| New York City Task Force on Hoarding Transcript "When Hoarding Causes Suffering-Working Together to Address a Multifaceted Problem." |
Compulsive Hoarding..
Randy O. Frost, Ph.D...
Smith College...
NYC Task Force on Hoarding 1-19-04
This is an edited transcript of Dr. Frost's talk at the New York City
Task Force's conference, When Hoarding Causes Suffering - Working
Together to Address a Multifaceted Problem. The conference, held on
January 19, 2004, was sponsored by Weill Medical College of Cornell
University, Cardozo Bet Tzedek Legal Services of Cardozo School of
Law, and The New York City Task Force on Hoarding and Older Adults.
"Good Morning. It is a pleasure to be here. What you see here is an
illustration from Dante's Inferno. I do not know how many of
you have studied this at school or may be classical scholars, but the
storyline is that Dante had a dream one night that he saw a beautiful
hillside. And he dreamed he just had to climb this hillside to get to
the top, which was like a paradise. He started to climb the hill but
his journey was interrupted by a monster who told him that before he
climbed to the top of the hill, he first had to descend through the
nine circles of hell, down to the pit, and back again. Only then
could he ascend to the top. His guide on this journey was the ancient
poet Virgil. When Dante and Virgil entered the 4th circle of hell,
they saw two armies of people at war with each other, rolling huge
stones with their chests, crashing about. One army would shout "Why
do you hoard" and the other army would shout back "Why do you waste"?
Virgil told them that these were the hoarders and wasters in life.
They had spent so much time worrying about their wealth and
possessions "that they lost the light of God and were forever doomed
to this joint punishment." These heavy stones represent the
possessions they tried so hard to possess in life. I am not
suggesting this is the fate that awaits people who suffer from
hoarding problems but rather the hell in which they live on earth.
What I would like to do in the next few minutes is to tell you what
this hell is like in order to understand something about the nature
of this phenomenon.
Hoarding can be associated with a variety of dangers. This is a
picture of a house, not unlike most hoarding housing. Large volumes
of combustible materials can be a fire hazard, a danger not only for
residents but also for their neighbors. Blocked egresses can cause
death or other kinds of injuries. Unsteady stacks of heavy materials
can crush or trap people, as was the case a few weeks ago with the
gentleman in the Bronx who was crushed under his possessions.
Severe hoarding cases often involve structural problems. Accumulation
of newspapers, boxes and other heavy materials can stress joists and
beams, causing floors to sag, crack, or even collapse.
Mobility is an issue in homes that are filled with clutter. As you
can see, trying to get up or down the stairs alongside stored
materials could be dangerous if emergency personnel had to get into
this apartment to rescue someone. Clutter also increases the risk of
tripping and falling, especially for the elderly.
Accumulation of trash, food, and animal waste can cause disease,
vermin and/or insect infestation, not to mention violation of laws
and health ordinances. Use of appliances can be either completely
impossible or very dangerous and are often associated with this
problem.
Hoarding of animals can cause all these conditions, plus the
suffering of animals.
Hoarding of animals is often associated with starvation, disease,
accumulation of feces, and the decomposing remains of deceased
animals. Dr. LaFarge is going to talk about this more in detail later
on today.
There is a considerable cost in terms of cleaning up these materials.
In a small town near where I live, the Department of Health spent
approximately 75% of the town's budget clearing out one person's
home. Eighteen months later the home was back the way it was before.
In addition to the health and safety costs of the individual and the
community, there is also a psychological cost to living in this kind
of environment. This is a picture of a woman that was featured on an
episode of 20/20 several years ago. Everyday, she and her nine-year-
old son sit in this living room where they watch TV, among other
things. You can imagine what the nature of that life is like,
especially for the little boy.
When we talk about compulsive hoarding, we use a definition that is
three-fold. The first part of the definition talks about the behavior
itself:
The acquisition and failure to discard possessions that appear to be
useless or of limited value. This describes the behavior that many of
us engage in. It is not really a problem, maybe an eccentricity,
unless we see the other two features of the definition.
Living spaces so cluttered that using the room as intended is
impossible. The third defining feature is significant distress or
impairment in the ability to function.
This is the home of a 53-year old woman who suffers from compulsive
hoarding. She contacted me some time ago after her husband left her
because of the clutter. She has three children. I will talk briefly
about each of these pictures, as they are the beginning of what I
will talk about in respect to this phenomenon. That can we learn by
looking at these pictures? This is a kitchen that is reasonably full,
certainly not the worst case, but probably a moderate level of
hoarding. As you can see, every surface is covered. They only have
space in the corner for one person to eat, and they have to move
things around to do so.
Cooking is somewhat of a problem. She still cooks, and her stove is
still working, but you can see the pile of papers beside the stove.
This is not a particularly safe situation. The entire area underneath
the table and the chairs is full. There is no ability to move the
chairs around. There is only a very small area of available floor
space in the kitchen.
This is her dining room. You can see that the nature of things change
somewhat but you still see a random mix of clothing, books,
containers and so on. One of the things I want to you notice is the
narrow one-foot pathway that runs on the left side of the table and
along the back.
This path, which is sometimes referred to as a "goat path", is the
only way she can get through the room.
This is another picture of the room. As you can see, this room
contains the two exit doors to the house and they are both blocked.
There is no way she could get out of these doors if she had to, as
there is too much stuff blocking the exit.
I would like to discuss the three major manifestations of hoarding,
which we have just seen in these pictures.
The first one is acquisition; materials have to come into the house
in some way. We want to understand something about the way this
material comes in.
The second manifestation is saving. We can think about saving as a
behavior of keeping things or an inability to throw things away. At
this point, we may want to think about it both ways until we
understand it better.
The third manifestation is the level of clutter and disorganization.
This problem exceeds the problem of volume. It really doesn't matter
how much stuff a person has.
We want to take a look at these three features to understand the
phenomenon of hoarding.
I want to start with acquisition. This is the upstairs hallway of the
woman's house we just toured, filled with a sea of bags. In these
bags are gifts, purchased over the course of a decade. She had every
intention of giving them away, but has not been able to do so, and
here they have sat for over a decade.
This is very characteristic of the problem. We see compulsive buying
as a significant part of compulsive hoarding. This woman also has
great difficulty in walking by a newsstand. Once she sees the
magazines and newspapers she thinks to herself: "Somewhere in all
that information is a piece of information that could change my life.
How could I walk away and lose that opportunity." It is such a
powerful thought for her that the only way she can manage it is to
cross the street and look the other way. So you can see that the
power of this phenomenon is remarkable.
The second feature that we see is the compulsive acquisition of free
things, for example, newspapers and handouts. I do a lot of speaking
at organizations such as Messies Anonymous and I tend not to bring
handouts as they are gone by the front row.
The woman whose home we just toured had made an arrangement with her
local post office to save undelivered magazines and newspapers and
every week she would go and collect them.
We also see people who will collect things out of dumpsters, off the
street and so on. Again, it is this powerful compulsion to acquire
things.
This picture shows you what a living room looks like when you have a
hoarding problem. There is a lot of stuff, but if you were to
organize it and put it along the edges of the room, you could make
this room, although somewhat full, at least functional. However, she
can't do that. There is something about this problem that is giving
her difficulty in organizing rooms.
Why do these people save things? Are their reasons different than
ours? Understanding their reasons can help us develop treatments. Our
research indicates that they save things for exactly the same reasons
we all save things. The difference seems to be that people who suffer
from compulsive hoarding apply these reasons to a wider variety of
things.
There are three types of such reasons:
Sentimental saving refers to the attachment of emotional value to a
physical object. It is, in a sense, a way of extending our identity
to incorporate objects. "This is a part of me, of who I am." One day,
we were going through this client's possessions, helping her make
decisions about what to throw out. She came upon an empty ATM
envelope, and on the envelope was written how she had spent the
money. It was nothing remarkable.This ATM envelope that she had not
looked at in five years held the emotions associated with that day.
The envelope was a sentimental object. Many of us keep sentimental
objects; however, we typically do not keep ATM envelopes like this
one. "Go to the grocery store, go to the drug store," and so forth.
She said: "I can throw this away" and as she put it in the throwaway
pile she immediately started crying. She said: "If I throw this away,
I'll lose this day, it will be gone from me and I won't be able to
remember it."
Instrumental saving refers to saving things because we need them, or
because we can imagine a use for them. The woman whose home we just
toured saved the inside cardboard of toilet paper rolls - the
cardboard you have left over at the end. She saved them in the space
between her refrigerator and the cupboard; there were hundreds there.
I asked her what she was saving them for. She said: "Well, I'm saving
them for my son's art teacher because they will be great to use in
art projects." Now she was not an art teacher, she never met her
son's art teacher, and had not asked him if he needed these things.
But once she had imagined a use for these paper rolls, she felt a
sense of responsibility for keeping them and turning them into a
useful possession.
The following is a good example of intrinsic saving. The same woman
came to me one day with a clear plastic bag filled with bottle caps.
She said: "Look at these bottle caps. Aren't they beautiful? Look at
their shapes and colors." I asked her what she would be wasting if
she threw them away. She said that she would be wasting the color and
the shape of the bottle caps. This is a kind of funny aesthetic
because when you look at her house, it is certainly not aesthetically
pleasing. But when she looks at her individual possessions, some
sense of aesthetics leads her to save them.
So far, we've talked about the acquisition of possessions and the
inability to discard them. But if this were all there was to this
problem, it would be easy to fix. The real problem with hoarding is
that the possessions interfere with the ability to live. It doesn't
really matter how many possessions we buy, own, or keep, as long as
they don't interfere with our ability to function. What we see in
hoarding is a serious problem with the organization of and control
over possessions.
When we look at these pictures we see are a couple of different
features. We see random piles of things, worthless items paired with
items that are quite valuable – piled in the center of the room.
While we were working with this client, we were sorting a pile of
newspapers, helping her to throw them away. However, she had to go
through each one, carefully detailing it before she could throw it
away. Finally, we got her to the point where she was ready to throw
away a whole newspaper without looking at it.
She said: "I'll just pick it up and shake it to make sure there is
nothing important there." Out fell an ATM envelope with a hundred
dollars of cash in it! It was a bit of a therapeutic set back, but it
demonstrates something about the phenomena. Even though these piles
looks like junk - it is not always junk or it is not solely junk.
This is an important feature to keep in mind, especially when the
home has to be cleared out for health and safety reasons. It
poses a real problem for being able to do that efficiently without
throwing away things that are of true value.
We also see another phenomenon here that's quite striking: fear of
putting things out of sight. In this client's bedroom, there are
clothes on top of the dresser, piled all the way to the ceiling, much
like you saw in the dining room. But her dresser drawers are empty.
She remarked: "If I put my clothes in the drawer, I won't be able to
see them, and if I can't see them I won't remember that I have them.
They will be lost to me." There is something about the sight of a
possession that somehow keeps it in mind. Whenever she's dealing with
a possession she wants to keep, her tendency is to put it on the top
of the pile in the middle of the room. Then she knows where it is and
can see it.
Indecisiveness is also one of the hallmarks of this problem. This
carries over to any kind of decision, not just decisions about
possessions, but decisions about what to wear in the morning, what to
order at a restaurant, and so forth. It is very characteristic of
this disorder and a good clue for us about where to start looking for
causality. Where does this lead us in terms of trying to understand
this phenomenon better?
We also see another phenomena that is called churning, which is the
result of indecisiveness. I will describe churning here. This is the
woman's TV room and office, where all of her important papers are
kept. Every day, she spends about three hours trying to work her
way through this mess. I asked her if we could watch her sort through
her papers while reporting to me everything she was thinking as
she did so. She agreed and I spent the afternoon watching her pick
things off the pile and examine them while talking about their
different features. I was amazed at how much she was able to
recollect about each of these items she picked up. But in the end,
she was unable to make any decisions. She would say, "I need to do X,
Y and Z before I can get rid of this. I can't do that right now so I
am going to put this right here on the pile so I know where it is."
Then she would pick something else up and this process repeated
itself until the pile had been "churned" but nothing had been thrown
away.
As you can see, a very big part of this phenomenon has to do with the
inability to make decisions. In addition to these manifestations, an
important part of the phenomenology is how this relates to the
psychology.
Most people with hoarding are thought to have obsessive-
compulsive disorder (OCD). Even though hoarding is not in the
diagnostic and statistical manual, most experts in OCD consider
hoarding one of the symptoms.
In fact, about a third of the people who are diagnosed with OCD have
hoarding as a symptom. We also see hoarding behavior in dementia, but
we do not know yet whether it's a different kind of hoarding then we
see associated with OCD.
We see other disorders that are highly comorbid. There is a lot of
social anxiety in individuals with hoarding behavior. We see
isolation and relatively few contacts with other people. We see
depression. We also see a lot of features of
attention deficit hyperactivity disorder, particularly in the
attention problem side.
In terms of education, we have not seen any relationship between
education level and hoarding. If there is a relationship, I suspect
that people who have higher levels of education may be more likely to
hoard things. With respect to age, it appears that hoarding behavior
begins sometime in childhood or adolescence.
The behavior typically does not get to a problematic level until much
later, so you can see that it is a very chronic kind of problem. We
also see a lot of hoarding in the elderly. In our studies with the
elderly, when we ask how long they have been doing this, they
invariably say: "Oh, I've been doing this all my life." We think that
this expanded level of hoarding in due to the fact that service
providers and other professionals are just becoming aware of the
problem. Elderly hoarders may have lived that way before, but no one
noticed: there was no reason for other people to come into their
homes to provide a service.
Marital status is an interesting phenomenon. People who have this
problem tend less often to be married. For those who do get married,
they tend not to stay married. In a study of 70 older adults with
hoarding problems, 55% had never been married. The base rate for
never marrying by age 65 is only about five percent. There is
something about people who hoard that keeps them isolated and apart
from other people.
We do not have adequate information on the frequency of hoarding. In
our survey of health departments in Massachusetts, the rate of
complaints is about 26 out of every 100,000 population. This may not
sound like a lot, but most people with hoarding problems do not get
reported very often. An elders-at-risk program in Boston reported
that approximately 15% of their elderly clients had hoarding problems
severe enough to cause
difficulties for them. Here in New York City, the Visiting Nurse
Association estimates that 10 to 15% of their clients have hoarding
problems, and The Community Guardianship Programs - about 30 to 35%.
Again, these are only estimates.
There are other features that we see. There are familial patterns. In
one study, we found that a much higher percentage of people with
hoarding problems had a family history of hoarding.
One of our first hypotheses was that people who hoard went through a
period of material deprivation early in their life. They lived
through the depression, or holocaust, or something like that. We
looked at this hypothesis in several studies and did not find any
evidence. We see hoarding behavior in people who grew up in both
wealthy and impoverished backgrounds.
The other feature that we see quite regularly is difficulties with
recognition insight into the phenomenon. There are people who say, "I
do not have a problem; I should be able to live the way I want. Leave
me alone." We also see people who seek treatment because they
recognize they have a problem, but once they have to think about
throwing a possession away, the insight leaves them. They no longer
have the recognition of the absurdity of keeping "this tin can." It
is an interesting phenomenon.
There are three sub-types of hoarding.
The first is common hoarding, where the hoarding is of items no
different than the items most people save. Sometimes this type of
hoarding is associated with other OCD symptoms. Insight into their
behavior fluctuates over time and across situations.
Diogenes syndrome is another kind of hoarding that is associated with
self-neglect. Examples include living in squalor and the hoarding of
trash. Here we see a different quality to the nature of the material
that's saved. More of it seems to have less value.
The third type of hoarding is animal hoarding, which is the
accumulation of large numbers of animals together with a failure to
provide minimal nutrition, sanitation and vetinarian care. It also
involves a failure to act on the deteriorating condition of an
animal, and recognition that these living conditions have an impact
on them as well. Dr. LaFarge will talk more about this later on.
Our attempts to develop a treatment program for compulsive hoarding
have been organized around a cognitive-behavioral model of
hoarding. This model is based on our research, interviews with people
who hoard, and our attempts to treat this problem.
This model is phenomenological in that it focuses on the phenomenon
of hoarding and their meaning to the hoarder. It is heuristic in
that it attempts to organize what little information we have about
this problem so we can begin to ask questions and test hypotheses. We
do not mean to suggest that this is the truth regarding hoarding.
This model will hopefully allow us a way of getting to the truth
about this problem. The model assumes that hoarding is a multifaceted
problem that is made up of three types of problems or deficits. One
is information processing deficits. Another is beliefs about and
attachments to possessions. The other is distress avoidance.
Information processing deficits have to do with the way in which
information gets processed. The attentional part of it has to do
with the input of information. This is problematic, especially the
length of time people can stay focused on the task.
Categorization may be an important feature with respect to
organization. It appears that the way people who hoard think about
possessions is more complex than the way most of us think about
possessions. For instance, I have a favorite pencil that I use all
the time. I really like it, but if I were to lose the pencil, save
for the cap, I would throw the cap away as I consider it lueless. If
I suffered from hoarding, however, I would think of all the potential
uses for this cap. It is like the old game of thinking about all the
uses of a brick. It's that kind of phenomenon. The way they think
about possessions is much more complex.
There are a number of hoarding-related beliefs.
The first one is emotional attachments to possessions. Some are fear-
based in that there is a fear associated with throwing something
away. There is also a sense in which these possessions have come to
signal safety. If I throw this symbol of safety away, I feel
vulnerable. This item makes me feel safe. If I throw it away I feel
unsafe. The woman whose home we toured said to me one day: "I had
such a terrible week. I just wanted to come home and gather all of my
treasures around me." Her possessions were sources of comfort to her
and that made getting rid of them difficult.
The second belief is about memory. The belief that I won't remember
something unless I keep it in a certain place. Most of us, though,
organize our lives categorically. We have categories for things and
we put things in those categories - in that location or in that file.
People who suffer from hoarding problems do not think categorically:
they think more spatially and visually. If I ask a person who hoards
where her telephone bill is, they might say: "Well, it's about a foot
down in that pile and a little over to the left." Having to remember
the location of every item is probably over-taxing their memory.
Consequently, they believe that they have a terrible memory as they
cannot remember where all their items are located. Our perspective is
that it is not the memory that is the problem, but the system of
organization.
The third hoarding-related belief is responsibility and guilt. It is
almost as if ownership carries with it a responsibility to make sure
a possession is not wasted. This is something we see quite often.
We also see issues related to control over possessions. The first
time we worked with this woman, she had a coach, a friend whom she
felt comfortable with. When we went the second time, he was not
there. When I asked about him, she said: "Steve is never coming
to my house again. I am not sure but I think he picked something up
and threw it away. I think it was just a gum wrapper, but he didn't
have my permission and he's never coming back."
We also see a need for perfection and completeness. We run group
treatments in Boston at the Center for Anxiety and Related Disorders.
In our early groups, we were still working out our methods and our
materials. We had given the group a handout, an exercise that we
wanted them to work on during the week. After the meeting, we
realized there was a mistake in it, so we made a new handout and gave
it out at the next meeting.
We said: "Why don't you give us back the old one?" We didn't get a
single one back. In talking about the reason, they said: "This
handout was a complete record of what happened. If I give it back to
you, I'll lose that record. I won't be able to remember what
happened." So a sense of perfection and completeness is involved.
All these behaviors lead to levels of distress and avoidance. People
experience distress at the possibility of throwing things away, and
at the Herculean effort it would take to clean up the house. They
develop avoidance to decisionmaking and discarding. They avoid
putting things out of sight. We think hoarding behavior is in large
part an avoidance behavior.
One of the tools the Task Force is developing is an assessment tool.
Let me briefly go through this. There are three parts to this
assessment tool: telephone screening, conditions of the
dwelling, and a client assessment.
During the telephone screening, you receive basic information, an
initial description of the problem, and some kind of initial
indication of the severity of the problem. This is just the
beginning point.
Then we move into an assessment of the condition of the dwelling. Are
there utilities and appliances that are not functioning? In severe
hoarding cases, we commonly see non-working appliances as individuals
are too afraid to have someone in to fix the appliances that break
over time.
We also want to focus on the living conditions. What kind of
materials are there? Are there animals involved? Are there food
items? Is there structural damage, insect and rodent infestation, and
so forth? What is the condition in which people are living?
The third feature is safety issues. What parts of the house are
unsafe? Are there fire hazards? Are there mobility issues and so
forth? Then finally we want to know about function, about the
activities of daily living. What activities are they prevented from
doing because of the clutter? Can they cook, sit down, sleep in their
bed, and so forth.
What kinds of things are involved that may determine how we approach
it? For example, is there
dementia?
What is the family situation? Typically in these cases,
family situations are rocky at best. The family and/or close friends
these people once had, have tried at some point to help. The problem
is they do not understand what it is like for an individual who
hoards.
Typically, they say, "I will help you. I'll bring over my big truck
and I'll throw out all your stuff." That never goes over very well.
We also want to know something about financial status.
Then we have a hoarding interview, which is a set of five questions.
We want to get their assessment - their idea of the extent to which
these things are problems. We ask questions about acquisitions, about
difficulty discarding, and of course, about organization and clutter.
If we can pair these responses to what we see in the activities of
daily living section, we can get an idea of the depth of their
insight, understanding and recognition of the problem. That is the
insight piece.
Let me stop here and open it up for questions before we move on to
the next segment.
Q. If material deprivation in childhood does not contribute to the
problem, what about emotional deprivation?
This is a likely hypothesis. In particular, one of the things we see,
especially in the animal hoarding area, are people who grew up in
very chaotic families. With respect to people with common hoarding
problems, we see people who had a controlling parent who did
not allow the child to make decisions. Or we see parents who put them
in situations that were frightening or scary. There may be some kind
of childhood deprivation of that sort.
One of the themes that keeps coming up is a theme of loss, which
seems to extend to everything. Losing a possession to them is, in
many ways, like losing a close friend or family member. This theme of
loss suggests that there is something about this phenomenon in
childhood.
Q. What is the difference between individual and group treatment?
We have found that people make more rapid progress in individual
treatment. However, one of the amazing things that we see in the
groups that we run, is that many individuals, not all of them, have
prickly personalities. You would think that if you get them in a
group, it is going to be like fireworks, and sometimes it is. But we
have also seen that individuals in these groups really bond together.
They start to care for one another, and they want to come to the
group, even if they are not working on the problem. We run a group in
which people have made no progress with respect to clutter nd the way
in which they live, but yet they have made progress in establishing
some kind of social ties with other people. So there is a trade-off.
The group treatment keeps them motivated and going. Clutters
Anonymous and other groups like this, on the one hand, keep people
involved and invested. The downside is that it sometimes becomes an
identity: "This is who I am and why I am here." This occasionally
gets in the way of people making progress.
Q. I have two questions - one of them has to do with this issue of
having to remember everything and the second has to do with how
effective is it to clean out a home?
With respect to the first issue, this goes back to the notions of
perfection and completeness. It is almost as though they think: "If I
possess this possession, I have to get complete use of it, and I have
to be able to remember." The woman whose home we toured had a pile of
decades-old newspapers. We were talking about them and I said: "What
would happen if you threw this one out?" She said: "Well, before I
can throw this out, I have to read the whole thing, and I have to
remember it." Now, I do not know anybody who can do this. So, it is
this perfection - what I should be like as a perfect person. This
ideal is carried over into their real life. Most of us think it would
be nice if I could do that or maybe I should do that, but none of us
actually do it. She could not do it either, so she saved the
newspapers until the time that she could. So it is part of a
phenomenon and it is something that has to be addressed.
With respect to the second question, what is the efficacy of heavy
duty cleaning? There are other people with a lot more experience with
this then I have, but my judgment is that these seldom work very
well. I think we have to remember that when we get to the point
that we have to go into someone's apartment and clean it out, we are
dealing with two problems. We have the immediate problem of
environmental safety and of the person's behavior. We can clean out
the apartment and take care of the first problem, but we have
not addressed the second problem. In fact, we may have made
addressing the second problem more difficult. Again, I think that is
another challenge for the Task Force. We need to figure out
alternative ways of dealing with these kinds of situations
that make it more likely that we are going to have a good result
in the end.
Q. Do people use their things as memory aides or memory cues?
If we ask someone why they do not write something down, they will
say: "I can look at it written down but it doesn't bring back the
memories in the same way as looking at this object. This object puts
the tape back on in my head and it's like a movie. The movie starts
again when I see this and if it's gone I don't see it." It's a real
conundrum in terms of figuring out a more efficient way of helping
them learn. Maybe they can do without this. Maybe the importance of
being able to live now is higher than the importance of remembering
something that happened ten years ago.
Q. Do these people know they have a problem?
There are people who know they have a problem. Many people contact
me saying, "I have a problem, I need treatment." Yet, when it comes
down to the nitty gritty of throwing away "this newspaper", the
recognition slips away. Can a person function in their environment in
an adequate way? That includes issues related to safety and health.
People can tolerate a certain level of clutter. When it crosses that
line with respect to safety and ability to function - that makes it
pathological. I think we're right at ten o'clock so we better wrap it
up in terms of questions. We will have more time later on today to
deal with them.
*************************************
Randy O. Frost, Ph.D...
Smith College...
NYC Task Force on Hoarding 1-19-04
This is an edited transcript of Dr. Frost's talk at the New York City
Task Force's conference, When Hoarding Causes Suffering - Working
Together to Address a Multifaceted Problem. The conference, held on
January 19, 2004, was sponsored by Weill Medical College of Cornell
University, Cardozo Bet Tzedek Legal Services of Cardozo School of
Law, and The New York City Task Force on Hoarding and Older Adults.
"Good Morning. It is a pleasure to be here. What you see here is an
illustration from Dante's Inferno. I do not know how many of
you have studied this at school or may be classical scholars, but the
storyline is that Dante had a dream one night that he saw a beautiful
hillside. And he dreamed he just had to climb this hillside to get to
the top, which was like a paradise. He started to climb the hill but
his journey was interrupted by a monster who told him that before he
climbed to the top of the hill, he first had to descend through the
nine circles of hell, down to the pit, and back again. Only then
could he ascend to the top. His guide on this journey was the ancient
poet Virgil. When Dante and Virgil entered the 4th circle of hell,
they saw two armies of people at war with each other, rolling huge
stones with their chests, crashing about. One army would shout "Why
do you hoard" and the other army would shout back "Why do you waste"?
Virgil told them that these were the hoarders and wasters in life.
They had spent so much time worrying about their wealth and
possessions "that they lost the light of God and were forever doomed
to this joint punishment." These heavy stones represent the
possessions they tried so hard to possess in life. I am not
suggesting this is the fate that awaits people who suffer from
hoarding problems but rather the hell in which they live on earth.
What I would like to do in the next few minutes is to tell you what
this hell is like in order to understand something about the nature
of this phenomenon.
Hoarding can be associated with a variety of dangers. This is a
picture of a house, not unlike most hoarding housing. Large volumes
of combustible materials can be a fire hazard, a danger not only for
residents but also for their neighbors. Blocked egresses can cause
death or other kinds of injuries. Unsteady stacks of heavy materials
can crush or trap people, as was the case a few weeks ago with the
gentleman in the Bronx who was crushed under his possessions.
Severe hoarding cases often involve structural problems. Accumulation
of newspapers, boxes and other heavy materials can stress joists and
beams, causing floors to sag, crack, or even collapse.
Mobility is an issue in homes that are filled with clutter. As you
can see, trying to get up or down the stairs alongside stored
materials could be dangerous if emergency personnel had to get into
this apartment to rescue someone. Clutter also increases the risk of
tripping and falling, especially for the elderly.
Accumulation of trash, food, and animal waste can cause disease,
vermin and/or insect infestation, not to mention violation of laws
and health ordinances. Use of appliances can be either completely
impossible or very dangerous and are often associated with this
problem.
Hoarding of animals can cause all these conditions, plus the
suffering of animals.
Hoarding of animals is often associated with starvation, disease,
accumulation of feces, and the decomposing remains of deceased
animals. Dr. LaFarge is going to talk about this more in detail later
on today.
There is a considerable cost in terms of cleaning up these materials.
In a small town near where I live, the Department of Health spent
approximately 75% of the town's budget clearing out one person's
home. Eighteen months later the home was back the way it was before.
In addition to the health and safety costs of the individual and the
community, there is also a psychological cost to living in this kind
of environment. This is a picture of a woman that was featured on an
episode of 20/20 several years ago. Everyday, she and her nine-year-
old son sit in this living room where they watch TV, among other
things. You can imagine what the nature of that life is like,
especially for the little boy.
When we talk about compulsive hoarding, we use a definition that is
three-fold. The first part of the definition talks about the behavior
itself:
The acquisition and failure to discard possessions that appear to be
useless or of limited value. This describes the behavior that many of
us engage in. It is not really a problem, maybe an eccentricity,
unless we see the other two features of the definition.
Living spaces so cluttered that using the room as intended is
impossible. The third defining feature is significant distress or
impairment in the ability to function.
This is the home of a 53-year old woman who suffers from compulsive
hoarding. She contacted me some time ago after her husband left her
because of the clutter. She has three children. I will talk briefly
about each of these pictures, as they are the beginning of what I
will talk about in respect to this phenomenon. That can we learn by
looking at these pictures? This is a kitchen that is reasonably full,
certainly not the worst case, but probably a moderate level of
hoarding. As you can see, every surface is covered. They only have
space in the corner for one person to eat, and they have to move
things around to do so.
Cooking is somewhat of a problem. She still cooks, and her stove is
still working, but you can see the pile of papers beside the stove.
This is not a particularly safe situation. The entire area underneath
the table and the chairs is full. There is no ability to move the
chairs around. There is only a very small area of available floor
space in the kitchen.
This is her dining room. You can see that the nature of things change
somewhat but you still see a random mix of clothing, books,
containers and so on. One of the things I want to you notice is the
narrow one-foot pathway that runs on the left side of the table and
along the back.
This path, which is sometimes referred to as a "goat path", is the
only way she can get through the room.
This is another picture of the room. As you can see, this room
contains the two exit doors to the house and they are both blocked.
There is no way she could get out of these doors if she had to, as
there is too much stuff blocking the exit.
I would like to discuss the three major manifestations of hoarding,
which we have just seen in these pictures.
The first one is acquisition; materials have to come into the house
in some way. We want to understand something about the way this
material comes in.
The second manifestation is saving. We can think about saving as a
behavior of keeping things or an inability to throw things away. At
this point, we may want to think about it both ways until we
understand it better.
The third manifestation is the level of clutter and disorganization.
This problem exceeds the problem of volume. It really doesn't matter
how much stuff a person has.
We want to take a look at these three features to understand the
phenomenon of hoarding.
I want to start with acquisition. This is the upstairs hallway of the
woman's house we just toured, filled with a sea of bags. In these
bags are gifts, purchased over the course of a decade. She had every
intention of giving them away, but has not been able to do so, and
here they have sat for over a decade.
This is very characteristic of the problem. We see compulsive buying
as a significant part of compulsive hoarding. This woman also has
great difficulty in walking by a newsstand. Once she sees the
magazines and newspapers she thinks to herself: "Somewhere in all
that information is a piece of information that could change my life.
How could I walk away and lose that opportunity." It is such a
powerful thought for her that the only way she can manage it is to
cross the street and look the other way. So you can see that the
power of this phenomenon is remarkable.
The second feature that we see is the compulsive acquisition of free
things, for example, newspapers and handouts. I do a lot of speaking
at organizations such as Messies Anonymous and I tend not to bring
handouts as they are gone by the front row.
The woman whose home we just toured had made an arrangement with her
local post office to save undelivered magazines and newspapers and
every week she would go and collect them.
We also see people who will collect things out of dumpsters, off the
street and so on. Again, it is this powerful compulsion to acquire
things.
This picture shows you what a living room looks like when you have a
hoarding problem. There is a lot of stuff, but if you were to
organize it and put it along the edges of the room, you could make
this room, although somewhat full, at least functional. However, she
can't do that. There is something about this problem that is giving
her difficulty in organizing rooms.
Why do these people save things? Are their reasons different than
ours? Understanding their reasons can help us develop treatments. Our
research indicates that they save things for exactly the same reasons
we all save things. The difference seems to be that people who suffer
from compulsive hoarding apply these reasons to a wider variety of
things.
There are three types of such reasons:
Sentimental saving refers to the attachment of emotional value to a
physical object. It is, in a sense, a way of extending our identity
to incorporate objects. "This is a part of me, of who I am." One day,
we were going through this client's possessions, helping her make
decisions about what to throw out. She came upon an empty ATM
envelope, and on the envelope was written how she had spent the
money. It was nothing remarkable.This ATM envelope that she had not
looked at in five years held the emotions associated with that day.
The envelope was a sentimental object. Many of us keep sentimental
objects; however, we typically do not keep ATM envelopes like this
one. "Go to the grocery store, go to the drug store," and so forth.
She said: "I can throw this away" and as she put it in the throwaway
pile she immediately started crying. She said: "If I throw this away,
I'll lose this day, it will be gone from me and I won't be able to
remember it."
Instrumental saving refers to saving things because we need them, or
because we can imagine a use for them. The woman whose home we just
toured saved the inside cardboard of toilet paper rolls - the
cardboard you have left over at the end. She saved them in the space
between her refrigerator and the cupboard; there were hundreds there.
I asked her what she was saving them for. She said: "Well, I'm saving
them for my son's art teacher because they will be great to use in
art projects." Now she was not an art teacher, she never met her
son's art teacher, and had not asked him if he needed these things.
But once she had imagined a use for these paper rolls, she felt a
sense of responsibility for keeping them and turning them into a
useful possession.
The following is a good example of intrinsic saving. The same woman
came to me one day with a clear plastic bag filled with bottle caps.
She said: "Look at these bottle caps. Aren't they beautiful? Look at
their shapes and colors." I asked her what she would be wasting if
she threw them away. She said that she would be wasting the color and
the shape of the bottle caps. This is a kind of funny aesthetic
because when you look at her house, it is certainly not aesthetically
pleasing. But when she looks at her individual possessions, some
sense of aesthetics leads her to save them.
So far, we've talked about the acquisition of possessions and the
inability to discard them. But if this were all there was to this
problem, it would be easy to fix. The real problem with hoarding is
that the possessions interfere with the ability to live. It doesn't
really matter how many possessions we buy, own, or keep, as long as
they don't interfere with our ability to function. What we see in
hoarding is a serious problem with the organization of and control
over possessions.
When we look at these pictures we see are a couple of different
features. We see random piles of things, worthless items paired with
items that are quite valuable – piled in the center of the room.
While we were working with this client, we were sorting a pile of
newspapers, helping her to throw them away. However, she had to go
through each one, carefully detailing it before she could throw it
away. Finally, we got her to the point where she was ready to throw
away a whole newspaper without looking at it.
She said: "I'll just pick it up and shake it to make sure there is
nothing important there." Out fell an ATM envelope with a hundred
dollars of cash in it! It was a bit of a therapeutic set back, but it
demonstrates something about the phenomena. Even though these piles
looks like junk - it is not always junk or it is not solely junk.
This is an important feature to keep in mind, especially when the
home has to be cleared out for health and safety reasons. It
poses a real problem for being able to do that efficiently without
throwing away things that are of true value.
We also see another phenomenon here that's quite striking: fear of
putting things out of sight. In this client's bedroom, there are
clothes on top of the dresser, piled all the way to the ceiling, much
like you saw in the dining room. But her dresser drawers are empty.
She remarked: "If I put my clothes in the drawer, I won't be able to
see them, and if I can't see them I won't remember that I have them.
They will be lost to me." There is something about the sight of a
possession that somehow keeps it in mind. Whenever she's dealing with
a possession she wants to keep, her tendency is to put it on the top
of the pile in the middle of the room. Then she knows where it is and
can see it.
Indecisiveness is also one of the hallmarks of this problem. This
carries over to any kind of decision, not just decisions about
possessions, but decisions about what to wear in the morning, what to
order at a restaurant, and so forth. It is very characteristic of
this disorder and a good clue for us about where to start looking for
causality. Where does this lead us in terms of trying to understand
this phenomenon better?
We also see another phenomena that is called churning, which is the
result of indecisiveness. I will describe churning here. This is the
woman's TV room and office, where all of her important papers are
kept. Every day, she spends about three hours trying to work her
way through this mess. I asked her if we could watch her sort through
her papers while reporting to me everything she was thinking as
she did so. She agreed and I spent the afternoon watching her pick
things off the pile and examine them while talking about their
different features. I was amazed at how much she was able to
recollect about each of these items she picked up. But in the end,
she was unable to make any decisions. She would say, "I need to do X,
Y and Z before I can get rid of this. I can't do that right now so I
am going to put this right here on the pile so I know where it is."
Then she would pick something else up and this process repeated
itself until the pile had been "churned" but nothing had been thrown
away.
As you can see, a very big part of this phenomenon has to do with the
inability to make decisions. In addition to these manifestations, an
important part of the phenomenology is how this relates to the
psychology.
Most people with hoarding are thought to have obsessive-
compulsive disorder (OCD). Even though hoarding is not in the
diagnostic and statistical manual, most experts in OCD consider
hoarding one of the symptoms.
In fact, about a third of the people who are diagnosed with OCD have
hoarding as a symptom. We also see hoarding behavior in dementia, but
we do not know yet whether it's a different kind of hoarding then we
see associated with OCD.
We see other disorders that are highly comorbid. There is a lot of
social anxiety in individuals with hoarding behavior. We see
isolation and relatively few contacts with other people. We see
depression. We also see a lot of features of
attention deficit hyperactivity disorder, particularly in the
attention problem side.
In terms of education, we have not seen any relationship between
education level and hoarding. If there is a relationship, I suspect
that people who have higher levels of education may be more likely to
hoard things. With respect to age, it appears that hoarding behavior
begins sometime in childhood or adolescence.
The behavior typically does not get to a problematic level until much
later, so you can see that it is a very chronic kind of problem. We
also see a lot of hoarding in the elderly. In our studies with the
elderly, when we ask how long they have been doing this, they
invariably say: "Oh, I've been doing this all my life." We think that
this expanded level of hoarding in due to the fact that service
providers and other professionals are just becoming aware of the
problem. Elderly hoarders may have lived that way before, but no one
noticed: there was no reason for other people to come into their
homes to provide a service.
Marital status is an interesting phenomenon. People who have this
problem tend less often to be married. For those who do get married,
they tend not to stay married. In a study of 70 older adults with
hoarding problems, 55% had never been married. The base rate for
never marrying by age 65 is only about five percent. There is
something about people who hoard that keeps them isolated and apart
from other people.
We do not have adequate information on the frequency of hoarding. In
our survey of health departments in Massachusetts, the rate of
complaints is about 26 out of every 100,000 population. This may not
sound like a lot, but most people with hoarding problems do not get
reported very often. An elders-at-risk program in Boston reported
that approximately 15% of their elderly clients had hoarding problems
severe enough to cause
difficulties for them. Here in New York City, the Visiting Nurse
Association estimates that 10 to 15% of their clients have hoarding
problems, and The Community Guardianship Programs - about 30 to 35%.
Again, these are only estimates.
There are other features that we see. There are familial patterns. In
one study, we found that a much higher percentage of people with
hoarding problems had a family history of hoarding.
One of our first hypotheses was that people who hoard went through a
period of material deprivation early in their life. They lived
through the depression, or holocaust, or something like that. We
looked at this hypothesis in several studies and did not find any
evidence. We see hoarding behavior in people who grew up in both
wealthy and impoverished backgrounds.
The other feature that we see quite regularly is difficulties with
recognition insight into the phenomenon. There are people who say, "I
do not have a problem; I should be able to live the way I want. Leave
me alone." We also see people who seek treatment because they
recognize they have a problem, but once they have to think about
throwing a possession away, the insight leaves them. They no longer
have the recognition of the absurdity of keeping "this tin can." It
is an interesting phenomenon.
There are three sub-types of hoarding.
The first is common hoarding, where the hoarding is of items no
different than the items most people save. Sometimes this type of
hoarding is associated with other OCD symptoms. Insight into their
behavior fluctuates over time and across situations.
Diogenes syndrome is another kind of hoarding that is associated with
self-neglect. Examples include living in squalor and the hoarding of
trash. Here we see a different quality to the nature of the material
that's saved. More of it seems to have less value.
The third type of hoarding is animal hoarding, which is the
accumulation of large numbers of animals together with a failure to
provide minimal nutrition, sanitation and vetinarian care. It also
involves a failure to act on the deteriorating condition of an
animal, and recognition that these living conditions have an impact
on them as well. Dr. LaFarge will talk more about this later on.
Our attempts to develop a treatment program for compulsive hoarding
have been organized around a cognitive-behavioral model of
hoarding. This model is based on our research, interviews with people
who hoard, and our attempts to treat this problem.
This model is phenomenological in that it focuses on the phenomenon
of hoarding and their meaning to the hoarder. It is heuristic in
that it attempts to organize what little information we have about
this problem so we can begin to ask questions and test hypotheses. We
do not mean to suggest that this is the truth regarding hoarding.
This model will hopefully allow us a way of getting to the truth
about this problem. The model assumes that hoarding is a multifaceted
problem that is made up of three types of problems or deficits. One
is information processing deficits. Another is beliefs about and
attachments to possessions. The other is distress avoidance.
Information processing deficits have to do with the way in which
information gets processed. The attentional part of it has to do
with the input of information. This is problematic, especially the
length of time people can stay focused on the task.
Categorization may be an important feature with respect to
organization. It appears that the way people who hoard think about
possessions is more complex than the way most of us think about
possessions. For instance, I have a favorite pencil that I use all
the time. I really like it, but if I were to lose the pencil, save
for the cap, I would throw the cap away as I consider it lueless. If
I suffered from hoarding, however, I would think of all the potential
uses for this cap. It is like the old game of thinking about all the
uses of a brick. It's that kind of phenomenon. The way they think
about possessions is much more complex.
There are a number of hoarding-related beliefs.
The first one is emotional attachments to possessions. Some are fear-
based in that there is a fear associated with throwing something
away. There is also a sense in which these possessions have come to
signal safety. If I throw this symbol of safety away, I feel
vulnerable. This item makes me feel safe. If I throw it away I feel
unsafe. The woman whose home we toured said to me one day: "I had
such a terrible week. I just wanted to come home and gather all of my
treasures around me." Her possessions were sources of comfort to her
and that made getting rid of them difficult.
The second belief is about memory. The belief that I won't remember
something unless I keep it in a certain place. Most of us, though,
organize our lives categorically. We have categories for things and
we put things in those categories - in that location or in that file.
People who suffer from hoarding problems do not think categorically:
they think more spatially and visually. If I ask a person who hoards
where her telephone bill is, they might say: "Well, it's about a foot
down in that pile and a little over to the left." Having to remember
the location of every item is probably over-taxing their memory.
Consequently, they believe that they have a terrible memory as they
cannot remember where all their items are located. Our perspective is
that it is not the memory that is the problem, but the system of
organization.
The third hoarding-related belief is responsibility and guilt. It is
almost as if ownership carries with it a responsibility to make sure
a possession is not wasted. This is something we see quite often.
We also see issues related to control over possessions. The first
time we worked with this woman, she had a coach, a friend whom she
felt comfortable with. When we went the second time, he was not
there. When I asked about him, she said: "Steve is never coming
to my house again. I am not sure but I think he picked something up
and threw it away. I think it was just a gum wrapper, but he didn't
have my permission and he's never coming back."
We also see a need for perfection and completeness. We run group
treatments in Boston at the Center for Anxiety and Related Disorders.
In our early groups, we were still working out our methods and our
materials. We had given the group a handout, an exercise that we
wanted them to work on during the week. After the meeting, we
realized there was a mistake in it, so we made a new handout and gave
it out at the next meeting.
We said: "Why don't you give us back the old one?" We didn't get a
single one back. In talking about the reason, they said: "This
handout was a complete record of what happened. If I give it back to
you, I'll lose that record. I won't be able to remember what
happened." So a sense of perfection and completeness is involved.
All these behaviors lead to levels of distress and avoidance. People
experience distress at the possibility of throwing things away, and
at the Herculean effort it would take to clean up the house. They
develop avoidance to decisionmaking and discarding. They avoid
putting things out of sight. We think hoarding behavior is in large
part an avoidance behavior.
One of the tools the Task Force is developing is an assessment tool.
Let me briefly go through this. There are three parts to this
assessment tool: telephone screening, conditions of the
dwelling, and a client assessment.
During the telephone screening, you receive basic information, an
initial description of the problem, and some kind of initial
indication of the severity of the problem. This is just the
beginning point.
Then we move into an assessment of the condition of the dwelling. Are
there utilities and appliances that are not functioning? In severe
hoarding cases, we commonly see non-working appliances as individuals
are too afraid to have someone in to fix the appliances that break
over time.
We also want to focus on the living conditions. What kind of
materials are there? Are there animals involved? Are there food
items? Is there structural damage, insect and rodent infestation, and
so forth? What is the condition in which people are living?
The third feature is safety issues. What parts of the house are
unsafe? Are there fire hazards? Are there mobility issues and so
forth? Then finally we want to know about function, about the
activities of daily living. What activities are they prevented from
doing because of the clutter? Can they cook, sit down, sleep in their
bed, and so forth.
What kinds of things are involved that may determine how we approach
it? For example, is there
dementia?
What is the family situation? Typically in these cases,
family situations are rocky at best. The family and/or close friends
these people once had, have tried at some point to help. The problem
is they do not understand what it is like for an individual who
hoards.
Typically, they say, "I will help you. I'll bring over my big truck
and I'll throw out all your stuff." That never goes over very well.
We also want to know something about financial status.
Then we have a hoarding interview, which is a set of five questions.
We want to get their assessment - their idea of the extent to which
these things are problems. We ask questions about acquisitions, about
difficulty discarding, and of course, about organization and clutter.
If we can pair these responses to what we see in the activities of
daily living section, we can get an idea of the depth of their
insight, understanding and recognition of the problem. That is the
insight piece.
Let me stop here and open it up for questions before we move on to
the next segment.
Q. If material deprivation in childhood does not contribute to the
problem, what about emotional deprivation?
This is a likely hypothesis. In particular, one of the things we see,
especially in the animal hoarding area, are people who grew up in
very chaotic families. With respect to people with common hoarding
problems, we see people who had a controlling parent who did
not allow the child to make decisions. Or we see parents who put them
in situations that were frightening or scary. There may be some kind
of childhood deprivation of that sort.
One of the themes that keeps coming up is a theme of loss, which
seems to extend to everything. Losing a possession to them is, in
many ways, like losing a close friend or family member. This theme of
loss suggests that there is something about this phenomenon in
childhood.
Q. What is the difference between individual and group treatment?
We have found that people make more rapid progress in individual
treatment. However, one of the amazing things that we see in the
groups that we run, is that many individuals, not all of them, have
prickly personalities. You would think that if you get them in a
group, it is going to be like fireworks, and sometimes it is. But we
have also seen that individuals in these groups really bond together.
They start to care for one another, and they want to come to the
group, even if they are not working on the problem. We run a group in
which people have made no progress with respect to clutter nd the way
in which they live, but yet they have made progress in establishing
some kind of social ties with other people. So there is a trade-off.
The group treatment keeps them motivated and going. Clutters
Anonymous and other groups like this, on the one hand, keep people
involved and invested. The downside is that it sometimes becomes an
identity: "This is who I am and why I am here." This occasionally
gets in the way of people making progress.
Q. I have two questions - one of them has to do with this issue of
having to remember everything and the second has to do with how
effective is it to clean out a home?
With respect to the first issue, this goes back to the notions of
perfection and completeness. It is almost as though they think: "If I
possess this possession, I have to get complete use of it, and I have
to be able to remember." The woman whose home we toured had a pile of
decades-old newspapers. We were talking about them and I said: "What
would happen if you threw this one out?" She said: "Well, before I
can throw this out, I have to read the whole thing, and I have to
remember it." Now, I do not know anybody who can do this. So, it is
this perfection - what I should be like as a perfect person. This
ideal is carried over into their real life. Most of us think it would
be nice if I could do that or maybe I should do that, but none of us
actually do it. She could not do it either, so she saved the
newspapers until the time that she could. So it is part of a
phenomenon and it is something that has to be addressed.
With respect to the second question, what is the efficacy of heavy
duty cleaning? There are other people with a lot more experience with
this then I have, but my judgment is that these seldom work very
well. I think we have to remember that when we get to the point
that we have to go into someone's apartment and clean it out, we are
dealing with two problems. We have the immediate problem of
environmental safety and of the person's behavior. We can clean out
the apartment and take care of the first problem, but we have
not addressed the second problem. In fact, we may have made
addressing the second problem more difficult. Again, I think that is
another challenge for the Task Force. We need to figure out
alternative ways of dealing with these kinds of situations
that make it more likely that we are going to have a good result
in the end.
Q. Do people use their things as memory aides or memory cues?
If we ask someone why they do not write something down, they will
say: "I can look at it written down but it doesn't bring back the
memories in the same way as looking at this object. This object puts
the tape back on in my head and it's like a movie. The movie starts
again when I see this and if it's gone I don't see it." It's a real
conundrum in terms of figuring out a more efficient way of helping
them learn. Maybe they can do without this. Maybe the importance of
being able to live now is higher than the importance of remembering
something that happened ten years ago.
Q. Do these people know they have a problem?
There are people who know they have a problem. Many people contact
me saying, "I have a problem, I need treatment." Yet, when it comes
down to the nitty gritty of throwing away "this newspaper", the
recognition slips away. Can a person function in their environment in
an adequate way? That includes issues related to safety and health.
People can tolerate a certain level of clutter. When it crosses that
line with respect to safety and ability to function - that makes it
pathological. I think we're right at ten o'clock so we better wrap it
up in terms of questions. We will have more time later on today to
deal with them.
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