Treatment for Hoarding Disorder provides a clear and comprehensive guide for overcoming this disabling problem, in the form of a therapist manual and accompanying client workbook. Since the recent inclusion of Hoarding Disorder as a separate diagnosis in the DSM-5, there has been growing awareness of hoarding, and it is likely that increasing numbers of sufferers will present for treatment. The manual and workbook therefore provide a timely and much needed addition to the literature.

The books are part of the “Treatments that Work” series, which aims to disseminate cutting edge, empirically supported interventions that have been carefully selected against stringent criteria. Treatment for Hoarding Disorder is based on over 20 years of research and is written by renowned experts Gail Steketee and Randy Frost. The books have been updated from the first edition to reflect the changes made in the DSM-5 and to include the latest research findings, including the positive outcomes of the cognitive-behavioural treatment trials on which this edition is based.

The first few chapters of the treatment manual include an introduction to Hoarding Disorder and the evidence base for its treatment, followed by advice on assessing and formulating the problem and preparing for treatment. In the assessment chapter, comprehensive instructions are provided, along with useful measures and forms that can be used for assessment purposes. The authors include advice on planning home visits, including written instructions for “coaches” who may assist and support the client during treatment. The formulation chapter includes a general conceptual model, which includes vulnerability factors, cognitions, emotional reactions and learning theory to account for the development and maintenance of hoarding. A simplified version is provided to use with clients. The model does not specifically include the physiological effects and consequences of hoarding (e.g. feeling overwhelmed may result in fatigue and reduced motivation for sorting possessions). However, later in the book it is mentioned that fatigue and health problems could be incorporated into the formulation as vulnerabilities and avoidance behaviours. A positive version of the model in the “Treatment Planning” chapter gives hope and helps to guide treatment. The authors also encourage the use of functional analysis to gain an understanding of specific situations.

The therapist manual continues with chapters on the cognitive and behavioural treatment components. Much of the work early in treatment is aimed at helping clients to learn skills and challenge their thinking about possessions, rather than focusing too much on the clutter. The “Reducing Acquiring” chapter includes rules for acquiring, exposure based exercises such as “non-shopping trips”, cognitive techniques and finding alternative sources of enjoyment and coping. The “Training Skills” chapter addresses organizational and problem solving skills including the development of a Personal Organizing Plan. “Making Decisions about Saving and Discarding” includes step-by-step guidance for evidence based techniques. The “Cognitive Strategies” chapter incorporates traditional cognitive therapy techniques alongside strategies such as defining the importance and value of possessions. The “Maintaining Gains” chapter includes a treatment review and relapse prevention techniques, but there is no written relapse prevention plan, which would be a useful addition.

Throughout the manual the authors address the difficulties that can arise when treating Hoarding Disorder. A dedicated “Enhancing Motivation” chapter includes examples of how motivational interviewing techniques may be applied with this client group. There is a section about troubleshooting barriers to progress, and towards the end of the book other complications (such as co-morbidity, housing, financial and safety concerns) are addressed. The client-therapist transcripts throughout the manual demonstrate strategies for assessing clients’ needs and skilfully bringing about change. There are also references to online videos of the authors demonstrating therapy techniques.

The client workbook follows a similar format to the therapist guide. It contains briefer information and blank worksheets and forms for clients to use with guidance from the therapist. The authors state that the workbook is a critical part of therapy, and they recommend that clients bring it to all sessions. It is worth noting that some clients may choose not to purchase the workbook, and it may not be feasible to provide clients with workbooks in NHS settings. However, the worksheets are available in the therapist manual and are also downloadable. The workbook is well structured and its large size, clear formatting and multiple copies of worksheets make it a helpful resource for clients who do choose to purchase it. On the whole it is very clear and easy to understand, but the occasional use of jargon, such as the terms “positive and negative reinforcement” in the hoarding model, may be somewhat confusing to clients. It is therefore important that this is used alongside therapy and that clinicians take time to ensure a shared understanding of clients’ difficulties.

It is noted at the start of the therapist manual that “Although the 12 chapters in this manual suggest a sequence of intervention strategies, we do not provide session-by-session instructions but, rather, adopt a modular approach”, and it is recommended that clinicians “decide on what aspects of hoarding to focus on first and what methods to use” after completing an assessment and individualized formulation. There may be a danger that less experienced therapists will forgo this advice, as the step-by-step, manualized, approach can be seductive when in a busy clinic environment. However, if used as intended by the authors, I believe the treatment manual and accompanying workbook are valuable resources for clinicians who treat this problem, no matter their level of experience, and I would not hesitate to recommend them. Treatment for Hoarding Disorder is a timely addition to the literature on Hoarding Disorder, and it brings clarity, structure and hope in overcoming a problem that may sometimes seem insurmountable.