Tolerance-building exercises gradually teach patients to resist the urge to acquire. At first, patients simply drive by a store they would like to visit without stopping to go inside. Then they learn to walk right past the store. In the final stage they enter the store, pick up an item that they really want to buy, put it down and leave. Similar exercises teach hoarders to discard items they already have and do not need. Helping hoarders declutter their homes bit by bit is far more effective than hiring a cleaning service to remove everything in one shot: the sudden and dramatic loss can enrage hoarders or plunge them into depression; some go into hoarding hyperdrive to replace what was taken from them.
In one test of hoarding-specific CBT, 18 volunteer hoarders immediately began a course of treatment, completing 26 one-hour-long sessions over several months; another 19 volunteers had to wait 12 weeks before beginning the same treatment program. In those first 12 weeks volunteers receiving hoarding-specific CBT improved far more than wait-list participants on measures of clutter and difficulty discarding items, indicating that the treatment was working and that improvements were not just an effect of time. At the conclusion of the study, after all 37 participants had completed their treatment, 26 (70 percent) had improved in some way and therapists concluded that nine patients (24 percent) were "very much improved."
Some of Tolin's neuroimaging studies suggest that hoarding-specific CBT changes the brain activity of compulsive hoarders. In one small study six compulsive hoarders completed 16 weekly 90-minute CBT sessions. Before treatment, activity in the cingulate cortex and insula was unusually high when hoarders had to make choices about their possessions, as observed in earlier studies. When their treatment was complete, the activity in these regions was much lower, sometimes approaching levels seen in healthy participants, although their habits had not changed much. Tolin thinks that even if therapy changes brain activity relatively quickly, significant changes in behavior require more time.
To increase awareness about hoarding-specific CBT, Steketee, Frost and Tolin and co-authored a book entitled Buried in Treasures. The book has become the basis for peer-organized support groups for people with problematic clutter—especially for those who cannot afford one-on-one therapy. In typical Buried in Treasures workshops, which are free, between eight and 12 participants complete many of the same exercises and homework assignments central to hoarding-specific CBT over a period of 20 weeks, guided by a peer "facilitator." In various trials of the Buried in Treasures workshops, symptoms of hoarding declined by between 22 and 27 percent and, in one study, an inspector judged more than 70 percent of participants as "much" or "very much" improved after visiting their homes. Buried in Treasures workshops, which originated in Massachusetts, are now active in San Francisco and Miami and will soon begin in New York City.
In 2007, not long after moving into his Easthamptom home, Shuer met Frost through colleagues and volunteered to run a series of Buried in Treasures workshops. In the process, Shuer began to change his self-image and his habits. "Over time my self-esteem and identity shifted," he says. "I learned that I didn't need those props anymore to have a social life. I don't feel a sense of loss or pain anymore when I give something up." He is now the director of Mutual Support Services, a component of the mental health and social services organization ServiceNet, and he continues to sort through his colossal collection, getting rid of what he does not really need and cannot accommodate in his home. A recent photograph that he provided depicts a charming and neat living room: no boxes of knickknacks or piles of magazines and concert flyers; nothing draped on the beige couches; one stray pillow and some cat toys on the carpet; and a single bookshelf with framed pictures, vases and figurines carefully arranged.
"I have learned to limit myself," Shuer says. "I'm not saying that I can never get anything again. If I find a cool book, I now know that I have to make space for it on the bookshelf. I have more free time and a much happier partner who really appreciates it. She loves me but she definitely did not love living with all that stuff."