The Objects of Desire: A Cultural Case Study in Hoarding

Hoarding is increasingly recognized by North American psychiatry and popular culture as a distinct disorder that warrants specialized treatment. These understandings are predominantly based on biological and cognitive-behavioral conceptualizations that view hoarding as a part of the obsessive-compulsive spectrum. In this article I conceptualize a psychotherapy case study of hoarding by drawing on the extensive sociocultural literature on “person-object” relations. Understanding hoarding through this lens appropriately contextualizes it as an extreme within a spectrum of relationships that people have with objects. This lens gave me a better understanding of my patient’s meaning and relationship with her objects, which allowed for more meaningful therapeutic interventions. I specifically examine the unique relationship hoarders may have with objects in regards to public and private value of material possession attachment and the difficulties with the disposition of the objects in their lives.


Introduction
The desire to possess objects has increasingly become a larger part of humans' lives, especially in North America. Csikszentmihalyi [1] argues that the possession of objects can exert a positive influence on individuals in three ways: by demonstrating power, giving permanence to relationships, and revealing the continuity of the self. When objects end up engulfing usable space we consider it clutter. At its most extreme, clutter can indicate an insatiable yearning for objects and an inability to discard them, known as hoarding or clinically as hoarding disorder. As opposed to collectors, who tend to proudly display their collections in an ordered and methodical manner, hoarders secretively hold onto objects, too embarrassed to reveal their possessions, yet too connected to them to let them go. The North American psychiatric community is currently discussing how to best classify hoarding as a disorder within the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Debate continues as to whether the hoarding phenomenology should be considered a subtype of obsessive-compulsive disorder (OCD), a component of obsessivecompulsive personality disorder (OCPD), or a distinct entity in itself [2,3]. In some instances, hoarding of objects can be seen as utilitarian and 'rational' as in the hoarding that often occurs in response to unstable economic situations, like in the transition from a state-based to free market economy [4]. Historically, hoards of items have also been observed in anticipation of food shortage with the Anasazi tribe in the Southwest [5]. In clinical settings, however, the hoarding of objects takes on a more 'irrational' nature [1]. Oftentimes, hoarders are not willing participants in their treatment, being brought in by social service agencies and facing risk of eviction from their landlords for living in unsanitary conditions.

Hoarding in popular culture
Hoarding has been a focus of popular attention recently, with a flurry of books, movies and reality shows highlighting the issue. For example, E.L. Doctorow's [6] latest novel "Homer and Langley" is a fictional account of the Collyer brothers, two real brothers who are perhaps the most infamous "packrats" in United States history. Their Harlem Brownstone was discovered to be "filled from floor to ceiling with piles of newspapers, suitcases and boxes, 14 pianos, half a dozen toy train sets, chandeliers, a car chassis and more than 100 tons of garbage along with the brothers' corpses" [7]. A&E's reality show "Hoarders" provides another example of the growing interest in this phenomenon. Each episode is a "fascinating look inside the lives of two different people whose inability to part with their belongings is so out of control that they are on the verge of a personal crisis". This increasing interest in hoarding comes at a time when North Americans are questioning their consumptive patterns more than ever. In this context, hoarding "can be read as a metaphor for an entire culture that has lost perspective on the relative importance of things and desperately needs help" [8].

Psychological conceptualizations of hoarding
Currently, the most accepted model for understanding and treating hoarding is a cognitive-behavioral one. This model looks at hoarding as a distorted manifestation of three behaviors: acquisition, saving, and cluttering. According to this model, these three behaviors result from basic deficits in information processing, beliefs about and attachments to possessions, and emotional distress and response behaviors that develop as a result. The cognitive processing problems thought to be associated with hoarding include attention, categorization, memory, and the use of information to draw conclusions and make decisions. Beliefs about material attachments are highly emotionally charged and often provide a sense of comfort and a fear of loss of something important or a sense of self and identity. The combination of the information processing problems and the emotional attachment to possessions, leads to emotional distress at the thought of not acquiring or discarding and avoidance behaviors around decisions that would cause anxiety or loss around their possessions. These behaviors can each be targeted for therapeutic intervention using skills training, exposure and cognitive therapy, motivational interviewing, in-home visits, schema therapy, and relapse prevention [9].

Person-object relations
The cognitive behavioral model of hoarding has been an important approach to understanding and categorizing the hoarder's experience, but it has been shown to only have partial therapeutic benefit. Hoarders, when they do come to clinical attention, are highly resistant to changing their behaviors and when they do, are highly prone to have a relapse in their hoarding. One area that has been deemed essential in being able to devise meaningful therapeutic interventions is having a good understanding of the beliefs and emotional attachments to possession. Significant work that has been done in the social science subfield of "person-object" relations, which examines the cultural meaning and attachment to consumer goods [10] and may be a useful integration into understanding the hoarder's experience of possessions. This field combines perspectives from consumer research [11], sociology [12], anthropology [13], and economics [14]. Although there has been extensive writing in this field on the topic of collecting, there is little in the literature about hoarding. Maycroft [15] is one of few people in this field who looked at hoarding specifically as a disordering: "in relation to the regular circuits of disposition (i.e. to the acceptable forms of spatial re-situating), in relation to the classification of objects as useful or useless, in relation to the 'normal' practices of domestic arrangement and placing and, in relation to the nature of material boundaries within 'collected' matter itself " This is a very different understanding of hoarding compared to the clinical one being proposed for the DSM. In this article, I propose to create a bridge between the psychological literature on hoarding and the sociocultural literature on person-object relations, looking specifically at the public value of commodities, the private value and construction of self through possessions, and the disposition of objects. There may be heuristic value in comparing these bodies of literature, because doing so appropriately places hoarding on an extreme of a relationship we all have with objects, and situates it in a cultural and historical context. The integration of these distinct bodies of literature is an important advancement of current CBT approaches, because it places a greater emphasis on the hoarder's meaning and relationship with their possession using a phenomenological methodology. The development of a clearer understanding of the relationship between hoarders' inner and social lives with objects will provide a better framework from which to develop more effective behavioral interventions. These different constructs are brought together through a cognitive-behavioral therapy case study that was assigned to me during psychiatric residency. To my knowledge, this type of case study, examining hoarding through this lens, has not been written before.

Case Study: Anita
When I first met Anita at our Washington D.C. psychotherapy clinic in 2009, she struck me as an articulate, well-educated, older African American woman who was desperate for help. Despite her way of communicating clearly with me verbally, her physical appearance always communicated to me another feeling, of being discombobulated and rushed. Her presence in the room during our first evaluation could be described in no better way than "cluttered." I felt bombarded by everything Anita tried to squeeze into the hour, as if this would be our last time meeting. She first came to see me because she had a sense that her "compulsive hoarding" behavior was a significant problem in her life as it had caused her to be evicted from an apartment three years ago and was again causing her problems in her current residence. She shares a room in a house with several other women and the landlord complained that Anita's clutter in her room and in the shared spaces of the home was getting out of hand.
Beyond the "hoarding," which was indirectly causing distress through the complaints of others, Anita was also seeking help because she felt like a failure in her life, both personally and professionally. She felt uncomfortable around successful African-American professionals and saw Barack Obama's election as further proof that she had done nothing with her life. Despite getting a masters degree, she worked in mid-level administrative jobs most of her life and was currently working a temporary job periodically and trading small amounts of stocks from her home. This disappointment with her professional success spilled over into her social life, which she felt was lacking in the pleasures she associated with an upper middle class lifestyle (i.e., dinner parties, intelligent conversations with educated friends, home ownership, travel, etc.). Anita was an only child and grew up in a predominantly black neighborhood of Milwaukee where, as she noted, "even the blacks were moving out." Her family was relatively well educated for that community, her father having partially completed a degree in college and her mother being trained as a registered nurse, but nevertheless times were tough for them. Despite their precarious financial situation, Anita felt that her parents always seemed to live beyond their means. They had season tickets to the local baseball team and Anita always felt that she presented herself as more wealthy than she actually was. Anita always had a sense that maybe their luck would run out and that the things they owned would be gone one day. She felt ostracized by the black kids in her school because she was too bookish and spoke differently from them, but also felt uncomfortable with her white peers who did not overtly discriminate against her, but never fully accepted her. Anita had one significant romantic relationship in her life many years ago, never had children, and at the age of 65 was the only remaining member of her family. She had a few close friends, one of which, Rose, was a roommate who had been concealing Anita's hoarding from their landlord, but was growing tired of doing so.
I quickly learned that one of Anita's main hoarded objects was newspapers, which for her seemed to symbolize knowledge, gentility, and being well educated. She described in detail her experience of first discovering the New York Times at the age of 14 when she began attending a predominantly white school. When Anita realized her obliviousness to the New York Times' existence she felt extremely ignorant, and she consistently referred back to this experience as a key example of why she always felt behind in her life. To rid herself of this feeling she made it an integral part of her life to read up to six newspapers a day, ensuring that she was not behind on current events. Unfortunately, this behavior led to a buildup of newspapers from previous days that she was not able to finish. As a part of her psychotherapy with me, we set a therapeutic goal to not accumulate any newspapers beyond the day of their issue. Consequently, Anita made herself throw out newspapers that she never had a chance to read, which resulted in her feeling like she had permanently lost information and reinforced her feelings of ignorance and being behind. Unable to fulfill her need to hoard daily information, she was left with a feeling that she had nothing of value to share with others.
I also conducted home visits during which I discovered that Anita was engaging in another kind of hoarding: audio information. As we entered her room to begin our session, I was bombarded with stock news blaring from both the TV and the internet. I asked her to turn off these reports so that we could focus better on the therapeutic task at hand. Only after several requests and lengthy discussion did Anita completely turn off all of her media. When discussing this phenomenon with her in a later session, she was able to acknowledge that this behavior also stemmed from her fear of losing important information. This was an example in which she hoarded information that did not occupy physical space, but did create noise pollution, again fueled by her feeling of being behind.
Other objects that Anita had the most difficulty with discarding were clothes, especially shoes. She had more shoes than she was able to count, yet I saw her wear the same old pair of shoes at every one of our sessions. As a part of our therapy, we set a goal to pick a pair of shoes to discard. Interestingly, Anita chose to throw away the most comfortable pair of shoes that she wore the most instead of the fancier, unworn shoes that she might wear at imagined dinner parties of the future, preferring to hold onto an idealized future, rather than her everyday experience.
It was Anita's hoarding of food, however, that caused substantial conflict in her home. Because she lived in a home with other roommates, each boarder was designated a specific space in which to store their food. Anita's food, however, would consistently overflow her space, as she bought large quantities of items that were on sale. Additionally, she was reluctant to discard food she already had, and only felt comfortable with disposing of these items by actually consuming them, even if they were expired, although she would never serve expired food if she did have guests because of her belief that they deserve better than she does.
The irony in Anita's accumulation is that as a result of her hoarding, she was actually distancing herself from her goals of upward class mobility and the ability to invite intelligent, professional friends over for dinner parties. Her underlying belief that more is better had created an environment of filth, and extreme clutter that caused embarrassment over her living situation. She could not afford to live in a home of her own because on top of the rent she paid for her room in the house, she was paying rent on five storage units every month that held the remainder of her possessions, which could not fit into her current living space. This additional expense greatly taxed her finances and she had fallen two months behind on the rent for the storage units. Despite her desire to live an upper-middle class lifestyle she was barely surviving poverty.

Public and private value of commodities
Looking through a cultural lens, Anita's hoarding can be seen as a dissonance between her psychological processes and consumer behavior in the context of a throwaway North American society valuing increased dispossession of objects [16]. What led to her having a relationship with objects so different from others that she then requested psychiatric help? The answer may reside in a deeper understanding of how she determined the value of her possessions. Richins [17] has argued that possessions have a value that is both ascribed by the owner (private) and one that is ascribed to them by society at large (public). The public value of possessions pertains to categorical symbols that enable one to express social standing, wealth and status, and group membership [18], while private values are meanings ascribed to possessions by the owner. Public values of commodities play a large role in determining which objects are desired, while the private meanings play a larger role in objects that are already possessed. For Anita, the public value of commodities played a large role in her impulsive acquisition of objects, while the private value of her possession played a larger role in the difficulty she had discarding and managing her clutter. Both the public and private values of possessions probably play a varying degree of consideration in the three hoarding behaviors (acquiring, cluttering, and an inability to discard) that are targets for therapeutic interventions.

Power: The Public Value of Commodities
Some of Anita's accumulations were expressive symbols of those on a higher social stratum, of which she wished to be a part of. This was first articulated by Thorstein Veblen [19] in The Theory of the Leisure Class, in which he described the material wealth used by the nouveau riche to distinguish themselves from society at large in turnof-the-century Britain. Due to their status, the nouveau riche controlled matters of taste, which members of the lower classes then emulated out of a desire to share in the power and prestige of those above them in the social hierarchy. Veblen shows that the significance of ordinary goods can change if a social group with greater distinction consumes them.
Anita's manifestations of her higher-class aspirations, however, were not merely displays of material wealth. Her desires for upward mobility were more understandable in terms of cultural capital [20]. For example, Anita valued newspapers because of their implicit association with the knowledge of educated people, not because they directly reflected economic or material wealth. Similarly, "nice" clothes were thought of in the context of imagined dinner parties where she was hosting a group of well-educated guests who would appreciate her culinary flair. Perhaps most tellingly, Anita often asserted that she felt closest to reaching her aspirations when she was working in the administrative offices of an Ivy League University, looking into the world of aesthetic, intellectual, leisure and culinary tastes, of which she wished to be a part. It might be explained that Anita's emotional attachment to aestheticized, stereotyped objects of this higher cultural class was an attempt to attain group membership through shared consumption symbols [21]. Her approach to valuing possessions also mirrored that of class differences on the valuing of possessions. In Britain, unemployed working-class people were found to be more focused on the instrumental functions of their possession, while middle-class business managers valued possessions in terms of their symbolic aspects [22]. In her attempt to emulate a higher social class, she thought of her possessions more in symbolic, rather than instrumental functions, which was a way of locating herself higher in the social hierarchy. Unfortunately, her endless accumulation of what she saw as powerful symbols of upward mobility distanced herself further from actually joining this reference group. This unintended consequence was predicted by Marx [23] who saw commodities as having the potential to subordinate social relations among people to the relationships people form with objects.

Attachment: The Private Value of Possessions
Anita was drawn to certain commodities both because of their larger public meaning, but also because of her more private idiosyncratic interpretations of them. The danger in reducing commodities to displays of status or power is that it misses the expressive and symbolic functions that objects play in each individual's psyche [14]. If the only narrative of our relation with objects is one of cultural dominance in which we are passive recipients of commodity production and marketing, then consumption cannot be understood individually as an active social, relational or psychic phenomenon. Instead of a purely topdown control of cultural representation, a hermeneutic relationship between marketers, consumers and others is a more nuanced way of understanding how goods are used in social relations. Regardless of how the producer imagined the use of the product, consumers can always re-appropriate the product in the way that they see fit to their uses creating a new social value [24]. Being a commodity is merely a phase of an object's life [25], although the purchase of commodities is done en masse, people maintain the idea that it is a personalized  [26] in which they form an attachment. It is through the different stages of ownership: preacquistion, early ownership, mature ownership, predisposal, and postdisposal [27] that individual attachments to possessions are formed and eventually lost.
Although Anita's desire to hoard objects may have been fueled by a desire for upward mobility and emulation of a higher cultural class, she chose specific objects to surround herself by. Her hoarding wasn't merely the by-product of a ubiquitous advertising culture, but an individual response to what she identified as important, enchanting objects [28]. Anita's objects had a specific meaning to her that was decomodified, singularized, and personalized and it was this idiosyncratic meaning that led to her excessive attachment with certain items [11]. Thus, these objects felt to her "subjectively unique, removing them from ordinary social exchange as they attained absolute value rather than exchange value" [29].
Kleine and Baker [30] described nine characteristics that portray attachment between specific individuals and specific objects: "(1) attachment forms with specific material objects, not product categories or brands; (2) attachment possessions must be psychologically appropriated; (3) attachments are self-extensions; (4) attachments are decommodified and singularized; (5) attachment requires a personal history between person and possession; (6) attachment has the property of strength; (7) attachment is multi-faceted; (8) attachment is emotionally complex; and (9) attachments evolve over time as the meaning of the self changes." Part of the problem that led to Anita's hoarding was her excessive attachment to possessions, making them more difficult to discard. These attachments were based on singularized, psychologically appropriated possessions that felt like an extension of herself. The longer the history she had with these possessions the more emotionally complex was the attachment and the more difficult it became to discard them. Going back to her relationship with newspapers, it was clear that for Anita, a newspaper had a unique meaning. For her, it symbolized knowledge and by retaining it she retained her ability to become a knowledgeable person. When she tried to clean out her storage unit, she would find papers decades old, but still could not throw them out in bulk because of the possibility that something important would be lost, not just in the material, but also in her self.

Objects and the Self
Once an attachment is formed with possessions, they play a specific value that helps define the self either through autonomy or affiliation [31]. These possessions have an autobiographical and story-telling value by marking life events and telling "personal stories of search, self-discovery, growth and achievement" (p. 7). They also have a contemplation and action value by explaining who we are and what we are capable of doing. They have an ability to define boundaries of self and to demonstrate cultivation and development. The previously listed values highlight how objects help define the autonomous self, but possessions also represent the important affiliations we have in our life as well. Finally, possessions indicate continuity or change within oneself. They have an adaptive value in helping people cope and adjust through change and a preservation value in allowing objects to be one's legacy.
Possessions also have the ability to extend the self [11]. Simmel [32] argues that "material property is…an extension of the ego, and any interference with our property is…felt to be a violation of the person" (p. 322). James [33] claimed "part of our depression at the loss of possessions is…a sense of the shrinkage of our personality, a partial conversion of ourselves to nothingness" (p.293). Later, Fromm [34] argued that if our focus is on having possessions as a means of defining our identity, then we are always at risk of losing ourselves if we lose our possessions. Thus, people's relationship with objects becomes an intimate reflection of themselves, their positions, their self-identity and their communication with others Anita's possessions were an attempt at affiliating with those of higher social strata than hers. The difference in Anita's possessions was their singularity [25]. That is, they did not facilitate social relations; they actually marginalized her because of a lack of shared meaning. One way of approaching this therapeutically was to bring her back into the cultural fold. This involved a painstaking process of removing, piece by piece, those things that seemed 'necessary' to define her. She would often proclaim that as we stripped her life of these objects, she felt increasingly bare with a diminished sense of her self. The next stage involved rebuilding the pieces of her life through objects that built on, and are conducive to, actual social relations. She expressed a passion for music and playing in orchestras that had been absent in her life for many years, so the violin (her instrument of choice) was discussed as an object that could become a part of her life again. This was an object that symbolized past positive self-representations and an attainable future goal that would require a shared meaning of an object if she were to play in an orchestra again.
Anita's possessions also maintained continuity between past and future times, which was a way of maintaining her view of what she had been, what she is, and what she was attempting to become. In this way, her possessions were an attempt to define herself in a temporal space [35,30]. Anita often spoke with great longing of possessions that she had felt tied her to her past, which she lost in the early 80s when she could no longer pay for a storage unit. Whenever the functions and properties of individuals are taken over by institutions, as by economic circumstances, there is a regrettable loss of self or personal history [36]. She described the belongings that remained in her current storage units as her connection to the future. Having no children of her own, her objects became both her legacy and her imagined future. One of the mantras that I continuously reinforced in the therapy was the statement 'I am current,' meaning the objects and events of the past and the potential future did not have to control Anita's present. This also meant distinguishing between the possessions that gave her a positive sense of self-worth and ones that reminded her of her failures.

Disposal and storage: dispositions in the lives of possessions
Almost all daily activities generate rubbish [37]. According to Thompson [38] objects can be seen in three different phases based on the assumptions and values of the possessor: durable, transient, and rubbish. Durable objects have a consistent high status and value with clear social recognition. Transient objects lose status and value over time and are eventually rubbish, which has little or no status and value. In other words, rubbish is deconstituted material culture [39].
Throughout my treatment with Anita, we were predominantly focused on her ability to dispose possessions. She had an inability to discriminate between transient objects and rubbish, which created cognitive dissonance, ambivalence, and usually led to her retaining possession of the object to avoid losing what might be an important possession. The material use of the objects seemed less important for Anita then the idea of the objects being a physical repository of memories. As a result, we would often come face to face with specific objects (i.e., dishes, books, newspapers, clothes) and question whether her holding onto these objects was necessary for her to hold onto the memories. There was always a fear that excessive discarding could lead to permanently losing objects that were too important to lose, resulting in the loss of a part of her self. The difficulty for Anita often related to the unrecorded second life of her objects, in which they no longer played a purpose, but still hung around in her life [40]. These objects may be considered 'contemplation objects' as they had a value that existed based on conscious reflection and not through use [13]. La Branche [41] suggested that retention of such possessions is due to "the fear of annihilation of our current histories" (p. 165).
Storage is usually seen as an antidote to clutter in the home, as a way of regaining a degree of control over the chaos of modern consumption [42], but for Anita it became a way of holding on to the old belongings from a previous eviction and avoiding the intense anxiety of sorting through her possessions when transitioned to group living. This resulted in many of her belongings being put into five storage units, costing $900/month. Her utility of these objects was limited, which contrasts with most theories of consumption that emphasize presence, visibility, use and display [42]. Despite her limited monthly income, she insisted on spending almost half of that money on storage unit space for belongings that would fill her new living space once she was able to afford it. She saw suggestions or threats of losing these belongings as a huge failure and loss that would require her to have to start accumulating again. For her, storage was less an antidote to clutter and more a repository of time and identity.
Parallel to the divestment ritual [10] of the belongings of an elderly person when they transition to group living [43], Anita was put in a situation where she was forced to separate from some of her belongings as a result of eviction. Divestment rituals in the elderly generally involve the individual giving their possessions to those within their social circle, thus, becoming a reflection of an individual's social connectedness. Kamptner [35] found the most frequently mentioned source of value among adults in creating meaning of possessions is interpersonal ties. In Anita's case, holding onto her belongings during the forced move may have also been a reflection of her isolation and inability to share her possessions as much as her inability to discard. This reflected an ongoing pseudo-social relationship she had with her storage unit possessions, which became particularly difficult to part from. Valued possessions help to both individuate the self from others and integrate self with others [30]; but for Anita, they only served to individuate, as she could not be a successfully generative person.
When possessions are recognized as inconsistent with our images of self (ego-dystonic), we gladly neglect or dispose of them [41]. Divesting negative extensions of a former self assists the person in leaving that past behind [44]. The focus of our treatment was to try and reframe her view of many of her possessions as a contamination of herself, as opposed to a core part of her self. Upon successfully reducing the amount of her storage space, she reported for the first time enjoying getting rid of some of her belongings. These items felt inconsistent with herself and a relief to be rid of (i.e., "it's not me any longer"). She began to realize that if she wanted to be rid of this negative past self, getting rid of those objects in storage was part of the process.

Conclusions
Through the lens of a psychotherapy case study, I have attempted to show the relationship that Anita, a self-proclaimed 'hoarder', had with her material possessions and how her views on her possessions fit into the spectrum of person-object relations. Understanding this relationship Anita had with her possessions allowed me as her therapist to devise more meaningful behavioral interventions that targeted her destructive behavior. Based on her upbringing as an African American woman that was constantly aware of her perceived (and socially reinforced) lower social status, Anita was attracted to material possessions that were symbolic of a cultural class she wanted to be a part of. The public value of these commodities quickly became enmeshed with her private value of these possessions the longer she owned and formed a personal history with them. Over time, an attachment formed with these possessions that became intimately linked with the view she constructed of herself. Disposing of these possessions became especially difficult if they represented a past view of herself that felt ego-syntonic or if they represented an idealized, imagined possible future. Divestment of these possessions, which is a common route of disposition in the elderly, was rarely an option because of her poor social connectedness. The combination of all of these factors led Anita to have a cluttered domestic space that was considered unacceptable to her previous and current landlords because of concerns of hygiene, damage to the property, and the limited amount of space available in her group living situation. This clutter overflowed to other spaces as well, including her car and her need for five storage units. Explaining Anita's hoarding through this lens gives it a complexity and individuality that uniquely demonstrates why her relationships with objects led to such discord in her life. Beyond the cognitive conceptualizations and behavioral interventions I used to target Anita's hoarding, I found it useful to think of her material possession attachments as a means of attaining continuity and extending her self. Ultimately, the agreed upon treatment goal for Anita was to feel comfortable about herself, regardless of the possessions in her life and to replace her pseudo-social relationship to objects with more substantive ones with people.
Although it is difficult to make larger generalizations about hoarding from a case study, this case does highlight the value in understanding this phenomenon as a disordering of material possession attachment, domestic arrangement and disposition, similar to that mentioned by Maycroft [15]. In addition, this case highlights how the problems of hoarders are clearly influenced by financial, social, and living constraints that could have disastrous consequences (i.e. eviction, forced cleanings, health code violations) or merely cause a nuisance. More in-depth research remains necessary in both the subfield of person-object relations and psychiatry that continues to examine hoarding through this complex sociocultural lens.

Coda
At this stage of the writing, Anita has avoided eviction from her home and is only using one large storage unit. She is beginning to slowly accept the fact the she is not behind in all aspects of her life and that she has a role as a producer, not just a consumer.