Speaking of Psychology - Why People Hoard with Julie Pike, PhD

Episode Date: January 15, 2020

While television shows about hoarding are quite popular and the term has now been embedded into our general lexicon, there is still a lot about hoarding disorder that is not well understood. Hoarding disorder is complex, difficult to treat and causes a lot of pain and suffering for people who have it and their loved ones. Our guest is Julie Pike, PhD, a clinical psychologist in private practice who treats people with hoarding disorder. She has appeared on the Discovery/TLC show, “Hoarding: Buried Alive.” She helps explain more about hoarding disorder, what treatment options are available and how people can take the first steps to clearing the clutter. Join us online August 6-8 for APA 2020 Virtual.   Learn more about your ad choices. Visit megaphone.fm/adchoices

Hello and welcome to Speaking of Psychology, a bi-weekly podcast from the American Psychological Association that explores the connections between psychological science and everyday life. I'm your host, Caitlin Luna. You've probably seen it on TV shows about hoarding, people living in homes so full of clutter or mess that walkways are blocked, doors cannot be opened, and full rooms are unusable. In some cases, their homes may even be on the brink of becoming condemned. Despite these shows popularity, hoarding disorder itself is complex and hard to treat. It was only given its own official diagnostic criteria in the Diagnostic Manual, commonly known as the DSM, in 2013. There's still a lot about hoarding disorder that is not well understood, but we do know that it causes a lot of pain and suffering for the people who have hoarding disorder and their loved ones.

Here to help explain more about hoarding, what treatment options are available, and how people can take the first steps to clearing the clutter is Dr. Julie Pike, a clinical psychologist in private practice who treats people with hoarding disorder. She has appeared on the Discovery TLC show, Hoarding Buried Alive. Welcome, Dr. Pike. Thanks for having me, Caitlin. I appreciate it. I'm really happy to have you here on this show today. I think it's helpful to first start off by defining what hoarding is and what it is not. Can you give us a brief explanation of what constitutes hoarding disorder? Horting disorder is a phenomenon. where people collect so much stuff, so to speak, that they can't use their home or their space for

its intended purpose. So, for example, we've all seen, you know, pictures and videos of homes that are so cluttered that can move to cars or garages or storage spaces. And the important distinction is that we look for what we call impairment, meaning that it's causing some kind of problem in the person's life. For example, things can become a safety hazard. More frequently, it's that people, loved ones in the person with hoarding disorders, lives are really upset about the clutter and all of the things and the difficulty in getting rid of things. So whenever we're making a distinction of what is a disorder and what is not, a disorder has to cause a clinical impairment. So meaning it has to be damaging in some aspect of life. Okay, so that's the tipping point between a home that's just messy or overly

cluttered to being in a hoarding home, right? Exactly right. And really what we say in the APA, DSM, the diagnostic and statistical manual of disorders, is that it has to cause distress, but it's more likely that, in my experience, that hoarding causes impairment. So we say distress or impairment. People who hoard, usually hoard things that don't have a lot of value to most people. They buy in bulk. They acquire so many things that people can't move through their homes. It can cause a fire hazard, a safety hazard. In extreme cases, people will lose their homes or they will lose their children. So it can really become very dire for people. Absolutely. And why do people with hoarding disorder have such a hard time letting things go? As you mentioned, a lot of times it's things that

to someone without hoarding disorder, to the general population, it's something that doesn't have value. Maybe it's paper, maybe it's, you know, old antiques that just sit in a room and are not on display or something. So what is it about someone's brain and how they appreciate in a process information and when they're looking at something, they attach so much meaning to it where others see it is trash, basically. It's a great question. One of the things that we know is that there is a chromosomal abnormality on chromosome 14, which is typically associated with information processing and decision making.

So that abnormality is suggested to play a part here. And I think it's always important for people, especially loved ones who have someone who hoards in their lives, to hear that, that this is not volitional behavior, this is not someone being lazy, this is, this is a genetic, there's a high genetic component. So 80% of people who have hoarding disorder have a first degree relative. So it's a very, very high heritability index is what we call that. So you are very likely to have a first degree relative if you have hoarding disorder, who also has it. And, you know, then the genetic component, the chromosomal, rather component of chromosome 14 is really intriguing too. It's also very, very highly related to other disorders such as ADHD and occasionally OCD, but more frequently other anxiety or depressive disorders.

So a lot of people that I've treated with hoarding disorder have a very difficult time staying focused. and being linear. So when you talk about, we just mentioned about being comorbid. So hoarding disorder is in addition to something like depression or anxiety. I think it's important for our listeners to understand that someone with a hoarding disorder is probably suffering in some other way. So as a psychologist, how do you treat that? Are you treating both at the same time? Are you focusing on what's leading to the hoarding disorder? Good question. I treat both. For example, in my experience, it is very likely, especially for people with later onset hoarding, to have a trauma history, which is also important to think about. It's also, in my experience, this is just anecdotal,

that people may have addictions to deal with. So it's really important that we treat this holistically, meaning that we look at all aspects that are getting in the way of someone's hoarding problem. And also I want to talk about, I know you and I spoke earlier about this, like how do you define hoarding as opposed to being a collector? What are the differences? Some people might say, well, I have a lot of stuff, but I collect, you know, antique China, for example. So where does it go from just being a collector to a hoarder? Well, collectors are usually very proud, and they usually very carefully display and curate and they usually want to show you their collections. Whereas people who hoard, it's not that organized.

It's not usually beautifully displayed. It's never beautifully displayed. And there's usually a lot of secrecy and shame around hoarding. So people hoard in private. And part of the reason for that is they are frequently given the feedback that their stuff is not valuable. And what people need to understand is their stuff is precious to them. Why do you think there's a lot of shame around hoarding? And, you know, if you watch the programs about hoarding, you can see it, you can feel it.

You can feel how so many people on the show there's this sense of shame. Maybe it's because they're being confronted by family members and by people trying to intervene about the disorder that's causing chaos in their lives. But what is it about hoarding disorder that might cause a person to feel a deep sense of shame? I think most of the shame comes from being told frequently that their stuff is not worthwhile. and why can't you just get rid of this and it's not that hard and focus and just try a little harder?

Whereas, you know, the person who hordes, it's not easy for them in any way. Their stuff is precious to them. It feels really good to acquire things. We get essentially a shot of dopamine and other feel-good chemicals every time we get something that we view as precious. And we watch the brains of hoarders light up

when we're looking at scans, when they acquire something, it feels great. And then if you look at the opposite, it feels awful to get rid of things that you deem sacred. It feels awful to try to focus and become overwhelmed and have a really hard time getting rid of things. So my perception is that people in the outside world usually shame people who have hoarding disorder. they, you know, sometimes they mean it and more frequently they don't. They're well-intentioned. I've certainly had many cases where loved ones go in the house when the person with hoarding disorder is not there and get rid of their stuff. So it's kind of constantly having to keep their stuff safe from the outside world. And what can that do to someone if someone came into their home and got rid of their possessions?

I mean, I imagine that's not the best way to go about helping someone who is hoarding to. order? Getting rid of someone's stuff against their will is one of the worst things you can do. We've actually had cases where people commit suicide, and I'm not trying to suggest that that is a common response, but it has happened. And I think it just causes a further breach of trust. It makes the person more dug in because it now creates a fight dynamic. And the reality is that if someone has hoarding disorder, even if you clean out every single thing in their house, they will fill that space again. It's only a matter of time. And they tend to fill every space that they are allowed to, meaning I've seen many people who fill their children's rooms because they're running out

of space. They will buy new storage units. So the analogy I always make is that getting rid of someone's stuff against their will is like trying to pour out alcohol. if someone is an alcoholic, they are just going to go buy more. Right. You have to be ready to make a change if you want to see change. And you said that the person who is a hoarder doesn't usually see their behavior as a problem. So going along with what we just talked about, but everyone else in their life can easily walk in and say, whoa, we have a problem situation on our hands.

Why do you think that is? Like, is it just because they assign such sentimental or deep value to the possessions they own? Exactly right. So when we're looking at diagnosis, we're also, as psychologist, asked to make a distinction in terms of the level of insight the person has around the problem. And I would tell you the majority of the people I've worked with, I've probably worked on around 400 cases in various ways. And the majority of the people I see, I would say around 80% have poor insight into the problem, which sounds very judgmental. It's not meant to be it. What that means is that the person does not deem the hoarding a problem.

They think the problem is that their loved ones have a problem with it or, you know, government officials have a problem with it. And, you know, part of that is because their stuff is treasured and precious to them. And, you know, I have had people who hoard who say, I feel physical pain looking at an empty space. it seems so wrong to me. Yeah, that's why I did want to touch on too, is like it just seems like when you talk about if you forcibly removed things from a hoarder's home and did not address the underlying issues that the aftermath could be even worse than the original situation. It just seems like a lot of sense people feel a sense of comfort when they have their spaces filled up and that

an empty space might make them feel worried, scared, insecure. Is that, is that on point? That's exactly on point. You know, I think hoarding is so complex, given that there's a genetic component, there's a chromosomal, there's so much environmental pieces going on here. You know, especially if you have a first degree relative, chances are really good that you grew up in a home where there was hoarding. So that's probably also comfortable. We also know that people who have trauma often feel safer surrounded by their stuff. I've also talked to people, where they say, I just feel this emptiness. And when I have my stuff around me, that that void is filled

temporarily at least. Yeah, that's really interesting to think about it from that perspective that it gives someone comfort. And as I mentioned in the intro, that hoarding was only given its own diagnostic criteria in the DSM in 2013, but in the past it was considered a subtype of obsessive compulsive disorder. Has the fact that it's been given its own distinctive criteria benefited people with hoarding disorder? And why do you think it took so long for it to get its own place in the DSM? Well, I think it's taken so long because it's been so poorly understood and it's still not really well understood. You know, most of our research started around 1993, which is very late, but we have hundreds of years of documented instances of hoarding colloquially. And there's a reference

in Dante to someone who hordes. So, you know, very long. time ago. And the first task force in America to be set up was in Virginia in 1989. They formed a hoarding task force. So this is not something that has gone unnoticed. I think what has really been beneficial with both the diagnosis and with the television shows is that people can give it a name. That to me, the point of making a diagnosis is not to label or stick. And, you know, someone or pathologize them. The point of making a diagnosis is to inform treatment and increase understanding and empathy. So I think really the benefit of having a discrete diagnosis now is that we know what it is. We can explain it to people. We can perhaps even more importantly

explain it to loved ones. And we can work on treatment methods. And I imagine showing hoarding on TV can be both detrimental and beneficial because, you know, in one hand, you have people in the programs who are being helped and you have people at home who see it. And if they're a hoarder themselves or have someone in their life who's a hoarder, they may feel relieved that they're not alone and that there is help out there. However, the people in the show, you know, they could be subject to, like you said, you know, being, I don't know, you know, stigmatized a little bit or ridiculed or this order could be trivialized because I think it's so common for people make a casual comment when they have a cluttered home to say, oh, I'm such a hoarder.

Like similar along the lines of OCD where people casually throw that statement around, but in fact, they're likely probably don't have that disorder and that there are people out there who do, and it's very detrimental to their life. So with all this shared, given your experience on the TV programs and with clients and private practice, what are your thoughts? And do you think it's stigmatizes hoarding? Do you think it's helped more people get help out there? I think it's done both, and I think it's a double-edged sword. So the intended purpose of the show that I was on hoarding, Buried Alive on Discovery or TLC, was to look at the phenomenon of hoarding and more importantly to investigate treatment, effective psychological treatment. And I think the shows have brought awareness, which is incredibly important. I still daily get emails for.

help and email saying thank you for showing us. You know, I didn't know this had a name. My aunt has it. My mom has it. I didn't realize I grew up in a home and that's what it was. And so I think it does help validate people that this is a known entity. We know what it is, you know, 2.5% or 2 to 3% of people suffer from it. So you can imagine how many loved ones that reaches and effects. And I think the flip side of that is some people watch to relate and to learn and other people watch to compare. And I have so many people also come up to me and say, oh, I'm so glad I'm not a hoarder. Like I could never be like that. I, you know, let me tell you about how clean my house is. Yeah. And I understand that as well. I think it is a, it's a difficult thing to understand. I get it. And I think anything that we find

difficult to understand or to relate to, we have difficulty reaching empathy or compassion. I do hear a lot of jokes in popular media and social media about hoarders. And I don't love that word itself. I prefer to say people with hoarding disorder or people who hoard. It just, it sounds like a slur to me. And I think it kind of has taken on that flavor. Yeah, it is really important, as you mentioned. to say someone, people who have as opposed to hoarders. You know, I think that's really important is how we describe people, even in the same vein of addiction too, because I've done a podcast about opioid addiction earlier in the summer this year. And I talked about people with addiction

as opposed to addicts. So how we talk about people with a disorder is really important. Absolutely. It's funny. I was just thinking the same thing that labeling someone, an addict or an alcoholic suggests that that's all there is and then, you know, we can just put them in a box. And people are so much more complex than that. And I think if people are struggling with empathy and connection to hoarding or to addiction, because they look baffling from the outside. And I often make a comparison between addiction and hoarding. They don't have the same brain pathways or mechanisms, but I think they are equally baffling to the public. And perhaps to person who has the problem. But I think we all know what it's like to feel ashamed. We all know what it's

like to feel anxious or sad. And that's really how we connect universally is by looking at shared emotions, which are universal. What are some of those misconceptions about hoarding that you think are out there? The biggest misconception about people who hoard is that they are lazy, which couldn't be less true. People who hoard are often perfectionistic, and that actually becomes part of the problem in treating hoarding is that they want to do everything perfectly. They don't want to make a mistake and get rid of the wrong thing. And so they become so overwhelmed, they're not able to get rid of anything, which is true with most perfectionism. Most perfectionists become so overwhelmed that they start procrastinating, which is a huge component. Another

common misconception is that people who hoard are, you know, like shut-ins and very reclusive or unfriendly. And that is not my experience at all. Most people that I have met, the vast majority of people I've met with hoarding disorder are very gregarious. They are generous really to a fault, very kind-hearted, are very, very much family-oriented. And of course, there are exceptions. but by and large, the people I've met are extraordinarily friendly and loving and have big hearts. I think that's really important for people to understand that, again, it's not someone who's reclusive and necessarily people who have hoarding disorder are going out every day, going to work, raising families, you know, being involved in their communities.

And yet they do suffer from a problem that's very serious. But it is important to note that too. that maybe some of the things we see on TV programs can be misleading in that way or might, you know, portray people in a certain light that may not necessarily be the full scope of how, of how they are. Absolutely. Agreed. I think people are just so much more complex than, you know, one disorder or mental health

problem or physical problem. So what about hoarding across the lifespan? I mean, at what age do people tend to show hoarding tendencies? I know you've talked about that genetic component, but, when do we see that part activated and does it get worse as you get older? It does. You are three times as likely to have hoarding disorder between ages 55 to 94. Very specific, right? I have certainly seen hoarding as early as 11, but it's harder when you're a young person like that to know what you're seeing. is this a kid who is just really fond of these things?

And the confounding variable is that they have parents. And parents will make them get rid of things. And in fact, I have had an increasing number of parents contact me and say, you know, I'm worried about my child. Could we come in and talk about their behaviors? Which I love. I love the idea that increased awareness of hoarding, both through the creation of this separate diagnosis in 2013 and increased awareness through the television shows and talking about hoarding

has allowed people to look out for some of the warning signs of, you know, my kid can't get rid of things. They collect things. They have such a hard time sorting and settling. And is there anything that we could do so their life doesn't have to go down this trajectory? I think that's incredibly hopeful. Can you describe the process you use while working with a client who is hoarding disorder? I'm not sure if that varies depending on the age, but, you know, say someone in that range, that 55 to 94 range comes to you or their loved one comes to you and they have hoarding disorder and they want to seek treatment. Can you describe how you approach working with a client like that?

So how I approach working with a client like that is sort of complex. It depends on who's contacting me. I would tell you that 95% of the time, the people who are contacting me are loved ones. And it is very rare that people contact me because they personally want help with their hoarding disorder. The main reason the people who hoard contact me is they have some kind of really difficult circumstance, like they're about to lose their home, they're about to lose their children. There is something that is so painful that it's pushing. them to seek treatment. So it's far more common that I am approached by by families and friends. In that case, I try to provide them resources and I can give you those at the end of the show.

I try to adjust their expectations and describe just how difficult it is for their loved one. I try to do what we call psychoeducation, which is teaching people about hoarding disorder and kind of correcting some of the stereotypes that we've been talking about and some of the misconceptions around hoarding that, you know, this is not the problem of a loved one being willful or just selfish or picking their stuff over loved ones, which is a common misperception. Now, if the person who hordes, who is usually brought by loved ones, is willing to seek treatment, then there's kind of a mix of cognitive behavioral therapies that I use. So the first part would be motivational interviewing, which is, roughly speaking, a technique that is used to try to increase the person's desire to work on the problem and get them to commit on a values driven basis.

I also use act therapy, which stands for acceptance and commitment therapy. And it's a way of teaching people concrete tools so they can act in service of their own values. versus acting in service of fear or shame or despair and sadness. And that can be very helpful. We also use something called exposure therapy, which is exposing the person systematically to the upsetting feelings and thoughts that they have about getting rid of things and teaching them what we call distress tolerance little by little. We also use some cognitive reframing.

and kind of classic cognitive restructuring, you know, the common thought is, I will die without my things. You can see that that is not really going to be conducive to someone letting go of items. Are there particular treatments you think that are more beneficial than others? I mean, I've heard a lot about CBT being used in treatment of hoarding disorder, but do you, I know you use act, do you use exposure therapy, use CBT? Is there anyone you prefer of the other? Is it just depend on the person? I think it really depends on the individual case. And I have had people with sort of higher levels of insight, if you want to call it that, the very first shoot that I did for hoarding, buried alive, the lovely woman that I was working with had very high insight.

She was very disturbed by the idea that her children would grow up with this problem. And she was highly motivated to change. So act therapy was a great choice for her. She was very values driven. And it's not to say that other people with hoarding disorder don't have their own values. Of course they do. They love their families very much. They may just have a different level of insight. Motivational interviewing is for me more geared towards helping people increase their insight, if that makes sense. Yeah, absolutely it does. Increase self-insight into one-south. That's what you mean. Exactly right. And I, you know, I would also say that there is no gold standard of treatment for hoarding disorder. It is very complex and it is considered very difficult to treat. That's not to discourage

people because there's certainly progress to be made. And I have had people contact me years later to say, hey, I just moved cross-country and it was fine. So it's really exciting to hear that kind of thing. And I also think it's important to be realistic that this is a very complex problem that didn't develop overnight. It is genetically loaded. These are behaviors that have been entrenched for a long time. There are often, as we mentioned, other moving parts, meaning the person may suffer from other anxiety problems or ADHD. In terms of medication, there is currently no medication that is considered particularly effective for hoarding disorder. That is not to say that medications can't be helpful, though, because like we've talked about, there are often other problems going on. So if a person

suffers from extreme ADD or ADHD, using a stimulant or a medication for that might be helpful. if someone suffers from depression, which often causes low motivation and difficulty moving, you know, moving around and just attending to daily tasks, then they might benefit from what we call an SSRI, a medication used for depression and anxiety. Okay. So there, as you mentioned it, and I mentioned in the intro and what you talk about, it is very difficult to treat, but we want people to know that it can be treated, it can be managed, that there is help out there? Absolutely, 100%. So if someone's listening today and they're ready to

seek out help for their loved one, perhaps maybe they have high insight and they're ready to look into their own issue, what are the first steps they can take to get help? That is my favorite question, is providing resources because I think once we're educated about something, then we can take steps. If we don't know what it is, if we can't name it, then we don't know how to treat it. And luckily, know what those steps are. So there are a couple really extraordinary resources. For people who are dealing with a loved one, my favorite website is called Children of Hoarders.com. And it has a comprehensive index of therapists across the nation who specialize in treating hoarding disorder. It has professional organizers. It has support groups. So lots of really, really good resources on there. And

In terms of learning more about hoarding disorder, my favorite website is called OCFoundation.org, and that's the International OCD Foundation. They have, since, you know, we know that hoarding used to be subsumed under OCD as a diagnostic category, I'm a member of that organization, and so they have just split out hoarding on its own. And there's a lot of really good, important information about treatment. about what it is, about epidemiology, meaning how often it occurs and in who. And so there's just really great resources out there. That's really wonderful to share. I think that would be very helpful for people to know that there is help out there. And as we wrap this up, I just want to

know from your perspective, like, if I'm taking away from this is that even though this is a difficult disorder to treat, there is hope out there, there is help, there are resources. Absolutely, 100%. I don't think anybody has to live with the despair that hoarding disorder brings. And I think no matter how big the problem, it can always be lessened. Even if we can't erase it completely, it can certainly be bettered. And I think most people would just take even a 10% decrease in the clutter or in the chaos and the fighting that can occur. I think it's also really important to teach people how to treat their loved ones. And so I often work with families. And I encourage family members to get help, whether it's from somebody like me or it's one of these websites, because they are really informative.

So for the family member, the loved ones themselves, to seek out additional help too. Absolutely. Okay. It's very stressful to watch, especially older parents who, you know, have increased fall risks. Absolutely. You know, I get many, many, many, relatives who are very concerned about their older parents who refuse to get rid of their things and it's unsafe. Or it could be a sanitary hazard. And the older people get, the more likely they are to, their hoarding becomes more intense. That's often because a partner has been lost, whether that is being widowed or divorced. So it's very typical once people lose a partner that their hoarding is kind of unchecked and it gets worse and worse. And it's also likely there are

some medical conditions that can increase or exacerbate hoarding, such as dementia. And so as people get older, they may not have had a hoarding problem in the past. Their hoarding might be due to a dementia or a cognitive disorder. So it's really important for families and loved ones to get all the support that they can and some really constructive, educated advice. Thank you so much for joining us today, Dr. Pike. I really appreciate you sharing these really valuable resources and your really valuable insight into hoarding disorder. I think that people out there who are interested in this topic want to learn more,

you've provided a lot of really great information to people and that I think will be beneficial. Thanks, Caitlin. I really appreciate you having me on. If you want to learn more about Dr. Pike and her work, you can visit Julie Pike.com. Before we go, just a reminder, that we want to hear from you, you can email your comments and ideas to speaking of psychology at APA.org. That's speaking of psychology, all one word, dot org. And please give us a rating in iTunes.

We'd really appreciate it. You can find previous episodes of Speaking of Psychology on Apple, Stitcher, Spotify, or wherever you get your podcast. You can also go to our website, speakingof psychology. I'm Caitlin Luna with the American Psychological Association. Thank you for listening.