late. There tends to be, and this we know, we know that there's some information processing issues involved in hoarding.

Dr. Randy Frost (31:42):

So one of the things that we frequently see in cases of hoarding behavior is an over-inclusive communicating style. So they tend to tell long stories, and sometimes those stories are convoluted and it's difficult to get to the point. I can tell when people call and leave a message on my answering machine whether they have a problem because they'll go through a whole story and they'll run at a time and have to call back before they get to their real question or their real concern on the phone.

Dr. Randy Frost (32:18):

So that kind of behavior is one where you think, "Well, maybe we should ask a little bit about it." And the scales we include in the book, The Clutter Image Rating, and some of the other scales are good ways, really quick ways, of determining whether there's a problem there.

Dr. Randy Frost (32:35):

You can start out by a simple question, are there things that you can't do because you've got a lot of clutter or disorganization at home? And that can lead you then into doing a little more substantial assessment. And the first step in that assessment as we outline in the book, is a risk assessment. What is the risk for this person and how serious is that risk? And is there a risk for another person, as Carolyn said, kids in the home, or elderly folks in the home?

Dr. Randy Frost (33:08):

And so then once that assessment is made, then the next step is to really understand more about the nature of the symptoms and whether there is some kind of immediate action it has to take to protect someone's health or safety.

Dr. Carolyn Rodriguez (33:22):

Randy, what you were saying made me think about some of the differences between in-person evaluations and online, which is that when I was conducting studies in person with hoarding disorder, some individuals would come with the grocery carts that have things or have very large purses with a lot of items or multiple bags. So I always found that really fascinating.

Dr. Carolyn Rodriguez (33:52):

There seemed to me, just as a clinical curl, my own sense that if people were carrying a lot of things with them, that was also a sign that it was even difficult for them to just leave something at home, they needed to have immediate access to it.

Dr. Carolyn Rodriguez (34:08):

And the other question as a clinical pearl that I always ask is, can you sleep in your bed? So individuals with hoarding disorder that again, can't part with their possessions will pile so many things on their bed that they'll have to sleep on the sofa or on the floor. So that's a very quick question that you can ask.

Dr. Randy Frost (34:24):

It is interesting you say that, Carolyn, one of the questions we asked people in this very first study we did was how much stuff they carried with them and we compared it to people who didn't have a hoarding problem and really the need to carry just in case items was significant for people with hoarding disorder compared to people who didn't have it.

Dr. Laura Roberts (34:51):

I'm beginning to self-diagnose, but that's all I want to say about that.

Dr. Carolyn Rodriguez (34:56):

Well, Laura, actually that's a great point, which is all of us, all of us have difficulty parting with possessions and all of us have the same strong connection to possessions and items. And just to give a shout-out to Randy's lovely book, Stuff, as well, that really captures this draw. So it's something that is really on a continuum and that individuals with hoarding disorder don't need to feel alone. It's like basically those innate drives that are survival based, that are pre-programmed in us, but taken to an extreme and there are treatments. So there's a lot of hope out there.

Dr. Randy Frost (35:32):

And the kinds of emotional experiences people have when they let go of things really are the same as what we see in people with hoarding disorders, just that in hoarding disorder, they're more intense and more persistent over time.

Dr. Laura Roberts (35:48):

I think that's so wonderful for both of your stories is that what happened was you paid attention to people around you. You were getting calls, Carolyn. Randy, you were getting calls or you had this experience with your student and you just saw it with your own eyes and knew it needed attention. And if you look at our society, we've got television shows.

Dr. Laura Roberts (36:07):

I recently saw a rerun of a firefighter show that went to try to save somebody in an apartment where the person had hoarding and there was a catastrophic outcome and it was the stuff of drama. So there's TV shows, there's stories, it's something that's in the continuum of our own personal experience. In a funny way, it's kind of everywhere. This one person wrote this book about finding joy and getting rid of objects. There's a whole industry.

Dr. Laura Roberts (36:38):

Another family member has been dedicated to some show where she has five rules for decluttering her home and it's like a big topic. It's everywhere. And yet it took a long time for the scientific clinical community to kind of get its act together to recognize it. So I see a little twinkle in your eye there, Randy. So what thought do you have as I'm carrying on over here?

Dr. Randy Frost (37:03): 

Well, it is amazing how this has spread out into the popular culture in focusing on stuff, and maybe it's a reflection of our times. Maybe it's a reflection of the affluence in, at least, many countries in the world. Although the cross-cultural data suggests that this is pretty common around the world, regardless of the level affluence of the society or the culture. There may be some minor differences in the kinds of attachments people form or beliefs people have about the importance of possessions. But it seems like this is something that is a common across virtually all cultures.

Dr. Laura Roberts (37:46):

Well, I think we've answered the question of why the world needed the book. I think we got that covered. I think we answered the question of why you two are the amazing colleagues who put this book together and are just the right people to put this work together. And we've come up with some clinical guidance and have illustrated beautifully, thank you both so much for just demonstrating how you would engage with people around this and think about it, maybe even implement even in a short interaction.

Dr. Laura Roberts (38:15):

I appreciate Randy, you're saying it takes a long time to make, I don't know, maybe deep change in a particular individual. But it doesn't take a long time as you've also illustrated to even just get a sense of whether this is a significant issue in somebody's life, all of that. I think we got that. What did I forget? Is there anything else that you really want to say to the field at this time about this disorder?

Dr. Randy Frost (38:41):

Gosh, there's so much to potentially talk about. I think one of the things that is important is trying to understand the nature of the attachments that people have, because that's really the core. Someone really has to experience what it is that makes this thing a part of their soul really, and why getting rid of it is so hard.

Dr. Randy Frost (39:11):

And in the book, we spend some time talking about the nature of these attachments, and they range from issues related to a sense of possessions being opportunities for something great, a new identity, a lot of identity kinds of things. So people save things because they believe that those things will allow them to do something they can't do now or to become a person they aren't now.

Dr. Randy Frost (39:40):

On the other hand, people save things because they are idealizing their past and they want to sort of focus on the past. And there's some fascinating questions along the lines here, and one of them has to do with memory. What's the nature of memory associated with possessions? A lot of people that we talk to, it seems as though a possession from their past is the repository for memories. And if they throw it away, the fear is, "I'm losing a piece of myself." So the sense of identity is really important.

Dr. Randy Frost (40:20):

Another example of a nature of attachment is a sense of responsibility. We're not wasting things. In fact, some research suggests that that might be the most important attachment, the strongest attachment that, "If I throw this away, it will be wasted." And that sense of waste makes people feel guilty. So a sense of loss, a sense of guilt.

Dr. Randy Frost (40:45):

We also see anger associated with this at having to get rid of things. And a lot of times a client will get angry with the therapist, even though the therapist is not telling them to throw something away, but they're beading them to evaluate and throw something away. And that can generate some significant negative emotions.

Dr. Carolyn Rodriguez (41:04):

And I wanted to add, thank you, Randy, that was beautifully put. For a lot of the calls that we get are family and friends. "Where do I go? What do I do?" First is really to get information, and that's why we wrote the book to help people get that up-to-date information, understand where we are in the field. And then next would be to get help for yourself. This is a disorder that touches lots of people and can very easily overwhelm one provider.

Dr. Carolyn Rodriguez (41:37):

So to really use a network, to use support groups, to get your own therapy, the own things that you need to do to get your own health and support and feel strong to be able to take a step back or to approach. So those are important.

Dr. Carolyn Rodriguez (41:56):

The other thing I would say is that there's wonderful organizations. American Psychiatric Association has a webpage that's dedicated for resources and Randy and I have a Q&A on there, and also the International OCD Foundation has a dedicated boarding website and resource page. And there's a really strong community, a lot of research going on. Really thanks to the work of Randy. And reach out if any of this interests you, you want to do research in this area, we need you. So come on in, the water's fine.

Dr. Laura Roberts (42:34):

That's great. Yeah, I think you beautifully illustrated biological questions, cognitive science questions, questions of personal meaning and existential meaning, grief, all kinds of things that are just rich with opportunity for investigation.

Dr. Laura Roberts (42:51):

Randy, I don't know your book called, Stuff. Is that a resource for people living with hoarding disorder or who love people with hoarding disorder? Is it more of a professional book?

Dr. Randy Frost (43:03):

It is actually a book designed for the general public, including people with hoarding problems, family members, friends and so forth. And it really is a presentation of a whole series of folks that Gail and I, got to know over the course of writing the book. And there's stories and they're presented in a way that doesn't demonize them. It really is an attempt to show what it's like to experience this, not only for people with the disorder, but we cover the response to family members as well in the book.

Dr. Randy Frost (43:41):

So it's really about people's lives, the lives of people with hoarding disorder. We cover lots of different bases on it, and it seems to resonate pretty well with people with hoarding disorder and their family members. Many of them have called and said, "I didn't realize what this was all about, and I understand more now." And it sort of helps get some perspective on what it all means.

Dr. Laura Roberts (44:11):

Yeah, that's great. I just want to encourage our listeners to take a look at this wonderful book from APA Publishing on Hoarding Disorder, but also it sounds like it would be great for all of us, including myself, to get familiar with some of the public facing resources, especially as we're trying to make sense of this and connect people with the resources and information that they need.

Dr. Laura Roberts (44:34):

I'm so grateful to both of you for developing this book and for being part of this community. And especially for your kindness in thinking about this very hard condition and what people go through. I feel like I've learned a lot about some of the social and societal implications, Carolyn, thank you for that and appreciate that point very much.

Dr. Laura Roberts (44:55):

And I feel listening to you, Randy, it feels like there are things you can do to make things better, and you're a living example of that. So thank you for all of that and for sharing that with us today. Thank you so much for listening to, Unbound, today.

Speaker 4 (45:11):

Psychiatry Unbound is hosted by Dr. Laura Roberts, and produced by Ian Martin, and our executive producer is Tim Mahoney. This podcast is made possible by the generous support of Stanford University. We are a production of American Psychiatric Association Publishing. Be sure to visit psychiatryonline.org/podcast. To join the conversation access show notes and a transcript, and discover new content or subscribe to us on your favorite podcast platform. Thank you for listening.

Speaker 5 (45:37):

The views and opinions expressed in this podcast are those of the individual speakers only, and do not necessarily represent the views of the American Psychiatric Association. The content of this podcast is provided for general informational purposes only and does not offer medical or any other type of professional advice. If you are having a medical emergency, please contact your local emergency response number.