Speaking of Psychology: Digging out: Can we help people with hoarding disorder? With Mary E. Dozier, PhD

Hoarding disorder affects about 2% of the population and is more common among older adults. Psychologist Mary E. Dozier, PhD, talks about the causes of hoarding disorder, its links to other mental health disorders, why many people who hoard are highly altruistic, and how a values-based intervention can help them—and others who simply struggle with clutter.

Mary E. Dozier, PhD, is an assistant professor of psychology at Mississippi State University. She studies evidence-based methods of assessment and treatment for psychopathology across the lifespan. Her current research focus is on hoarding disorder in older adults.

Kim Mills: If you've ever had to clean out someone's home after they died, you probably discovered that people save strange and random things. I recently helped clear out my dad's home and found, for example, the sales contract for the house he bought in 1957, my late mother's violin dating to her years in high school, and all my and my brothers’ elementary school report cards. These are things that made sense from a sentimental viewpoint and they didn't take up a lot of space. But what about people who save huge quantities of things with no apparent value, that have no sentimental meaning, and in the eyes of most people will be trash? Can saving too much stuff be pathological? Where is the line between being a messy housekeeper and having a hoarding disorder? What drives some people to save enormous quantities of indiscriminate things? And is such behavior merely a manifestation of something like obsessive compulsive disorder or is it a discrete mental illness?

Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I'm Kim Mills. My guest today is Dr. Mary E. Dozier, a licensed clinical psychologist and an assistant professor at Mississippi State University. Her research focuses on evidence-based methods of assessment and treatment for psychopathology across the lifespan, including hoarding disorder in older adults. More recently, she's branched out to study hoarding disorder in younger people. Dr. Dozier has developed some protocols for helping people who have hoarding disorder, which we will talk about today. 

Dr. Dozier, thank you for joining me.

Mary E. Dozier, PhD: Thank you so much for having me.

Mills: Let's start with the definition. What exactly is hoarding disorder? Is it in the DSM and how is it different from just being messy or indifferent to clutter?

Dozier: That's a wonderful question. So it's actually a relatively new addition to the DSM. So our latest edition came out in 2013, and that's when hoarding disorder was added as a discrete disorder. So before that, it was considered part of obsessive compulsive disorder or just a symptom secondary to other disorders like schizophrenia or autism or even major depression. But after 2013, we've been able to talk about hoarding disorder as its own distinct category. So what really lets us know that people have problems with hoarding is kind of like you said in the intro where the clutter level gets to the point that people aren't able to use their homes the way they would like to anymore, that the clutter has become impairing. And so that's the physical manifestation. But our psychological manifestation comes from difficulty discarding ordinary things that other people might be able to get rid of as well as a need to hold onto things that other people wouldn't see the need to hold onto.

Mills: What drives people to hoard? And you mentioned other psychological problems that people might have. So how are they associated? How do they sort of work together in the brain?

Dozier: Yeah, we see a lot of the reward pathways being activated with hoarding. So I think all of us, or many of us have had the joy of going shopping and seeing something, a new sweater that you really like, and you have that sense of almost accomplishment of, I found something good. And if you think about folks with excessive acquisition problems, it's like that, but magnified. And so anything that comes into the home can really make them feel good as kind of a coping strategy. We also see that just normal things that other people might not see the need to hold onto folks with hoarding problems will. So for example, junk mail is something that all of us bring into our home, and so somebody without hoarding problems might sort through that on a pretty regular basis, like I'll confess for me sometimes every other day, but somebody with hoarding problems, those things come into the home and they don't leave, and that's where the clutter starts to build up to the point where it becomes unmanageable.

Mills: How prevalent is this problem?

Dozier: So it's more prevalent than most people think. So it's about 2% in the general population, but we actually see that it increases in prevalence over the lifespan. So for most psychological disorders, we see a decrease over the lifespan that generally we think of older adults as having better emotion regulation. But for hoarding, we actually see that folks in their 70s have about a 7% prevalence rate for hoarding. It's very likely that the folks listening today know someone in their life who's struggling with clutter, and it might not be something they used to struggle with, but as they've gotten older, it's become something that keeps them from using their home.

Mills: Do people with hoarding disorder tend to live alone or are they more likely to live with others, whether that's, say, a partner who tolerates the behavior or, say, children who are powerless to stop it?

Dozier: Yeah, that actually is something that depends a lot on where they live. We're finding, so I initially did my work out in San Diego in graduate school, and there most of our folks that we worked with were single and had never been married. And these were older adults that just the fact that they had hoarding problems kept people from being in their lives. But now I'm in rural Mississippi, and what we find here is that folks are able to have more space, and because of that, they're more likely to have a spouse or somebody else who's able to live with them. The idea is that the underlying psychopathology that difficulty discarding or problems with acquisition might be the same, but the clutter, if it's able to be spread out, can be less impairing on a daily basis. And so you're more likely to have loved ones that are able to be in your life.

Mills: So based on what you've just said, it does make sense that the stereotype of people who hoard are older and depending on where they live, they may be solitary, but they may not be. But you've also begun studying younger people with hoarding disorder, and I'm just wondering, is there a profile of a typical person with hoarding disorder, whether that's based on sex or socioeconomic status or other demographics? And are there certain personality traits that are associated with hoarding disorder?

Dozier: Yeah, so I'll answer that last part first of some of the research I've done here in Mississippi is actually found that pretty much universally the folks we've been working with have really high rates of altruism, which fits with what I see clinically that often folks with hoarding problems will say, I'm holding onto these things for a reason. I'm holding onto these things because I want to give it to somebody else. Or I would be able to get rid of my pencil collection if I knew they could go to children who need pencils, that it's holding onto things out of this sense of responsibility to the items or to other folks. And even things like I've had folks that seemingly have what looks like trash, but they say, no, this is something that could be recycled. I just need to figure out how to recycle it.

And then sometimes kind of secondary of something that we see is that organizational problems can be pretty endemic in folks with hoarding problems, which can lead to a barrier to discarding that they might have a very specific way that they want to get rid of something, but it's the follow through that can become difficult. And with that, we actually see a fairly high rate of comorbidity with ADHD. Sometimes folks with ADHD who don't necessarily have hoarding problems, it can almost look that way because of disorganization in their lives. And then the other kind of main comorbidity we'll often see is major depression. So about 30% of folks with major depressive disorder also have hoarding disorder and vice versa. And I think the link there comes with feelings of apathy and just in terms of motivation, inability to get oneself out of bed and to do things like take out the trash, sort through junk mail.

Mills: So going back to my question that had too many questions embedded, is there a profile based on sex socioeconomic status, or other demographics?

Dozier: So we tend to see it more frequently in women, which is true generally of psychological disorders. And so there's always that tricky part of is it actually more prevalent in women or is that because women are more likely to present for treatment? And we do tend to see it more in older folks. And then the sad part about it, and I think where a lot of the stigma comes from is that hoardings often associated with poverty, and that's especially something that we see in rural areas where they're able to just keep adding onto the home or put it another side. And I think that's where, again, a lot of the stigma comes from. And so I think the folks who struggled most with hoarding in terms of the consequences to their health are going to be people who are poor.

Mills: Tell us about the research you've done with younger people with hoarding disorder. I mean, how do you identify younger people when maybe they don't even have a house yet? So how do you know that they're headed down that path?

Dozier: So this is actually a relatively new avenue of research for me that came about with the graduate student who's particularly interested in emerging adults and how we can stop hoarding from becoming so consequential in late life. And so what we're looking at is if we can have an early intervention. So we've been having undergraduates here at Mississippi State self-identify having problems with either acquisition or clutter, and then enrolling them in a group setting where we both teach skills around organization and around how one can let go of things. So thinking about object attachment is kind of the place where we're intervening. So helping folks to see that there can be more distance between themselves and items. And also back to the idea that acquisition generally feels good for all of us of helping folks to come up with what are other coping strategies. So when you feel that sense of, I really want to make myself feel better by buying something, is there something else you can do in that meantime to let that feeling go?

Mills: How does hoarding affect the children and other family members of people who hoard and when they grow up, do these children tend to hoard as well, or do they become clean freaks?

Dozier: Yeah, so that's a great question. So hoarding is definitely something that we see there's a pretty strong genetic component to it in that folks who have parents that had hoarding problems are going to be more predisposed to having hoarding problems themselves. But we also see that there tends to be consequences in that folks might maybe have worse relationships with their parents. But on the other side, some of the research I've done with folks back in California shows that people tend to still have really good relationships with their loved ones with hoarding problems, and often, even if it feels like a burden can still be something that they find a lot of reward out of.

Mills: I want to talk a little bit about treatment. You do hands-on sessions with people in their homes and trying to get them to moderate their behavior. What do you do and how does it progress? How do you reach a point of success?

Dozier: I've gotten funding now from the American Psychological Foundation as well as the National Institute of Mental Health. And what we're looking at is an intervention where, like you said, we go to their home once a week, and the idea is that we're being a neutral positive presence. So unfortunately, so often loved ones can be a little less than lovely when trying to help people discard, that often we go in and talk to our parents and might have our own ideas of what they should keep and discard. And so having someone who's kind of a blank slate who doesn't have their own thoughts about items or finding can actually be really helpful to motivate the person.

So our function is twofold. One is to give the person almost permission to take that space, take that hour to sort and discard things free of judgment. And then secondarily, we use something called motivational interviewing to help them talk through whether or not they want to keep and discard things based on their own values. Again, back to it's all what they personally think is important to keep. What we found is that this tends to be a pretty effective intervention for folks that they're able to both engage in the sorting session and that it increases their ability to sort in between sessions.

Mills: With a lot of mental disorders. Sometimes it's a combination of a sort of therapy, which is sort of what you're describing and some kind of a drug. Does that work with people who have hoarding disorder, is their combination therapy for people who hoard?

Dozier: Research on the treatment of hoarding is still a little bit new in terms of hoarding disorder specifically. And there've been some people who have done drug trials, but I don't think there's been a lot yet of research looking at medication combined with therapy to see what would be most effective. I think there have been some folks who have actually looked at, so back to the connection with ADHD looking at some ADHD medication, if that could be helpful, as well as SSRIs, which are used for other obsessive compulsive disorders.

Mills: If I had the disorder and you were to come into my home, how would we start the process? What does it look like for you to help me to deaccession?

Dozier: Yes. So we start with just asking you where you want to start, and part of my goal for somebody is to have them start in a place where they feel like they can make progress. That I don't want the first session to be just thinking about one cup, that if we spend all session thinking about that, you're not going to feel like you accomplish something at the end of the session. So we try to start in a place where the person says, I can sort through these things and come up with things to discard. So at the end of that session, they can say, I was able to get so much things out of the home, but it's all about building up that sense of self-efficacy and that sense of accomplishment. And with that, we actually, if folks are spending too much time on one item, we encourage them to set it aside. So it's a little bit, what I do is the opposite of exposure therapy. We're not making them sit with the distress. Instead we're on the sense of self-efficacy, again, of how many things can they sort in that time.

Mills: And how long does this treatment typically take?

Dozier: So the intervention we're looking at right now is 16 sessions, so once a week for about 4 months, but we've also piloted a six-session version that we didn't get as many gains as you get in 16 weeks, but we were able to just in that amount of time, actually significantly move people in terms of positive affect. So increasing just their general feelings of wellbeing as well as decreasing their sense of attachment to items, which are two things that we hypothesize that if we're able to move those, it'll keep people going in that direction that so often folks as they get older get this sense of feeling overwhelmed by their items. And we found that if we can get people to a place where they feel like they can start on their own, that it's something that it's not unmanageable, that they're able to keep maintaining that behavior of sorting and discarding.

Mills: And how effective is this over the long term? I mean, do you have the opportunity to go back in 6 months and see whether the person is in the same place or is reverting or has progressed?

Dozier: Yeah, that is a wonderful question, and I wish I could tell you the answer. So for the intervention I'm looking at specifically, we haven't yet been able to do follow up, but for other interventions for hoarding, we do know that they can be pretty steady about 6 months later. Even in terms of those longer, I guess I'll put a call out if anyone listening is in charge of funding priorities, long-term funding would be a wonderful thing to have because that is the question of are we able to help people not just in the immediate term, but for the rest of their lives. And what we do know on the other side of it is that often how hoarding gets treated in the absence of actual evidence-based treatment is through clean outs, right? So if somebody's gotten to the point that the city or the state deems that their home is unlivable, they're going to come in and take everything away. And what research shows is it basically is the same level of trauma as losing your home in a tornado—that it's a very acute, deep, traumatic experience for folks, and they tend to clutter the home environment within about a few months anyway, so it's not a long-term intervention.

Mills: Which speaks to the idea for some of our listeners where if you have a family member who has you think a hoarding disorder, the worst thing you could do then is to walk into the house and say, I'm throwing all this away, Mom. That's it. I'm done with this.

Dozier: Yes, there's even some folks out in California looking specifically at compassion-focused therapy. So I think the more, if you're out there looking to help someone in your life, trying to be that blank slate, trying to come in and really help them think about what they want is so important that I think there's something very valuable to having somebody tell you it's okay, right? It's okay to keep things, it's okay how it is. And that gives you the freedom to say, maybe then it is okay to get rid of this. But as people, we tend to be very reactive when folks tell us what to do. I know I certainly am. And so I think taking this, so the motivational interviewing approach is all about guiding somebody but not directing them and letting them set the priorities.

Mills: I want to talk about the stigma that surrounds hoarding disorder. What do you think of the media portrayals in, say, the show Hoarders or some of the coverage that we might see sometimes on the news when it reaches a crisis proportion?

Dozier: Yeah, I think there's kind of two sides to that. On the one side, I think it's helped make people more aware that hoarding exists, right? It's often something that can be very hidden. But on the other side, I think it's been very othering that—I think of it if we only talked about depression as suicide, which is a very extreme thing that can happen when folks are very, very depressed. And whereas hoarding similarly as depression exists across a continuum. So there are folks who look like the people in the shows, those are very real people, but there's also folks who you might initially walk into their home and it might not seem like an issue because they've hidden parts of it, but it can still be very dysfunctional.

And I think the shows have made people who are on more of the moderate to mild side of hoarding less likely to come forward for treatment because they think, well, I'm not like those shows. Oftentimes when I am trying to recruit for my studies, I try to not use the word hoarding because there's so much stigma around it that I try to just talk about high levels of clutter, dysfunction from the clutter.

And I think the other side to the shows that isn't talked about a lot is they're actually very exploitive of those people, that those are people that are having some severe mental health problems and are probably at kind of the end of the line of trying to find some way to have an intervention. And so I guess my final thought on the show is I wish that they hadn't happened because I don't think it's either a good portrayal of hoarding, nor is it ultimately helpful for those people.

Mills: Do most people with hoarding disorder even recognize it as a problem?

Dozier: So it's something we talk a lot about in terms of the level of insight. So actually in the DSM one of the specifiers is whether the insight's good or fair or entirely absent. And what I've seen with the folks I've worked with is that they're often able to acknowledge that the clutter is impairing, that they say that even just something as simple as, because of the clutter in my home, my daughter won't let the grandkids come visit, that they recognize that there's very real biopsychosocial consequences to the clutter, but there's often a disconnect between the clutter and the behaviors that lead to the clutter. In the sense of, I want to hold onto these things. And not realizing that if you hold onto every paper, every water bottle, that you're going to have that clutter. And so a lot of what we try to work with is helping people to think about how many water bottles do you need, and to come up with that sort of a priority. So before we even start to get all the water bottles together to say, how many for you do you need in your life? And then folks might say, I need four, I need 10, I need 20. And then they get them all together and they go, Oh, I have way more than that. I suppose maybe I will be able to let this go.

Mills: That's an important point because I think for our listeners, if you, for example, know someone who you think has hoarding disorder or maybe is on the verge, how can you help them just for a lay person? What do you do? How do you approach it with them in order to get them to maybe stop?

Dozier: I think one of the things I always say, if you're trying to intervene with somebody about any behavior is—choose your time. You don't want to talk about it at a time that maybe you're already fighting about. It is not the time to do it. You want to approach somebody when both of you are feeling calm, that it's maybe not late at night, but maybe early in the day, and talk about it less from you're doing something wrong and more of a, I'm concerned about you because, and offering to help. And I think one of the ways loved ones can help is to be that compassionate presence of offering to say, Hey, what if I come by once a week, once a month, and we sort through one box in the attic.

I really try to encourage folks to not say that this isn't going to be a weekend solution. You did not fill up a home in a weekend. You filled it up in a lifetime, and so you're going to want to declutter it bit by bit. Something that I see so often is folks say, okay, I'm going to go to my parents' home this weekend. We're going to go through every box in that attic, and their parents might agree to it, and they get up there, they see how much it's going to be, and it's entirely overwhelming. So they just shut down and they say, I can't do this. It turns into a fight and nobody talks about it again for a year. So I'll just say bite-size pieces coming from a place of compassion, I think are the key parts to this.

Mills: Now, I think for a lot of us, when we think of hoarding disorder, we think of piles of stuff, but some people collect animals. Isn't that another manifestation of the same disorder?

Dozier: Absolutely. And animal hoarding is trickier to study than object hoarding, in part because it can be a criminal activity that if you are found abusing animals, which can tend to happen if you have too many animals to care for, which is the definition of animal hoarding, and you're going to be really reticent to talk to somebody about that because you're going to be afraid they're going to take away your animals. But what we have found is the other side of animal hoarding is people have large amounts of animals for various reasons. So there are some bad actors out there who are doing what we call indiscriminate breeding of animals to sell them of kind of the puppy mills. But on the other hand, they're, what we tend to see, and what we would call animal hoarding, tend to be folks who, again, are doing it from a place of altruism.

In their mind, they're rescuing these animals. And I think many of them start out as a true rescue. But again, as they get older, maybe you're less able to take care of these animals, or folks tend to know of, Oh, Sally down the way, is somebody you can bring stray cats to. And so Sally might be able to take care of eight cats, but suddenly people keep bringing her cats and she doesn't want to say no, and she ends up with 20. And so I think, again, it can be a bit of a slippery slope where folks don't know how to get out of it.

Mills: Have you done any work using your technique for people who have an animal hoarding issue?

Dozier: So I haven’t myself, but actually how I got into motivational interviewing was because there's a woman in Great Britain in the U.K. who was using motivational interviewing to help with equine boarding. So across the pond, there's apparently a big issue with folks having too many horses. And I figured—

Mills: Who knew?

Dozier: Who knew, right? Talk about cultural differences. But I figured if it was good enough to help folks discard horses, it would surely be helpful for objects, and it has been.

Mills: So how did you get interested in this topic as an area of study and research?

Dozier: It was entirely by coincidence. This is where I should have some wonderful story about how it happened. But the truth is, going to grad school, I knew I wanted to study anxiety and older adults, and I ended up getting into a lab at the San Diego working with Catherine Ayers, who's a clinical psychologist out there who does anxiety and hoarding. And I just fell in love with the topic. And in part of one of the things that she found early on in her research is that by just intervening on hoarding, by just helping people have less clutter, everything else in their life seemed to get better too. So folks’ levels of anxiety and depression went down even though we did nothing that was meant to intervene on anxiety and depression. And to me, that just felt so powerful that we could have something that's an entirely behavioral intervention that seems to just raise up people's quality of life.

Mills: So what are you studying now? What are the big unanswered questions in this area?

Dozier: Yes. So I am continuing to look at the intervention of motivational interviewing, but I'm actually this summer going to start up a telehealth pilot version of it to see, okay, we know that it's working pretty well in going into folks' homes, but can we get that same impact through telehealth and the person's in their home, but the clinician isn't? And to see how powerful is part of it, having the person just there to talk to, or is there something about having the person in your home? So I'm excited to see where that goes.

Mills: Well, this has been very interesting, Dr. Dozier. I really want to thank you for joining me today.

Dozier: Thank you so much for having me.

Mills: You can find previous episodes of Speaking of Psychology on our website at speakingofpsychology.org or on Apple, Spotify, YouTube, or wherever you get your podcasts. And if you like what you've heard, please follow us and leave a review. If you have comments or ideas for future podcasts, you can email us at speakingofpsychology@apa.org. Speaking of Psychology is produced by Lea Winerman.

Thank you for listening. For the American Psychological Association, I'm Kim Mills.