Read an Excerpt

PILES UPON PILES
The Story of Hoarding
I attach meaning to things that don’t need it.
—Irene
I spotted Irene’s home immediately. Despite its commanding view of the countryside from atop a hill, it was dark and gloomy. Overgrown trees and bushes hid much of the house from the street. The paint was peeling, and the fence needed mending. A car parked in the driveway was packed with papers and clothes. I had brought along my student assistant, Tamara Hartl, and as we walked toward the house, we could see boxes, newspapers, clothes, and an assortment of unidentifiable objects pressed against the windows.
 We knocked on the front door but got no answer. We found a side door and knocked. Something stirred inside the house. Behind us, a door to the garage opened, and out stepped Irene, slightly overweight and rumpled, with straight brown hair and a friendly smile. She introduced herself with a nervous laugh and invited us in: “You can’t get in that way. You’ll have to come through the garage.” A sea of boxes, bags, ski poles, tools, everything imaginable—all in a jumble, chest-high—covered the entire length and width of the garage. Along the wall was a narrow pathway to the only door to her house that was not blocked by debris.
 The foreboding exterior of the house belied Irene’s personality. She was friendly, bright, and engaging and very curious about our research. Like others we’ve interviewed, she was tormented by her situation and demoralized by her inability to do anything about it. Though happy to see us, she worried that she was wasting our time, since her problems were of “no consequence to anyone but me.”
 In Irene I’d found an extraordinarily articulate and insightful subject. I agreed to work with her as she tried to clear her home. In exchange, she agreed to describe everything she felt and thought during the process and not to filter out any reactions, positive or negative.
 Irene lived about ninety miles from my college in Northampton, Massachusetts, which meant a long drive for each visit with her (forty-five visits over eighteen months). Each visit lasted about two hours. Tamara accompanied me on most of the trips. On our way to Irene’s home, we’d review what we had learned the week before, and on the way back we’d discuss the visit as Tamara made notes on a laptop. By the last of our sessions with Irene, we had generated a theory for hoarding—a framework for future research and a major breakthrough in understanding the phenomenon.
 Some theorists have posited that people with hoarding tendencies form attachments to possessions instead of people. Erich Fromm claimed that a “hoarding orientation” leads to social withdrawal. Hoarders, he suggested, are remote and suspicious, preferring the company of objects to that of people. Indeed, for some people prone to acute social discomfort, possessions can be stable and comfortable companions. Irene, however, defied this categorization. She had a wide circle of friends, some of whom I met in the course of my work with her. They displayed a great deal of affection for her, and she for them. She had a quick wit and a well-developed sense of humor. It was easy to see why people liked her. She laughed readily and was often amused by the ironies of her plight. One day, as she pondered why she had saved a newspaper ad for new tires, she fell into gales of laughter when she noticed the headline: SAVE THIS AD. She was also quick to shed tears when she encountered something sentimental, such as a picture drawn by her son when he was a toddler.
 With Irene as a model, the classic definition of hoarding as a socially isolating syndrome appeared to be flawed. One of Irene’s favorite things, she said, was to make connections between people with mutual interests. She would frequently give me the names of people she thought would click with me. She planned to give many of the things she saved to friends and acquaintances for whom they seemed suited. Unfortunately, her gift of seeing these connections was a factor in her keeping virtually everything she acquired.
 Irene was intelligent and well educated. She seemed to know something about almost every subject and displayed curiosity and a wide range of interests. She had a story to tell about each possession—most of them remarkably detailed and engaging. For instance, one day she found a piece of paper with a name and phone number on it among the pile of things on her kitchen table and excitedly recounted its history: “This is a young girl I met at a store about a year ago. She’s Hawaiian and had such wonderful stories about Hawaii that I thought Julia [Irene’s daughter] would like to write to her. They are about the same age. She was such an interesting person, I was sure Julia would enjoy getting to know her.”
 Her face lit up at the prospect of making this connection.
 “But Julia wasn’t interested. I thought about writing her myself, but I never did. Still, I don’t want to get rid of the contact. Julia might change her mind.”
 I have met few people who are as interested in the world around them as Irene, though I later learned that this attribute is fairly common in people with hoarding problems. As she talked, I could see the way each of her things was connected to her and how they formed the fabric of her life. The advertisement for the tires led to a story about her car, which led to a story about her daughter wanting to drive, and so on. A piece of the hoarding puzzle seemed to be falling into place. Instead of replacing people with possessions, Irene was using possessions to make connections between people and to the world at large.
 As we were soon to learn, the hoarding phenomenon is composed of a number of discrete factors, some well hidden and unexpected. But the most obvious factor was the simple problem of accumulation: from a scrap of paper with an unidentified and long-forgotten phone number on it to a broken vase purchased at a tag sale, Irene had great difficulty getting rid of things. The value she assigned to objects and the reasons she had for saving them were many and varied. Irene’s beliefs about what should be saved seemed isolated from everything going on around her. She was truly baffled that her son and daughter didn’t share her penchant for keeping things. One day, as she went through the mound on her kitchen table, she found instructions for one of her son’s toys. “I’ll put it here in this pile of your stuff, Eric,” she told him when he got home from school. Eric immediately picked up the instructions, walked to the wastebasket, and threw them away. She stopped what she was doing, looking surprised. Eric saw her and responded angrily, “I don’t need it. I know how it works.” She didn’t say anything. A few minutes later, she found a bookmark. “Oh, this has all the book award people on it. Do you want it, Eric? I’ll put it in your pile.”
 “No,” he responded before she’d finished her sentence.
 “Don’t you even want to look at it?” she asked incredulously.
 A few minutes after that, she found an old birthday card someone had sent Eric. She put it on top of the pile of things she was saving for him without saying anything. Almost as if on cue, he walked by, picked it up, and threw it out. Irene stared at him in disbelief. She simply could not comprehend his lack of interest in things she considered full of significance.
 The sense of emotional attachment that Irene felt for her possessions has been shared with us over and over by people seeking help with their hoarding problems. These sentiments are really not that different from what most of us feel about keepsakes or souvenirs—the abnormality lies not in the nature of the attachments, but in their intensity and extremely broad scope. I find many articles of interest in the newspaper, but their value to me is reduced when piles of newspapers begin to impinge on my living space and overwhelm my ability to read what I have collected. For Irene, the value of these things seemed unaffected by the trouble they caused.
 Hoarding involves not only difficulty with getting rid of things but also excessive acquisition of them. Irene’s upstairs hallway contained hundreds of shopping bags filled with what she described as gifts for other people. Whenever she saw something that she thought might make a great gift, she purchased it, even though she had no particular recipient in mind. The items were all still in their original wrappings. Many people shop ahead to have gifts on hand when the need arises, but Irene and many like her cannot control their urge to buy when they see something they fancy. In addition to buying excessively, Irene collected things that could be had for free. She had an agreement with the postmaster of her town: he placed any newspapers or magazines that were undeliverable in a box, and on Saturday morning he put the box in the foyer of the post office, where Irene picked it up. Her home was stuffed with these free newspapers and magazines.
The Tour: “Homogenized” Clutter
On our first visit, Irene gave us a tour of her house. Hustling through each room, she held her arms up in front of her bent at the wrists with her hands drooping down, like a surgeon who had just scrubbed for an operation. Her small steps propelled her deftly through the maze in each room. She insisted that we not touch anything, and she watched us carefully as we negotiated the space. It was hard to avoid touching things in some places because there was so little room to move; the stacks rose to the ceiling. Several things struck me about her hoard. She saved pretty typical stuff, the sorts of things we’d seen in other homes: stacks of newspapers going back years, newspaper clippings of interesting articles, thousands of books, mountains of clothes, containers of various sorts from previous attempts to organize. And also as we’d seen with other hoarders, the piles had no apparent organizational scheme.
 We moved through each room on “goat paths” (a phrase well-known in the hoarding self-help world), narrow trails not more than a foot wide where the floor was occasionally visible. My hand brushed the top of a chair back in the dining room. She saw it and immediately rushed over with a moist towelette to wipe off the chair. This curious behavior and the way she held her hands, as if to shield them from germs, led me to wonder whether she also suffered from more classic OCD contamination and washing symptoms. At this point in our research, we had seen few houses in worse shape than Irene’s. (Since then, we have seen many homes more extreme.)
 Irene was apologetic to the point of tears about her situation. Her husband had just left her because of the clutter. She had no money. She was afraid her children would be taken away because of the condition of her home if her husband were to petition for custody. Her daughter had developed severe dust allergies, making it difficult for her to stay in the house. Irene recognized that she had a problem and needed to do something about it. Some people who hoard never have lucid moments about their habits, so Irene was fortunate in this respect. She at least had what psychiatrists and psychologists call “insight” into the irrationality of her hoarding behavior. Yet despite having insight when talking generally about her problem, when trying to decide whether to discard a five-year-old newspaper, she could not see the absurdity of keeping it.
 Our first stop, the kitchen, showed the enormity of her predicament. A two-foot pile of stuff covered her kitchen table. The pile contained a wide assortment of things—old newspapers, books, pieces of children’s games, cereal boxes, coupons, the everyday bric-a-brac of family life. Only a small corner of the table’s surface was visible, about the size of a dinner plate. The table had been cleared once, according to Irene. Five years earlier, she’d removed everything to the floor so that her son could have a birthday party. After the party, the stuff went back on the table. Four chairs were covered with clothes, boxes filled with long-forgotten things, and more. It was possible to walk around the table, but the floor under the table and chairs was packed with boxes and paper bags. The kitchen counters were completely covered, their surfaces obviously long buried in the mess. A pile of unwashed dishes balanced precariously in the sink. Bottles of pills and piles of pens and pencils were strewn among the dishes, utensils, and containers covering the countertops. As Irene was going through each of the items in her kitchen, it became clear to me that there was something peculiar about the clutter. Most descriptions of hoards include piles of worthless and worn-out things. Initially, the clutter in Irene’s kitchen seemed consistent with this model—empty cereal boxes, expired coupons, old newspapers, plastic forks and spoons from fast-food shops. But mixed among the empty boxes and old newspapers were pictures of her children when they were young, the title to her car, her tax returns, a few checks. Once when I had convinced her to experiment with getting rid of an old Sunday New York Times without first looking through it for interesting or important information, she agreed but said, “Let me just shake it to make sure there is nothing important here.” As she did so, an ATM envelope with $100 in cash fell out. This wasn’t exactly the outcome I’d expected from this experiment, but it did illustrate something important. Irene’s clutter contained a mixture of what seemed to me both worthless and valuable things but what was to her a collection of equally valuable items. She described it herself one day as we worked through one of her many piles: “It’s like this newspaper advertisement is as important to me as a picture of my daughter. Everything seems equally important; it’s all homogenized.”
 As we learned more about her and her home, Irene’s contamination fears became more apparent. On the counter next to the kitchen stove was a relatively neat pile of newspapers, magazines, and mail, grown into a leaning tower that threatened to cascade onto the burners. This, Irene explained, was her “clean” stuff. No one could touch it, nor could it come into contact with anything else in the room, because everything else was “dirty” (contaminated). She kept her purse next to the stack and took it out only if she felt clean. If she didn’t feel clean, she covered her purse with plastic wrap before she picked it up so that she wouldn’t contaminate it.
 The dining room was clearly the worst room in the house. Every surface was covered. The piles of clothes, containers, books, and newspapers climbed above my head. One skinny path led from the kitchen along the side of the room to the door of the TV room. Another path, even narrower, ran along the adjacent wall to the front hallway. Again, the array of things was impressive: magazines, baskets, clothes, papers, boxes, even three or four books about organizing. But still Irene had a strategy to separate the clean from the dirty. On the dining room table were layers of items separated by blankets or towels. Irene explained that the towels and blankets were clean and that laying them over dirty objects protected the clean ones on top.
 Soon it became clear that Irene had different degrees of clean. Some objects had to be kept apart from all the others because they were “pure” and uncontaminated. The pure state was only nominal, however. In fact, making things clean often resulted in their deterioration. Once when we were helping her clear a pile of papers from her couch, an envelope from the clean pile fell onto the floor, rendering it contaminated. Irene stopped her work and rushed the envelope to the kitchen, where she ran it under the faucet. She carried the soggy letter back to the couch and propped it up to dry on top of the pile. The letter had already begun to dissolve into the envelope.
 As Irene walked us through the house that first day, she pointed out the piles of things that were clean and the piles that were dirty. This distinction was hard to grasp because everything in her house had a thick layer of dust, but gradually we gathered that everything on the floor was dirty and most things on the furniture were clean. We were dirty. Touching me or shaking my hand, or even hugging her children, left Irene dirty. Some days she strived to maintain a clean state, and some days she decided to be dirty. If she was dirty, she avoided touching anything in the house that was clean. Of course, she preferred to stay clean, but getting dirty allowed her to carry on a relatively normal life. In fact, her dirty state was what most of us consider normal.
 Irene developed unusual ways to clean herself when she became contaminated. She always kept a Wash’n Dri towelette tucked into her blouse, even when she was dirty. When something got contaminated, she pulled out the towelette and wiped the item off, thereby decontaminating it, as she had done when I’d touched the chair in the dining room. Caught without a towelette, she would put her fingers in her mouth to decontaminate them, as if she were licking off sticky food. Putting her fingers in her mouth looked like a normal behavior, as did wiping something with a wet cloth. I wouldn’t have noticed except that she reacted the moment I touched the chair. Only by watching closely could I tell that these behaviors were compulsions, designed to prevent the ill effects of contamination. But exactly what these effects were was unclear.
 For many people with OCD, obsessive fears and compulsive actions are tied to feeling responsible for some sort of harm that might possibly befall them or others. But Irene’s cleaning behavior was not exactly a fear of dirt or germs. She was not worried about getting ill or making others ill. She was, however, plagued by intense feelings of discomfort if certain things were not clean, including herself, but her clean was different from everyone else’s. She described it as a “pure” state, a way of being separate from everything, a state of perfection—pristine and unpolluted. She created her own world—a comfortable and safe one. Such desires play prominent roles in hoarding, as we would find out later.
 Frank Tallis, a British psychologist, has suggested that this type of washing compulsion is attributable to perfectionism rather than to a fear of harm. Indeed, our research has shown that most people who hoard are perfectionists and that the perfectionism plays a major role in their hoarding. Irene often spoke of having a place that was truly hers and things no one else could touch, as if yearning to achieve some type of ideal state. She longed for a place of retreat when she was stressed, a place where she was clean and secure, undisturbed by outside concerns. She had several such safe havens in her home where no one, including her children, was allowed. Her bedroom was one of them. Here she collected her most cherished possessions and kept them solely to herself. Her “treasure books” were there—books that had special meaning because she had once enjoyed reading them or she simply liked the way they looked. Magazines with pictures she liked were part of the hoard, as well as other things she wanted to keep her children from contaminating.
 Despite the complications it created, Irene’s cleaning compulsion was not as serious as her hoarding. She could function quite effectively despite her contamination fears by dabbing at dirty objects with her towelette whenever she felt she must. She seldom had to thoroughly wash contaminated items. Her rituals did not, as is sometimes the case, take up enormous amounts of time, and she could go for long periods in a dirty state. The biggest problem her cleaning compulsion created was the effort required to maintain the distinction between clean and dirty objects.
“Churning”
Irene’s TV room, where she and her children spent most of their time, was just off the dining room. One chair was completely clear; no other sitting space was apparent. Videotapes were scattered about—hundreds of them. Most of them were recordings of TV specials Irene had taped so that she wouldn’t lose the information they presented, but none of the tapes were labeled. She lamented that there were so many, but she had no plans to reduce her collection. On one side of the room was what appeared to be a couch, completely engulfed in papers. In fact, all that was visible was a pile of papers four feet high, extending about five feet out from the wall and running the length of the couch. A coffee table was also submerged beneath the pile. One small corner of the couch, about six inches wide, was clear. This was Irene’s sorting spot. She reported that she sat there for at least three hours every day trying to sort through her papers, but the pile was growing steadily despite her efforts. We asked her if she would show us how she worked.
 Irene began by picking out a newspaper clipping from the pile. It concerned drug use among teenagers and the importance of communication between parents and teens on this issue. The clipping was several months old. She said she intended to give it to her daughter as a way of initiating a conversation about drug use. However, since her daughter was away at school, she would have to wait until she got home. She said she would put it “here, on top of the pile, so I can see it and remember where it is.” She then picked up a mailing from the telephone company offering a deal on long distance. She said she needed to read it to tell whether she could get a better price on her long-distance plan. She put it on top of the pile so that she could see it and wouldn’t forget it.
 She followed a similar logic with the third item, which also went on top of the pile. This process continued with a dozen more objects. The clipping about drug use was soon buried. For each item, she articulated a reason to save it and a justification for why it should go on top of the pile. Most of her reasons had to do with the intention to use the object. Her rationale was that if she put it away in a file or anywhere else, she would lose it and never find it again. The result of all this effort was that the papers in the pile got shuffled and those on the bottom moved to the top, but nothing was actually thrown away or moved to a more suitable location. We have seen this process so often among people who hoard that we have come to call it “churning.”
 The churning we saw in Irene’s TV room was driven in part by something we’d found in our earlier studies of hoarding—a problem with making decisions. With each item Irene picked up, she failed to figure out which features were important and which were not, in the same way that she struggled to distinguish important from unimportant objects. Moreover, she thought of features and uses most of us wouldn’t. When she picked up a cap to a pen, she reasoned that the cap could be used as a piece in a board game. She couldn’t throw it out until we had talked through whether this was a reasonable and important purpose for the object. The same problem arose with a piece of junk mail from a mortgage company. She couldn’t get rid of it until she figured out what was really important (or unimportant) about it. Sometimes she could decide to throw things away, but the effort it took was enormous. Often the effort was simply too much, and things went back on the pile.
 As with other hoarders, her indecisiveness was not limited to possessions. One day her daughter, Julia, asked for some money to go to the mall with a friend to buy some shoes. Irene pulled a wad of cash from her purse and started to hand it to her daughter. As the money was about to change hands, she wondered aloud if it would be enough. She took the money back and pulled out her credit cards, but now she wasn’t sure whether to give Julia the MasterCard or Diners Club card. “Which should I give you?” she asked. Before Julia answered, she said, “I don’t know, maybe I should give you both,” and she handed both of them to her. “No,” she said, “I might need one to get groceries.” She took both of them back and handed Julia the MasterCard, but again took it back, adding, “I’ll probably need the MasterCard for the groceries.” She gave Julia the Diners Club card, but just a second later she said, “Is Diners Club accepted everywhere?” Before Julia could respond, she took back the card and said, angrily, “Oh, just take this one,” and handed Julia the MasterCard, obviously frustrated and flustered by the process. Her indecision seemed to stem from a flood of ideas about what might happen if she chose one action over another.
 Irene’s churning revealed another facet of her disorder besides her trouble with decisions: she wanted to keep objects in sight in order to remember them. When we toured her bedroom, this became even clearer. Stacked on her dresser, all the way to the ceiling, were clothes—while her dresser drawers were empty. When I asked about this, she replied, “If I put my clothes in the drawers, I won’t be able to see them, and I’ll forget I have them.” On another occasion, she was going through pamphlets advertising various home care products. She remarked, “I want to remember these things. If I throw them out, I’ll never remember them. I have such a terrible memory.”
 Irene frequently complained about her poor memory. This contradicted our observations of her elaborate stories about so many of the objects she found in her hoard. She remembered details about where and when she got things, whom she was with, and even what she was wearing that day. It wasn’t that she had a poor memory; she just didn’t trust it. Her organizing style may have played a role here as she tried to remember exactly where things were in space. With thousands of objects in her home, this was an impossible task. She was asking too much of her memory, and not surprisingly, she lacked confidence in her recall. We got a further sense of this one day as she was trying to get rid of a pile of newspapers she’d already read. She said she wasn’t comfortable discarding them because she couldn’t remember the articles she’d read in them. Saving them would be a good substitute for her memory. Her belief that she should remember all this information, much of it unimportant for her daily life, led her to save the newspapers. It also explained why she felt that her memory was poor.
 Another apparent problem had to do with the ability to categorize, to group like objects together. Most of us live our lives categorically—at least the part of our lives dealing with objects. Tools are kept in the toolbox; bills to be paid are kept in a special place in the office area and then filed after payment; kitchen utensils go in a drawer. But Irene organized her world visually and spatially, not by category. When I asked her where her electric bill was, she said, “It’s on the left side of the pile about a foot down. I remember seeing it at that spot last week, and I think I’ve piled about that much stuff on top of it.” Many of us do this on a smaller scale. I have faculty colleagues whose offices are populated by piles of paper, and although they get a bit nervous that I’ll label them hoarders, most actually know what each pile contains and can readily find what they need. Others, who are less sure of the content, remain confident that their piles have only low-priority, unimportant stuff. In short, they are unconcerned about their memories.
 Although a visual/spatial organizing scheme might work on a modest scale, it’s not an efficient way to deal with a large volume of possessions. In fact, Irene frequently did lose things in the piles and found herself buying replacements for items she knew she had but couldn’t locate. After we set up a filing system for her important papers, she reported being able to find things much more easily. But because she couldn’t see the papers, she felt uncomfortable, as if she had lost them. This dependence on the visual connection with objects is a common trait among hoarders.
 As Irene worked her way through the pile on her couch, something else struck me. She often picked up an item from the pile, looked at it for a second, and caught sight of something else. She then picked up the new item, putting down the first one. This happened often enough that it seemed like a pattern. She simply couldn’t keep her attention on things that posed a decision-making challenge or seemed boring. She preferred to focus on objects that had positive connotations or evoked a story. As she drifted into an anecdote, she lost track of the sorting she was supposed to be doing. Not maintaining our attention while performing tedious tasks is certainly common, but it seemed to be especially pronounced in Irene’s case.
 Thanks to our close observation of Irene, the first piece of our theory for understanding hoarding was taking shape. Hoarding appeared to result, at least in part, from deficits in processing information. Making decisions about whether to keep and how to organize objects requires categorization skills, confidence in one’s ability to remember, and sustained attention. To maintain order, one also needs the ability to efficiently assess the value or utility of an object. These mental processes seemed particularly challenging for Irene. As we shall see later, these dysfunctions may reflect problems with how the brain operates in people who hoard.
Irene’s History
After Irene gave me the tour of her home, she asked, “How did I get this way?” It completely baffled her that her home was nearly unlivable. “I know I am smart and capable, so why can’t I manage my stuff? I see other people doing it. Why can’t I?” I had no answer for her.
 When we began studying hoarding, we were told by other mental health experts that it was a response to deprivation. Living through a period of deprivation, such as the Great Depression of the 1930s or the Holocaust, might cause people to stock up on whatever they can find to prevent such an experience from occurring in the future. Indeed, in our first study of hoarding, we found that many people described much of what they collected as “just in case” items. But when we asked our hoarding research participants if they had ever experienced periods of deprivation, by and large they said no. In fact, many of them grew up quite wealthy and never faced any shortage of food, money, or luxuries. Irene’s experience was typical: She grew up in a middle-class family. Her father was a high school accreditor, and her mother taught typing and shorthand at the local high school. They had enough money and never experienced any material deprivation.
 Irene could not remember exactly when her hoarding began. She remembered saving her schoolwork from elementary school, much of which she still had. But when she was young, her room was not cluttered, and she had little trouble managing the things she owned.
 Her father traveled a lot for his job. She remembered being spellbound by his descriptions of the places he visited and the things he saw, and his stories left her with a lifelong interest in travel. Although she traveled very little herself, travel sections of newspapers and travel brochures could be found throughout her house. They were among the most difficult things for her to discard. Perhaps they represented a bond with her father that she cherished. The rest of her relationship with him was not so warm.
 Outside of his travel stories, Irene remembered him as distant and cold. Irene recalled her father’s terrible temper when she was growing up. Although he never hit her, she remembered being afraid of him. That dynamic continued into her adulthood. One day she showed me a letter he had written to her several years earlier. It was formal and criticized the way she cared for her house. “You have failed in your obligation to properly maintain the house and grounds,” he complained. He had helped them buy the house but now threatened to cut her off if things didn’t improve.
 On another occasion, not long after she got married, Irene went looking for a pair of gray wool slacks some friends had given to her husband. She recalled putting them in a box in the barn behind her house with some of her many “lists,” but the box was nowhere to be found. Her father had been in the barn, so she asked if he had moved it. He admitted to having thrown the slacks away, trying to secretly rid his daughter of stuff. Irene drove to the town dump and spent several hours searching through the trash. She never found the slacks.
 More recently, she saw her father tear up and throw away some of her late mother’s handwritten lesson plans. Irene was incensed that he would do this and rescued them. The shredded papers now rested in her living room. After her mother died, Irene stopped receiving birthday or holiday cards from her father, though she knew that he wrote to other people. Perhaps he feared contributing to her clutter, or perhaps out of frustration he’d lost interest in communicating with her, so different were they in their views of the world. We have often wondered whether cold and distant parenting may be a contributing factor in the development of hoarding. In several recent studies, people with hoarding problems recalled disconnected relationships with their parents, particularly their fathers.
 In contrast, Irene was extremely close to her mother. Whenever she faced a crisis, she turned to her mother for advice and comfort. She came to value anything connected with her mother, especially after her death.
 Irene’s earliest memories were of a very happy childhood, filled with lots of children and activities. She walked to school with the neighborhood kids. They all gathered together after school and on weekends, and there was always someone around to play with. When she was in the second grade, however, her family moved to the suburbs. With only one other child in the new neighborhood, Irene felt isolated and alone. She rode the bus to school by herself and found the bus driver loud and menacing. He frequently yelled at the kids. She was frightened of him and avoided speaking to anyone on the bus. Her teacher seemed no better. Irene was so scared, she seldom spoke in class and began to dread going to school. “I was scared all the time,” she told me. “It was horrible.”
 Under these conditions, she began to devise strategies to manage her emotions. She recalled getting wrapped up in objects as a child. “Things were fun, interesting, and different,” she said. “They were removed from emotional life—soothing. All my fears were gone.” She elaborated: “Things were less complex than people, less moody. People either leave or hurt you.” Ironically, it was her things that eventually caused her husband to leave.
 Fear still permeated Irene’s life nearly fifty years later. During one of our sessions, she admitted, “Every day, I wake up in fear,” although she couldn’t articulate exactly what she was afraid of. She coped with her fear by surrounding herself with things, just as she had as a child. One day she told me, “You know, yesterday, without thinking about it, I sat down and built a little fortress around myself. It felt nice, comfortable.” She made a number of such comments during the time we worked together.
 Around the age of seven or eight, Irene began ordering and arranging her possessions in peculiar ways. She arranged her books and papers so they were perpendicular and perfectly aligned with the edge of the desk. At first this compulsion was mild and did not interfere with her life. But over time the feeling got stronger, and she began to spend hours arranging and rearranging things. She had trouble getting her homework done, doing her chores, and even getting ready for school on time. If she was prevented from doing her arranging or interrupted in the middle, she felt uncomfortable and anxious. This was the first hint for Irene of problems related to possessions, and it is consistent with research finding symmetry obsessions and arranging compulsions in children who also have hoarding problems. Since symmetry, arranging, and hoarding all have to do with physical objects, the connection may suggest a deeper problem with how people interact with the physical world or separate themselves from it. Luckily for Irene, the symmetry obsessions and arranging compulsions eventually disappeared.
 During those early school years, Irene began to gain weight and had struggled with her weight ever since. At one point in high school, her eating habits became rigid and unusual. In retrospect, she thought that she may have been anorexic at the time. Now she believed that her weight and hoarding were connected: “My body and my house are kind of the same thing. I take things into them for solace.” We’ve had a number of other hoarding clients who believed that their weight problems were related to their hoarding, and in one study we found that people with hoarding problems had higher than average body mass indexes.
 When Irene was nine years old, her grandparents moved in with the family. They were elderly immigrants from Europe, and their grooming habits were at odds with Irene’s. They seldom bathed or used deodorant, and they seemed to Irene to leave an odor wherever they went. She would not sit in a chair that one of her grandparents had recently used; it disgusted her. Before long, she stopped sitting in any chair her grandparents had once occupied. Still, there was no cleaning compulsion, just a sense of disgust. In all likelihood, this was a precursor of her contamination fears.
 Objects seemed to have a special significance for Irene as a child. Although she was not deprived, she had relatively few toys and cherished the ones she had. She recalled never taking a number of them out of the package, perhaps foreshadowing her tendency to value mere possession over use of an object. She remembered one treasure, a cylindrical paisley pocketbook with a mirror on top, that her parents threw away when she was about ten. By this time, they had become annoyed with the number of things she was saving and occasionally took matters into their own hands. Perhaps this shaped her response, years later, to a friend who agreed to help her clean up but was dismissed for throwing away a gum wrapper. Irene developed elaborate strategies to foil those who insisted that she get rid of her stuff. When her husband threw out her piles of newspapers, she sneaked them back into the house by using them to line the bottoms of boxes she brought in to help her organize.
 Even losses that were not emotional were troubling, particularly the loss of a potential opportunity. I got a sense of this one day as we excavated in Irene’s TV room. She came across a piece of paper with a telephone number written on it. Judging from its depth in the pile and the fact that it was yellowing, it had been there for quite some time, possibly years. Clearly, she had written it in haste on whatever she could find. As was the case for most of the information in the pile from which it came, she had not taken the time to identify it or put it in a phone or address book—it was just a number on a piece of paper. When she picked it up, she exclaimed, “Oh, a phone number! I’ll put it here on the pile where I can see it and deal with it later.”
 “Why do you think it is worth keeping that number?” I asked. She said, “Well, I made an effort to write it down, so clearly it was important to me. And it will just take a minute to call and find out what it is. I don’t want to do it now, though, because it will interrupt us.” She hadn’t made the call in all the years the paper had sat in the pile. Whether making the call would have helped her make a decision about keeping the number is uncertain. Perhaps the idea of a potential opportunity that the number provided was better than the reality provided by making the call.
 In high school, Irene’s behavioral oddities became more rigid and extreme. She felt compelled to do things in a certain way, particularly her schoolwork. Irene was an exceptional student, but at some cost. She insisted on using a #3 pencil sharpened to a very fine point so that she could write precisely. She printed everything in very tiny letters, and the formation of the letters had to be perfect. If she did not form a letter just right, she would start over and rewrite the entire page.
 In college, her room was not cluttered, though she remembers having lots of stuff packed in boxes. But other peculiarities caused her considerable discomfort. She recalled feeling tormented when other students came into her room and sat on her bed. It reminded her of her grandparents sitting on chairs and leaving an odor. Still, this torment was private. By all outward appearances, she was functioning extremely well. She had friends and was getting straight A’s. As her senior year progressed, however, her tightly controlled world began to unravel.
 Irene majored in art history and decided to write a senior thesis on Iranian art and architecture. As she collected and read book after book on the subject, she began to see connections everywhere. One obscure fact led to another, and when she saw these connections, she felt compelled to pursue them. To keep track of it all, she kept copious notes on each book she read. Sometimes her notes approached the length of the book itself. She felt the need to collect information until she had a “complete” picture before sitting down to write. For the perfectionist Irene, anything less than perfect meant disgrace. As the end of the term approached, she had written very little, and for the first time in her life, she faced the prospect of failure. Still, she couldn’t quite see how to limit her material, and she went on collecting.
 When she realized that she didn’t have time to complete her thesis, she became suicidal. It began as a thought that gave her some respite from her terror about the upcoming deadline. Soon she found herself thinking about how to kill herself every day. Instead of writing, she made plans to drive her car into a nearby lake. Death seemed like a better alternative than failure. In the end, she put all her notes and the few pages of her thesis she had been able to squeak out in a manila envelope and gave them to her professor with an explanation of her problem. He took pity on her and gave her a C–, her only grade below an A in college.
 She had struggled with depression since then, though she had never again been suicidal. Irene’s depression impeded her ability to deal with her clutter. During her depressive episodes, no sorting or discarding occurred, and one of the few things that made her feel better, shopping, only added to the problem. Depression is a common affliction among hoarders. In fact, nearly 60 percent of the participants in our research meet diagnostic criteria for major depression—much of which results from the hoarding itself. People draw conclusions about their worth and competence based on their inability to control their living space, and not being able to entertain people in their homes isolates them and limits their social lives.
 On my first visit to Irene’s house, she said something unusual. When I asked her if she would agree to be studied while we tried to help her manage her stuff, she said, “Why would you want to waste your time on someone like me?” When I asked her more about what she meant, it became clear that her low opinion of herself reflected ambivalence or uncertainty rather than pure low self-esteem. When she was at work, talking to other people, or shopping, she did not have the same feelings. But when she was at home, her unworthiness was more apparent to her, mostly when she focused on the clutter. When she focused on individual items, however, her possessions seemed more comforting than threatening. The irony that her hoard could be comforting and tormenting at the same time was clear to her.
 After college, Irene lived at home with her parents for a year and took some additional courses at a local college. She planned to start graduate school the following year. This was the first time she remembered living in a messy room. She saved all her college books and notes and packed them in “clean” paper bags that nearly filled her room. The room had two twin beds, but only one was visible. She recalled someone looking into her room and not being able to tell there were two beds there. Thirty years later, she still had those books, papers, and clothes.
 The following year, Irene entered graduate school in library science. She had no problem categorizing, cataloging, and organizing library materials, as long as they did not belong to her. If they were hers, she struggled and failed to keep things organized. She lived in an upstairs apartment filled with books and papers. She described the room as very messy, but her landlady was blind and did not know. Her hoarding behavior became noticeable when she began carrying large paper bags wherever she went. The bags contained books, papers, and anything else she thought she might need—her “just in case” items. They became such a part of her image that the other students jokingly called her “the bag lady.”
 Her concerns about contamination also became stronger during this time. When teachers gave handouts in class, Irene licked her fingers before and after she touched them to neutralize the germs. This ritual became one of her primary “decontamination” strategies later when her OCD became severe.
 At the end of graduate school, Irene married her boyfriend, and they moved into an apartment together. Clutter was a feature of their household from the beginning, although it didn’t seem to affect their relationship until much later. Most of the clutter was in the form of boxes filled with books and papers. Irene began work at the college library and was put in charge of “weeding” the vertical files, a job that involved discarding newspapers, magazines, and books. Many of them came home with her and greatly expanded her developing hoard.
 Just how much of Irene’s history is relevant to her hoarding is uncertain, but particular features appear again and again in the histories of hoarders. From an early age, she was sensitive, anxious, and perfectionistic. Though highly intelligent, she felt afraid of adults and disgusted by physical contact. She found stability and comfort in her possessions. Perhaps these features led her to use things to give her life meaning and connect her to the larger world. Her hoarding took years to develop; getting rid of it would be hard.
Recovery
Plastic bins, most stacked and empty, littered Irene’s home. The containers were clear so she could see what was inside. Lids for the containers had migrated elsewhere. Irene had purchased the materials over the years with the intention of using them but had been unable to do so. Instead, they only added to the clutter, as did numerous books on how to organize. Invariably, people who suffer from hoarding problems fail to maintain even the most rudimentary organization of their stuff—but not from lack of effort. Like Irene, most have spent countless hours trying to organize their possessions, with little success. Deficits in executive functions such as planning, categorization, organization, and attention leave them lost amid a sea of things, unable to figure out what to do next.
 Irene and I worked to create a filing system for her papers. Despite the fact that she was a librarian and could do this easily with things that didn’t belong to her, the work was difficult. Each possession had too many meanings to be categorized in only one way, and cross-referencing everything was exhausting. But before long, her new filing system began to pay off. The week after we finished it, she excitedly told me, “You know, I had to find the letter from my insurance company about my car accident last year. I went to the insurance file and found it right away. It would have taken me weeks to find it before.”
 Still, her lifelong pattern of organizing by piles was hard to break. She complained that when she needed something, she pictured the item in its last location. Even though the item had likely migrated elsewhere, the mental picture gave her the sense that she knew where things were. Now, with a filing system in which she put things out of sight, she couldn’t do that, and she felt lost. We had to help her not only to develop a filing system but also to use it enough to create a feeling of comfort and confidence.
 Much of the work we did involved conducting experiments to test the nature and strength of Irene’s attachments to her things. When she had difficulty discarding the scrap of paper containing an unidentified phone number, I suggested an experiment to clarify how important this was to her. “Why don’t we throw it away just to see how it feels,” I said. She agreed and threw the paper into the recycling box. “I feel somehow incomplete,” she said. “It’s not earthshattering, but just nagging. I’m sure I’ll get over it.” She paused and then added, “But I could rectify it with a brief phone call.” She looked at me pleadingly. I suggested that we continue with the experiment just to see what would happen, and she reluctantly agreed. She resumed her excavation, but just a few minutes later she stopped and said, “You know, it would only take a few minutes to make the call. It may be important.” At this, she reached in and pulled the paper out of the box.
 Most hoarders are capable of discarding things if they can convince themselves that the object will not be wasted, that it will go to a good home, or, as in this case, that the opportunity it presented is no longer available. But the amount of time and effort involved in attaining this certainty makes it impossible to keep up with the volume of stuff entering the home. Eventually, most hoarders give up and simply let the piles accumulate again. Irene could have called the number and perhaps realized the opportunity it presented was lost. Then she may have felt comfortable discarding the number, but she would have learned nothing about how to give up on opportunities that have passed her by. One goal of the experiment was to teach her how to tolerate uncertainty regarding unrealized opportunities. We talked some more about this, and she agreed to keep going with the experiment. She put the paper back in the recycling box but couldn’t keep from glancing at it every few minutes. Each time she did, she reiterated her urge to make the call and how it would make her feel so much better. Finally, she said, “Having the paper in sight, it’s like a beacon. It pulls my eyes and then my thoughts. I’m going to cover it up so I can’t see it.” She covered the paper and never brought it up again.
 The more experiments like this she did, the more her thinking about things changed and her ability to make decisions improved. In the beginning, Irene could tolerate very little of the work I asked her to do. “Can we stop now?” she asked just five minutes into our first treatment session after she had discarded one scrap of paper. But Irene persevered and worked very hard for a year and a half to clear out her home. Each step brought her more of a normal life. When her kitchen table was cleared, she and her children started sitting down to eat together. When her whole kitchen was cleared, she resumed cooking, and it began to feel normal to be in an uncluttered room. By the time we stopped working with her, the majority of her home was virtually clutter-free.
 As I got to know Irene, it became clear that she was a prototype. She possessed all the characteristics we had been observing in other hoarders: perfectionism, indecision, and powerful beliefs about and attachments to objects. Possessions played a role in her identity, leading her to preserve her history in things. She felt responsible for the well-being of objects, and they gave her a sense of comfort and safety. In addition, things represented opportunity and a chance to experience all that life had to offer.
 Irene’s recovery taught us a great deal about how these behaviors can change. Most significant was the fact that she made every decision about what to keep and what to discard. Such freedom might have been a license to do little. Yet Irene willingly challenged herself to experience the distress of discarding cherished possessions. Had she not done so, she would not have succeeded. Each possession held a story. Often just telling that story loosened her connection to it and allowed her to let it go.