Introduction
Rather than there being a unitary syndrome of obsessive-compulsive disorder (OCD), there is increasing evidence that OCD is clinically heterogeneous, with such heterogeneity being stable over time (Mataix-Cols et al., Reference Mataix-Cols, Rauch, Baer, Eisen, Shera and Goodman2002). Four OCD dimensions have been identified: contaminations/washing, obsessions/checking, symmetry/ordering and hoarding, each with differentiating phenomenology, co-morbidity and aspects of genetic transmission (Mataix-Cols, Rosario-Campos and Leckman, Reference Mataix-Cols, Rosario-Campos and Leckman2005). This heterogeneity is not reflected in current diagnostic systems (e.g. DSM-IV, APA, 1994), although calls have been made for this to take place; particularly for compulsive hoarding (Saxena, Reference Saxena2007). Currently, hoarding is identified as one of the “symptoms” of obsessive-compulsive personality disorder (OCPD; DSM-IV, APA, 1994), yet good evidence for such specificity is actually poor (Winsberg, Cassic and Koran, Reference Winsberg, Cassic and Koran1999; Samuels et al., 2002).
Although hoarding has been relatively neglected in terms of clinical and research evidence, in recent years a nascent body of knowledge has begun to emerge across a divergent range of research methods, including brain imaging (Saxena et al., Reference Saxena, Brody, Maidment, Smith, Zohrabi, Katz, Baker and Baxter2004; Anderson, Damasio and Damascio, Reference Anderson, Damasio and Damascio2005), genetics (Samuels et al., Reference Samuels, Shugart, Grados, Willour, Bienvenu, Greenberg, Knowles, McCracken, Rauch, Murphy, Wang, Pinto, Fyer, Piacentini, Pauls, Cullen, Rasmussen, Hoehn-Saric, Valle, Liang, Riddle and Nestadt2007; Mathews et al., Reference Mathews, Nievergelt, Azzam, Garrido, Chavira, Wessel, Bagnarello, Reus and Schork2007), neuropsychology (Lawrence et al., Reference Lawrence, Wooderson, Mataix-Cols, David, Speckens and Phillips2006) and cognitive psychology (Kyrios, Steketee, Frost and Oh, Reference Kyrios, Steketee, Frost, Oh, Frost and Steketee2002). An area of slower progress has been the exploration of the possible aetiological roles played by developmental, attachment and trauma factors in compulsive hoarding. In an early study, Shafron and Tallis (Reference Shafron and Tallis1996) reported a consistent theme of attachment disturbance in a collection of hoarding case studies. Hartl, Duffany, Allen, Steketee and Frost (Reference Hartl, Duffany, Allen, Steketee and Frost2005) compared people who hoard and controls in terms of their trauma histories; people who hoard reported a significantly greater number of differing types of traumas and more frequent traumatic experiences. Cromer, Schmidt and Murphy (Reference Cromer, Schmidt and Murphy2007) noted that people who hoard tended to report the presence of more traumatic events than an OCD comparison group and that history of trauma for people who hoard was particularly related to clutter in the home.
In terms of the factors that motivate compulsive hoarding, three factors have been implicated: the perception of possessions containing instrumental, intrinsic, or sentimental resources (Furby, Reference Furby and Yates1978). The rate, range and mixture of instrumental, intrinsic and sentimental hoarding has yet to be established and associated targeted treatment strategies developed and evaluated. Instrumentally hoarded objects are believed to promise some future practical potential (Frost and Hartl, Reference Frost and Hartl1996), intrinsically hoarded objects are believed to possess a value, meaning or signifying perfection (Steketee, Frost and Kyrios, Reference Steketee, Frost and Kyrios2003), whilst sentimentally hoarded objects are perceived as containing key memories and affects (Kellett and Knight, Reference Kellett and Knight2003; Kellett, Reference Kellett2006). People who hoard therefore experience the chronic anxiety of making the perceived catastrophic mistake of discarding what are related to as useful, unique or emotionally resonant possessions (Warren and Ostrom, Reference Warren and Ostrom1988). Pervasive indecisiveness concerning the potential risks of making a mistake concerning discard, contributes to behavioural avoidance of discard (Frost and Shows, Reference Frost and Shows1993). Such vacillation is readily observable and evident when people who hoard “churn” possessions from pile to pile, rather than making the distinct decision to actually discard an object (Saxena and Maidment, Reference Saxena and Maidment2004). The dominant cognitive behavioural model of hoarding therefore posited the interaction of four main factors creating and maintaining compulsive hoarding: (1) information processing deficits; (2) emotional attachment to objects; (3) behavioural avoidance; and (4) erroneous beliefs concerning possessions (Frost and Hartl, Reference Frost and Hartl1996; Steketee and Frost, Reference Steketee and Frost2003).
Despite hoarding symptoms typically predicting poor response to both pharmacotherapy and behavioural therapy (Saxena et al., Reference Saxena, Maidment, Vapnik, Golden, Rishwain and Rosen2002; Rufer, Fricke, Moritz, Kloss and Hand, Reference Rufer, Fricke, Moritz, Kloss and Hand2006), advances in the targeted and specific psychological treatments of compulsive hoarding are taking place (Tolin, Frost and Steketee, Reference Tolin, Frost and Steketee2007; Kellett, Reference Kellett2006). Within the context of poor responsivity to intervention, the chronic negative impact of compulsive hoarding on both carers and partners is also an increasing area of interest (Wilbram, Kellett and Beail, Reference Wilbram, Kellett and Beail2008; Tolin, Frost, Steketee and Fitch, Reference Tolin, Frost, Steketee and Fitch2008). Notwithstanding the obvious progress made in recent years concerning compulsive hoarding (which has largely been made within a quantitative methodological tradition), the manner in which people who hoard make sense of their own hoarding behaviours, the home environment and their hoarded possessions, still requires clarification, articulation and enunciation. Therefore the current research employed a qualitative research methodology to attempt to investigate such phenomenological questions and concerns, in the effort to give greater clarity and lucidity regarding the “lived experience” of hoarding.
Methodology
Participants, recruitment and setting
A purposive sample of 11 participants (3 males and 8 females) participated in the study. The sample size was directed by guidelines for best practice in qualitative research (Turpin et al., Reference Turpin, Barley, Beail, Scaife, Slade and Smith1997), with the sample being adequate for the research purposes. The sample ranged in age from 26 to 63 years (mean age = 38.41, SD = 12.5 years), with 7 of the 11 participants living alone. All participants reported hoarding behaviours being present across their adult lives. Participants were recruited and self selected through OCD Action, a UK charity providing information, advice and support to people who have OCD. Only one of the participants was in contact with psychiatric services at the time of the research and was awaiting psychodynamic psychotherapy. The study advert stated that interviews would be conducted in mutually agreed places; 9 out of the 11 participants subsequently agreed to be interviewed in their own homes, which provided serendipitous evidence of the chronicity and severity of hoarding behaviours.
Two participants declined to be interviewed in their own homes, due to levels of associated embarrassment and shame concerning the appearance of their property. Following the research interview, one of those participants did allow a researcher (SK) to visit their home, something she had not allowed any person to do for many years. All participants were self-identified as compulsive hoarders; no quantitative screening measures of hoarding or structured clinical interviews were employed. The 10 homes visited were, without exception, cluttered to the degree that inhibited or prevented the original use of the property. Rooms tended to appear identical in participant homes, due to clutter being discarded in unmanaged piles, with all surface spaces over-utilized for storage purposes and often only narrow channels of space available for navigation purposes. Clutter reached head height and above in rooms in some of the houses; with some rooms not able to be entered, due to the extent of extant clutter blocking the entrances. Participants noted that such rooms had often not been entered for many years, due to such access problems.
Design
This was an investigation of lived experience of hoarding; designed to add meaning (Stiles, Reference Stiles, Llewelyn and Kennedy2003) to current understandings of compulsive hoarding, through gaining understanding regarding participants’ personal worlds (Smith and Osborn, Reference Smith, Osborn and Smith2003). Interpretative Phenomenological Analysis (IPA, Smith, Reference Smith1996) was chosen as the most appropriate research method for this study, as IPA is particularly concerned with the exploration of unique individual experiences, rather than seeking to make general or universal statements (Smith, Reference Smith2004). IPA allows the researcher to interpret data (using their own conceptions), to make sense of participants’ personal, emotional and psychological worlds (Smith, Reference Smith and Hayes1997; Smith, Jarmon and Osborne, Reference Smith, Jarman, Osborn, Murray and Chamberlain1999). This stance is based on the impossibility of gaining direct access to any individual's psychological world and recognizes that such an engagement and exploration must necessarily implicate interpretative analysis on the part of the researcher (Smith, Reference Smith1996). The general stance and background of the research team for the project is cognitive-behavioural, and interpretations of the data were made from this standpoint.
Data collection
The interview schedule was designed to facilitate a free exchange in discussion, guided by the narrative of the participant. Interviews were audio-taped; all interviews lasted between 1 and 1.5 hours, with tapes transcribed verbatim. Question areas served as prompts and covered the following: objects that participants found difficult to discard; when hoarding behaviours began, and whether there were any triggers; where possessions were hoarded; personal theories on why they hoarded; awareness of others who hoard; identity/self image issues and childhood history. The interview schedule was derived from the research literature, with the aim of accessing the ‘everyday experience’ of compulsive hoarding. As far as possible, the interviews followed the interests, concerns and experiences of the participants and encouraged participants to describe in depth and detail the process of compulsive hoarding and their thoughts and feelings concerning their hoarding behaviours.
Analysis
The Smith and Osborne (Reference Smith, Osborn and Smith2003) methodology for conducting research using an IPA framework channelled the process of analysis. Each transcript was read through repeatedly and notes were made of utterances of particular significance. These initial notes included preliminary summaries and interpretations of the material. The transcripts were then re-read and an initial list of preliminary themes identified, which were subsequently translated into emergent themes. Following further analysis, clusters of themes were listed, from which a number of superordinate themes were identified; at all times themes were checked against transcripts to ensure sustained foundation in the narrative. Themes emerged both within individual interviews and across interviews and repetition of the emergent themes (across individual transcripts) were taken as indicative of their status as recurrent themes, reflecting the “shared understandings” of the hoarding participants (Flowers, Duncan and Knussen, Reference Flowers, Duncan and Knussen2003). The emergence of a theme in the majority of transcripts was considered as appropriate for inclusion in the list of superordinate themes (Smith et al., Reference Smith, Jarman, Osborn, Murray and Chamberlain1999). Any themes either unsupported by rich evidence or having low cross-participant frequency were subsequently abandoned.
Validation methods
As IPA particularly relies on the researcher's interpretation of qualitative data, it is vital to ensure that any interpretations are as trustworthy as possible. The study was therefore conducted using the established validation standards for the conduct of good qualitative research (e.g. Stiles, Reference Stiles, Llewelyn and Kennedy2003; Turpin et al., Reference Turpin, Barley, Beail, Scaife, Slade and Smith1997). Such validation methods included: regular meetings between the researchers (ensuring transparency in procedures); moving collectively from data collection to final interpretations; group supervision to provide an ongoing critique of the work and to confirm adequate inter-rater reliability of emergent themes; triangulation of evidence (raw data, supervision and observation); and the identification of negative cases and outliers.
Results
Participants described the range and types of items hoarded, including: (a) information – magazines, books, newspapers, correspondence, electronic information, bills and bank statements; (b) household rubbish – vegetable peelings, cans, cartons and carrier bags; (c) household objects – white goods, furniture, clocks, pictures and china; (d) collectables – antique pens and toys; and finally (e) clothes and garments. Two participants described hoarding bodily products – hair, faeces and blood. The final analysis of the interview data produced four superordinate themes; such themes varied according to the number of identified associated sub-themes. The four superordinate themes consisted of: (1) childhood factors – parental relationships, attachment and abuse; (2) relationship to the hoarded items – emotions, utility and the object as memory; (3) avoidance of discard – behavioural and cognitive aspects; and finally (4) impact upon self, others and the physical environment. Ten out of 11 participants provided example quotations of themes, ensuring adequate coverage of themes across participants. The results will be now described in detail.
Childhood factors
Participants described that hoarding behaviours typically emerged during childhood and adolescence (initially involving the retention of common items, such as school books and photographs), before expanding in scope and range over adult life. Perceived links between childhood experiences and current problems with hoarding were frequently cited:
Well as a kid I had a cupboard full of toys and that was where I retreated from the hostile world, all the . . . you know, all the irritation of parents not answering my questions and adults being stupid and pushing me down and repressing me. I think the hoarding probably comes from fear. (Participant 2)
Parents were described to have been generally strict, rejecting and authoritarian and that hoarders as children learnt to reciprocally suppress their own emotions:
Oh no, you didn't get angry, you never had conflict. It's something you avoided like the plague, because it wasn't allowed. It was too scary anyway. (Participant 9)
Because he loved my mother he agreed to have children, but underneath he didn't want them. And that was physically exemplified by the fact that he divided . . . . He built himself a big house. He divided it into two. Quite extraordinary. And he had the children on that side, literally with a swing door separating . . . and a long corridor going . . . . At the mid point in the corridor you had a swing door separating the children. (Participant 2)
A number of interviewees reported a range of childhood abusive experiences, including sexual abuse, physical abuse and having all their possessions destroyed; again with a marked suppression of emotion component:
I've got all this anger inside and hurt, but I could never express it. I couldn't tell anybody. I had been abused and I was never allowed to get angry because of the situation of my brother having schizophrenia and he always came first. His feelings were paramount and he sort of ruled the roost. (Participant 1)
Relationship to hoarded items
All participants had complex relationships with their possessions, with the nature of such relationships being able to be considered within one or more of the following three subordinate themes: (1) emotional attachment; (2) utility; and (3) object as memory. All participants described a strong and distinct emotional attachment to their hoarded possessions:
I know it sounds daft really, I've never known anybody keep birthday cards. I don't know when I'm going to chuck them, because they're so sentimental. Everything's sentimental really. My mother had died when she was 52, so it's like 16 years ago and she gave me jewellery and things I just cannot chuck out. (Participant 6)
Two particular sub-themes emerged from the data concerning the emotional relationship to possessions; anthropomorphizing objects and a sense of fusion between the hoarder and their possessions. The following quotation illustrates the cognitive processes involved in the stated anthropomorphism:
If I see one, one packet of food left on the shelf I've got to have it. Even though we don't need it or want it, because I think that that thing will be really lonely left on the shelf, so I hoard it. (Participant 8)
Retention of objects over many years also involved a sense of fusion between participants and their possessions:
The person that has all this stuff, it's theirs, it's a part of them, even ridiculous year old newspapers. (Participant 10)
A recurrent theme in the data was the belief that hoarded items had the potential to have some distal, but often unspecified, utility and therefore such objects needed to be retained:
If I buy a pot of yogurt and oh the tub looks nice, I think I can't possibly throw it away, as I think it'll come in useful. (Participant 6)
I've got all these skirts that I've bought and they're all perfectly good skirts and a lot of them fit me or nearly fit me and I think, well if I threw that away then in some years time I might really, I might need this. (Participant 5)
The final subordinate theme that emerged from the relationship to the hoarded items, involved objects being related to as “anchors” for particular memories:
Well when I see that chair I'm back in the kitchen. Back in Bobby's kitchen. It's just, just a very happy feeling. She made me feel good . . . so but when I see the chair it's, I can't bear to throw it away. (Participant 4)
Avoidance of discard
Participants described persistent and major difficulties with the discard of possessions and this clearly linked with the previous theme of individuals’ relationships to hoarded items. The data suggested two broad categories – behavioural avoidance and cognitive avoidance. Behavioural sub-categories were “churning” of possessions, a slow pace of discard and behavioural avoidance. Cognitive sub-categories consisted of perfectionism and fantasy.
Participants provided many examples of how attempts to reduce clutter consistently resulted in failure to actually discard. Churning was described as a common behavioural avoidant procedure, with an associated sense of futility that discard efforts rarely resulted in any sizeable reduction in the amount of clutter. The following example typifies participants’ descriptions of churning actively sabotaging attempts at discard and organization:
If I were tidying, I would put stuff from the room I was tidying into another room. (Participant 10)
A further difficulty described as contributing to behavioural avoidance was the slow pace of discard. The funereal rate of discard was captured by the following description:
Forty years lets say that may seem a long time to many people, but to me I don't think it's that long to clear everything, when you think about it. Considering the pace, I mean that's what I'm judging by. You know the pace at which I'm shifting things. (Participant 6)
In terms of cognitive avoidance, participants often inappropriately rationalized their inability to discard. Perfectionism regarding the decision-making process itself concerning discard was reported to contribute to participants avoiding making definitive decisions about tackling the clutter and/or prioritizing certain possessions:
Taking a long time over things and not having enough time to do things the way I wanted. That also links in with being a perfectionist. (Participant 7)
One participant, for example, explained that as they were unable to reach perfect order in their home, they had gone to the other extreme of living in complete chaos. Another interconnected theme regarding cognitive avoidance concerned the development of fantasies relating to a future unspecified time, when the person would be finally free of their compulsions and their clutter:
Inside of me, I want it like how I imagine it's going to be when the extension is finished, which was the other house all in order. But that's how I imagine it will be. So some time in the future it will all be ordered. I shall be ordered inside and I shall be ordered outside. (Participant 4)
Most participants described precise and detailed fantasies of their “perfect homes”, characteristically involving minimalist décor and furnishings:
If a genie could come out of a bottle and grant me a wish I would wish to live in an . . . . empty loft apartment. (Participant 10)
Impact
All participants reported a negative impact of compulsive hoarding on their lives. Three main themes emerged from the data: (1) negative impact on self, which was divided into shame, stigma, entrapment and identity issues; (2) negative impact on others; and finally (3) negative impact on the physical environment. Participants described an acute anticipated or experienced sense of shame, when others were required to visit their home:
We never let anybody in. I mean the house isn't dirty but it's really full and cluttered and I'm ashamed and embarrassed of my problem and my house. I don't let anybody in. I'm not comfortable with anybody coming. (Participant 8)
I hate it when I have to have tradesmen in and I think oh god they must look at this place and think “nutter woman”. (Participant 5)
A number of interviewees reported feeling stigmatised by society, by dint of the fact that others would not or could not understand their need to hoard:
I know it will shock people. It will horrify people. (Participant 1)
I think it's like you wanna gather more friends. With this sort of problem as well you're quite alienated. People don't have time or patience or don't want to know you when you've got this problem. (Participant 8)
Participants described feeling surrounded and engulfed by the clutter around them, with this sense of entrapment appearing to relate to both psychological and physical features. The following description typifies the psychological experience of entrapment due to the enormity of the backlog of possessions:
I survey, sometimes occasionally survey it and I survey it with the prospect of dealing with it, with tackling, with clearing it and it just does become, it becomes overwhelming. (Participant 11)
A sense of physical entrapment was described whereby participants felt incapable of relocating, due to difficulties with selling their home and/or the impossibility of the task of physically moving all their possessions:
It's not my ideal of how I want to live but I find I, I find you know I'm gridlocked really. (Participant 5)
A particular theme that emerged from the negative impact on self was the belief that chronic and prolonged hoarding had the ability to change a person's sense of self and identity. This also links to the sense of fusion reported in the relationship with hoarded items superordinate theme:
It turns you into a real sneak and it turns you into a liar and then you end up exaggerating and erm you know, it turns you into somebody that you don't like and don't want to become. (Participant 8)
Participants spoke repeatedly of the repercussions of compulsive hoarding on family, friends and neighbours. The impact on others was generally described in a guilty and negative manner and was typified by the following description:
I met my partner when I was 14 and we're still together sort of now. He's virtually driven out by the problems. (Participant 7)
Finally, in terms of impacts, participants cited the effect of hoarding on the home physical environment. Participants spoke of how the extent of the clutter was “overwhelming” and an encumbrance to being able to function effectively in the home and in their lives:
I can't live there. I can't live a life there. I can't have a bath, I can't use the toilet there and I can't brush my teeth there, I can't use the cooker, I can't use the kitchen at all. (Participant 1)
In the past I used to be able to find things quite easily amongst this terrible, terrible mess, but I can't anymore because it's got too bad. Got out of hand. (Participant 7)
You lose time searching for a corkscrew, when hey you've already got two, but you don't know where they are. You lose money from having to go out and buy another corkscrew or whatever duplicates. That's if you keep up with your opening your mail and you can pay charges on your credit card. (Participant 10)
Similarly, descriptions also concerned the upkeep of properties and associated difficulties with tradesmen gaining effective access to properties to carry out essential maintenance work, creating vicious circles of environmental decline:
Your house itself if it's full up with, I'll call it junk, you have some household emergency, a pipe bursts. Hey, you can't easily call in a plumber because you know they are going to have to climb over a load of stuff. (Participant 10)
Discussion
This project has set out to describe, in detail, the lived experience of people who compulsively hoard and has identified four key themes: childhood factors, complex relationships with hoarded items, avoidance of discard and various negative impacts (self, others and the physical environment). Such themes evidence the misery and distress of the everyday lives of people who compulsively hoard. Unlike OCD sufferers, people who compulsively hoard tend to view their problem in an ‘ego-syntonic’ manner (Black et al., Reference Black, Monahan, Gable, Blum, Clancy and Baker1998) and yet the extant evidence persistently indexes psychological and emotional distress associated with hoarding (Frost, Steketee, Williams and Warren, Reference Frost, Steketee, Williams and Warren2000). Ego-syntonic in an OCD context refers to the elements of obsessive cognitions and compulsive behaviours that are acceptable to the person (Marchesi, Ampollini, DePanfilis and Maggini, Reference Marchesi, Ampollini, DePanfilis and Maggini2008). However, as Kellett (Reference Kellett2007) pointed out, although the “micro” behavioural symptoms of hoarding may be ego-syntonic (i.e. the retention of a broken cup), this needs to be clearly differentiated from the “macro” ego-dystonic negative emotional consequence of living amongst chaotic and often highly unsanitary conditions (Steketee, Frost and Kim, Reference Steketee, Frost and Kim2001).
OCD dimensions of contamination, checking and ordering (Mataix-Cols et al., Reference Mataix-Cols, Rosario-Campos and Leckman2005) have fewer environmental consequences, whereas hoarding has palpable, gross and wide ranging environmental consequences, which are impossible to conceal – apart from disallowing access to the property and social withdrawal. The high levels of schizoid tendencies amongst people who hoard (Frost et al., Reference Frost, Steketee, Williams and Warren2000), may be the end result of such concealment efforts, creating general avoidance, and dislike of, social contact (Kellett, Reference Kellett2007). Pertusa et al. (Reference Pertusa, Fullana, Singh, Alonso, Menchón and Mataix-Cols2008) found that people who hoard without OCD reported hoarding as a result of the emotional and/or intrinsic value of possessions, whereas 28% of hoarders with OCD, reported other obsessional ideas related to their hoarding, including fear of catastrophic consequences and a need to perform checking rituals in relation to hoarding. Hoarders without OCD have also been reported to have lower levels of negative affect, depression, anxiety and stress, relative to hoarders with OCD (Grisham, Brown, Liverant and Campbell-Sills, Reference Grisham, Brown, Liverant and Campbell-Sills2005). Several studies have concluded that compulsive hoarding is a distinct clinical syndrome, rather than a particular sign, symptom, dimension or subtype of OCD (Abramowitz, Wheaton and Storch, Reference Abramowitz, Wheaton and Storch2008; Pertusa et al., Reference Pertusa, Fullana, Singh, Alonso, Menchón and Mataix-Cols2008).
The developmental, attachment and trauma histories of people who compulsively hoard is an emerging area of research interest (Cromer et al., Reference Cromer, Schmidt and Murphy2007). The evidence from the current research suggests that for some people who compulsively hoard, negative childhood events and trauma are capable of acting as triggering events, which impact upon vulnerable individuals to create the conditions for hoarding to develop (Grisham, Frost, Steketee, Kim and Hood, Reference Grisham, Frost, Steketee, Kim and Hood2000). Treatment studies need to differentiate the effectiveness of intervening with “characterological” (no identified trigger) and “traumagenic” hoarding (identified trigger). For the latter group, the suppression of feelings frequently reported during childhood, evident in the current data, indicates that active attempts to access emotions in hoarders during CBT, may be a useful therapeutic technique in itself (Kellett, Reference Kellett2006). As the current research points to the possible role of childhood attachment and trauma issues, future methodologies could explore this issue further, using the adult attachment interview (AAI; Main and Goldwyn, Reference Main and Goldwyn1994) and/or appropriate self-report measures of attachment disturbance (Fraley, Waller and Brennan, Reference Fraley, Waller and Brennan2000). Prospective longitudinal “at risk” hoarding studies are also required that follow children through their development in families in which OCD in relatives is present (Samuels et al., Reference Samuels, Shugart, Grados, Willour, Bienvenu, Greenberg, Knowles, McCracken, Rauch, Murphy, Wang, Pinto, Fyer, Piacentini, Pauls, Cullen, Rasmussen, Hoehn-Saric, Valle, Liang, Riddle and Nestadt2007), in order to isolate the psychosocial stressors likely to trigger compulsive hoarding in vulnerable individuals.
People who hoard consistently report composite and convoluted relationships with their possessions (Frost and Hartl, Reference Frost and Hartl1996), with the current research identifying three factors: emotional attachment, anticipated utility and objects functioning as memory prompts. The current findings mirrors previous research emphasizing the motivation to hoard containing the factors of sentimental and instrumental resources (Steketee and Frost, Reference Steketee and Frost2003) – with less evidence for the aspect of ‘intrinsic-value’ hoarding (Furby, Reference Furby and Yates1978) evident in this sample. People who hoard appear to find it difficult to define the boundary between ‘who they are’ and ‘what they own’; a problem that presumably is reinforced by the scale and the chronicity of the clutter. This sense of “fusion” between people who hoard and their possessions, appears to be an area for further research, as such a factor may partially explain the low rates of help seeking and/or poor treatment responsivity previously recorded (Rufer et al., Reference Rufer, Fricke, Moritz, Kloss and Hand2006). In terms of objects functioning as anchors for certain memories, people who hoard have been illustrated to have low confidence in the efficiency of their memory (Hartl et al., Reference Hartl, Frost, Allen, Deckersbach, Steketee, Duffany and Savage2004), with objects that represent memories being retained for fear of “losing” the memory attached to the object, should that object be discarded. The aetiology of instrumental and sentimental hoarding is worthy of further research, as differing forms of hoarding dictate differing approaches to treatment.
The current research adds weight to the CBT theory of compulsive hoarding (Frost and Hartl, Reference Frost and Hartl1996) that behavioural and cognitive avoidance of discard appears a crucial maintaining factor of continued environmental chaos. The current research noted churning and the slow pace of discard as particularly common behavioural avoidant procedures. Clinically, the targeting of highly visible areas in the home is indicated, as the habitual slow pace of discard spread over and across a site, is unlikely to produce any visible and encouraging evidence of change (Neziroglu, Bubrick and Yaryura-Tobias, Reference Neziroglu, Bubrick and Yaryura-Tobias2004). Cognitively, two sub-themes were indicated: fantasy and perfectionism. Although perfectionism has been previously linked to compulsive hoarding (Frost, Novaro and Rheume, Reference Frost, Novaro, Rheume, Frost and Steketee2002; Steketee and Frost, Reference Steketee and Frost2003), the role of fantasy has not. The role of the fantasies appeared to function as a means of maintaining denial (Bley, Reference Bley1984) in participants as to the extent and chronicity of the surrounding clutter. Often elaborate fantasies were reported involving clear and uncluttered spaces, which appeared in direct contrast (and a reaction to) the actual reality of the appearance of people's homes. The role of fantasy in OCD (Merckelbach and Wessel, Reference Merckelbach and Wessel2000) and compulsive hoarding requires more detailed research attention.
Compulsive hoarding appears to create varied impacts for the individual, their social networks/support systems and crucially on the physical environment. Entrapment in the current context appeared to contain both a physical and psychological component (Wilbram et al., Reference Wilbram, Kellett and Beail2008), with the psychological aspect a response to existing in a physical space that no longer functioned anywhere near as originally intended. This was captured and described as “gridlock”. Previously, entrapment has been particularly related to depression (Gilbert, Gilbert and Irons, Reference Gilbert, Gilbert and Irons2004), with high rates of depression recorded in compulsive hoarding samples (Grisham, Steketee and Frost, Reference Grisham, Steketee and Frost2007). It appears that, should a sense of entrapment exist over a lengthy period, then people who hoard can believe and experience that their identity can alter, presumably due to learned helplessness mechanisms (Maier, Reference Maier1976). Participants seemed to refer to themselves fundamentally and primarily as “hoarders”, rather than a person who experiences problems with hoarding. Such identity fusion with the presenting problem has been previously observed in disorders such as bulimia nervosa (Keski-Rahkonen and Tozzi, Reference Keski-Rahkonen and Tozzi2005), schizophrenia (Windell, Norman and Malla, Reference Windell, Norman and Malla2006) and substance misuse (Millar and Stermac, Reference Millar and Stermac2000). A future research need in the hoarding arena is the exploration of such identity issues, possibly using naturalistic longitudinal studies or treatment intervention studies, as “identity shift” appears to be an important aspect of enduring positive psychological change (Windell et al., Reference Windell, Norman and Malla2006).
Previous OCD research (Calvocoressi et al., Reference Calvocoressi, Lewis, Harris, Trufan, Goodman, McDougle and Price1995) has identified that carers and partners can “accommodate” compulsions into the structure of everyday life. Wilbram et al. (Reference Wilbram, Kellett and Beail2008) in a hoarding context, extended the accommodation concept to that of both physical/environmental accommodation (the housing of clutter) and psychological accommodation (complying with the person's hoarding behaviours). In the current project, participants appeared aware of the negative impact of their hoarding on others and that coexistence was dependent on accommodation – once again, both at a physical and psychological level. Participants appeared to describe a vicious circle, in terms of a static or declining physical environment, in which objects become amalgamated amongst clutter, requiring further objects to be purchased, and then unfortunately added to the extant clutter, due to ongoing avoidance of discard and organization. Levels of compulsive acquisition amongst compulsive hoarders have recently been evidenced (Mueller et al., Reference Mueller, Mueller, Albert, Mertens, Silbermann, Mitchell and de Zwaan2007). When repairs to properties are required, this appears a difficult process, due to levels of shame/embarrassment and the very real difficulties with effectively accessing properties.
As a qualitative investigation using a small self-selected sample, then there are a range and number of methodological concerns requiring to be highlighted. Although the participants appeared a homogeneous group in terms of compulsive hoarding, they were purposively sampled, which may have resulted in a sample of people particularly motivated to discuss the personal and emotional impact of hoarding. The data were generated on a sample in which female participants dominated; however, findings from previous research illustrates that people who hoard are more likely to be female (Frost et al., Reference Frost, Steketee, Williams and Warren2000; Grisham et al., Reference Grisham, Steketee and Frost2007; Pertusa et al., Reference Pertusa, Fullana, Singh, Alonso, Menchón and Mataix-Cols2008). Furthermore, the fact that the sample was recruited from a self-help organization may have limited the generalizability of the results as a whole. However, being a member of a self-help organization may have facilitated the research process, through participants being accustomed to describing their various plights, dilemmas and stresses in a rich manner, through repetition. Any sampling technique unfortunately unintentionally deters potential study participants with high levels of shame, due to the issues of concealment that have been previously emphasized in compulsive hoarding (Kellett, Reference Kellett2007).
A major methodological concern is the degree to which the participants met the established clinical and research definition of compulsive hoarding (Frost and Hartl, Reference Frost and Hartl1996). The study could have been arguably strengthened by screening participants using clinical interviews and established hoarding measures (such as the Saving Inventory-Revised; Frost, Steketee and Grisham, Reference Frost, Steketee and Grisham2004), to further ensure that clients were compulsive hoarders. However, the use of such screening techniques would not have dovetailed with the methodological approach of IPA and the qualitative aims of the project (Smith, Reference Smith1996, Reference Smith and Hayes1997; Smith et al., Reference Smith, Jarman, Osborn, Murray and Chamberlain1999). It is worth noting that 10 out of the 11 homes were visited and provided far more conclusive evidence of the presence of compulsive hoarding than scores on a screening questionnaire might do and therefore reduced the risk for the potential for “false positives” (Allchin, Reference Allchin2001) on screening measures confounding the results. Recruitment did emphasize that interviews would be conducted in mutually agreed contexts and there was no need to visit the home of the participant. A validation aspect of IPA, is that participants are shown a draft of the themic results and supportive evidence to ensure that the research account closely matches their lived experience. This was not completed in the current study and is an aspect of validation that is open to question.
In conclusion, the current research has provided a detailed exploration of 11 people's experiences of their inability to discard and the impact hoarding has upon their lives and physical environment. The aim of the research was not to test previously hypothesized associations between hoarding variables, but rather to describe in detail the phenomenology of compulsive hoarding. The qualitative methodology employed echoed many of the findings from the extant hoarding quantitative evidence base, particularly the Frost and Hartl (Reference Frost and Hartl1996) cognitive behavioural model and suggests extensions to the model in terms of schema, trauma and attachment issues. Compulsive hoarding continues to present a huge challenge to researchers and clinicians (Maier, Reference Maier2004; Steketee and Frost, Reference Steketee and Frost2003), particularly in producing an evidenced-based biopsychosocial formulation of the disorder (Bystritsky, Reference Bystritsky2006) and the further development and thorough evaluation of targeted treatment approaches.
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