The Compulsive Hoarding and Acquiring books are a welcome guide for clinicians faced with this often daunting problem, thoughtfully written by authoritative authors. As Steketee and Frost point out, hoarding treatment trials are often characterized by high drop out rates and poor response. Hoarding-specific CBT has greater success; these publications guide the patient and therapist through treatment tailored for the particular demands of hoarding problems.

As with other titles in the Treatments That Work series, there is a patient workbook and therapist guide that are designed to be used alongside each other; the patient workbook does not stand alone. In the Therapist Guide, the introductory chapter is a thoughtful and concise summary of the phenomenology of hoarding and the evidence base for CBT for this problem. The following chapter on assessment sets the scene for the rest of treatment – an emphasis on structured techniques, work sheets and a significant proportion of sessions conducted in the patient's home. The appendix includes all measures recommended for assessment: the saving inventory-revised, clutter image rating, saving cognitions inventory and the activities of daily living for hoarding. A detailed hoarding interview is included; this is a useful tool as normal assessment procedures might not pick up on specific hoarding issues.

The chapter on formulation provides the rationale for using a collaborative model and lists key elements that may be included, such as information processing deficits and hoarding-specific beliefs. Brief case vignettes illustrate different elements of the model. The treatment planning chapter is particularly useful as both clinicians and patients often do not know where to start with what is typically a chronic and severe problem. Ten treatment goals are suggested, with an emphasis on first improving access to and use of space, moving on to tackling information processing problems and unhelpful beliefs about possessions, and finally focusing on preventing future hoarding. This is followed by clear rules about treatment – a mixture of rules related to the therapeutic alliance (such as the clinician is not to touch or remove any item without explicit permission) and pragmatic rules about the actual process of treatment (such as “only handle it once”).

Within the treatment planning section the authors include the “clutter visualization task”. This is a specific technique that is designed to help patients examine their feelings about their possessions and the likely impact of removing clutter; finally, the patient is asked to imagine what they will do with the uncluttered room. A detailed form guides the process. A similar form is recommended for acquiring; the recommended questions unpack the relevant thoughts and emotions related to acquiring new items. The chapter on cognitive strategies outlines basic cognitive ideas such as identification of cognitive biases and gives detailed vignettes and examples to illustrate how to adapt these techniques for hoarding problems. UK trained clinicians well-versed in cognitive models of anxiety disorders may find the formulation unfamiliar as maintenance factors are linked to emotion rather than beliefs. That is, the shared understanding is based on the premise that clutter builds up through efforts to obtain pleasure by saving or to escape/avoid unpleasant emotions.

Throughout the Therapist Guide it is acknowledged that this can be a very difficult problem to treat, with advice on troubleshooting, including comorbid problems. Steketee and Frost dedicate a chapter to motivational interviewing and other motivational enhancement methods. A direct skills training approach is recommended involving training in effective problem solving and organizing/categorizing. Following an emphasis on de-cluttering, the final chapters focus on preventing acquiring and preventing relapse.

The patient Workbook consists of an introductory chapter that provides brief, clear summaries of how hoarding is defined, relevant information processing problems, emotional attachment to possessions, thinking styles and behavioural avoidance. The treatment programme is then outlined. The next chapter is on assessment and includes all the questionnaires included in the appendix of the Therapist Guide. Many pages are dedicated to finding a “coach” from friends or family and agreeing rules to guide them in helping with the de-cluttering. Patients are guided through constructing a hoarding model and are introduced to thought records and the downward arrow technique, although the main emphasis in treatment is exposure.

When faced with a longstanding hoarding problem many clinicians feel overwhelmed and uncertain where to start. Without a doubt these books provide a clear framework for treatment. A particular strength of the book is the inclusion of novel specific techniques such as the structured visualization tasks. The detailed vignettes make the therapist guide highly accessible to clinicians whatever their level of experience or confidence. Clinicians who are not in the habit of following a structured programme of treatment may baulk at the idea of both therapist and patient turning a page rather than following a more idiosyncratic agenda. However, the treatment is only prescriptive in that it is presented in a logical and pragmatic order with sound clinical suggestions based on empirical research. As the evidence base for CBT for hoarding is growing rather than already established, I look forward to updates of these publications in the future.