When legal issues arise, clients who hoard or their family members tend to look for “the bad guy.” Because they may face homelessness or legal penalties that they cannot afford, clients and their families are understandably terrified and angry may blame any public health and safety official who is involved with the severe hoarding situation. In such circumstances, clinicians may feel pulled to “protect” the client from the antagonists who threaten him. However, these officials can be powerful allies in the struggle to assist a client with severe hoarding. Furthermore, in my experience, these officials are eager—and sometimes desperate—to find ways to avoid the loaming crisis and will look to the clinician for help.

Regardless of how the client views the severe hoarding problem, or how often he tells you he can manage the problem on his own, if he has a severe hoarding problem then he requires help from the authorities. No one person can manage a severe hoarding problem. Managing a severe hoarding problem over time requires a team of committed stakeholders (clinician, family members, service providers, and others) who are concerned for the safety and welfare of the person who hoards. Generally, the more people monitoring a hoarding problem, the safer the client is likely to be. Those who represent the town or the municipality have access to important resources, such as low-cost treatment clinics or professional organizers who specialize in hoarding. Clinicians may wish to connect the client to appropriate resources within the community as well as to assist family members to connect with resources that may help them.

At the same time, I do not recommend that clinicians include just any professional or authority on the HR team. As the clinician develops the HR team, she may encounter people who would not make good HR team members. For example, a code enforcement officer who interprets health and safety codes rigidly and is not open to collaboration does not make a good HR team member. At the same time, professionals are human too and do make mistakes. If the professional is willing to work with the clinician to correct his mistakes and to fully collaborate as a team member, he may make an excellent HR team member.

The clinician may wish to encourage the client to permit the clinician to reach out to those who the client perceives have acted badly toward him and to educate them about hoarding and even about the client’s specific struggle. Clinicians have knowledge about the condition that can help correct the beliefs professionals and family members may hold that have led them to resent the client or to believe that there is nothing that others can do to help. Correct information about severe hoarding and what actions the client is taking to manage and correct the problem can enhance empathy toward the person who hoards. Clinicians may wish to distribute a handout on the condition to family members and others involved in a severe hoarding situation (see Appendix 1) or a handout on the harm-reduction approach (see Appendix 2).

The clinician may wish to work with the client to reach out to family members and neighbors who are distressed by the hoarding problem. Some family members may wish to write letters to neighbors explaining that the client is working on the problem and that the family and a team are assisting the client to resolve the hoarding problem as quickly as possible. Family members or sympathetic neighbors who reach out in this way to the community can sometimes lessen the frustration and protests of neighbors and shift the community from antagonist to supporters of a harm-reduction approach.

It is essential that the clinician assist the client and family members to view all professionals as potential team members in the HR approach, even those who may threaten eviction of the client if he does not resolve the hoarding situation. Authorities involved in a severe hoarding situation are not “bad guys.” They are there to protect the client and the community. In addition, they are key players in a plan to keep the client in his home and the clinician may wish to help the client understand that he seldom benefits from refusing to speak to those who are there to do their job. Furthermore, the effective clinician will find ways to involve these professionals in the HR approach and, at the same time, to assist the client to work collaboratively with these professionals rather than oppose their inevitable participation in a severe hoarding problem.

Each municipality or state has its own set of health and safety codes. These codes are laws and regulations that ensure that residents live safely and comfortably in their homes and communities. Clinicians may wish to become familiar with the health and safety codes of nearby municipalities (see Fig. 11.1). Health and safety codes are minimal standards and thereby useful benchmarks for developing HR targets. Health and safety codes can differ greatly by region. In addition, clinicians who are aware of these codes can work with the client to bring the home into compliance before the hoarding situation comes to the attention of the authorities.

When someone is out of compliance with health and safety codes, code enforcement notifies the resident that the dwelling is noncompliant. The code officer then describes what the resident must do in order to bring the dwelling back into compliance as well as what citations and fines he faces if he fails to comply. The code officer will specify the date of the next inspection. In my experience, it is difficult for people who are frail or disabled to achieve compliance without assistance. Fortunately, most code officers provide community resources to assist the client to comply with the code standards. If the code officer does not mention these resources, clinicians may wish to ask the officer for a list of resources in the community that can help. For example, some meals-on-wheels programs and other community resources for the elderly send volunteers to help the client clear and clean a living space so that it meets minimal health and safety code standards.

Chronic and severe hoarding problems result in the gradual deterioration of the structural integrity of a home. Floors, subfloors, and floor joists may buckle under the weight of tons of debris or years of water damage. At times, the home is so dilapidated and beyond rescue that code enforcement has no other recourse but to condemn the property.

Code enforcement may condemn a home for reasons other than the structural integrity of the dwelling. For example, code enforcement may condemn a home because the resident is unable to remove the strong odors that are common in hoarded residents, such as the odor from animal or human waste, deteriorating animal corpses, spoiled food, stagnant water, or mold. Not only are these odors highly unpleasant, but neighbors may also experience serious respiratory problems and infections because of the odors emanating from a severe hoarding site. For example, in the apartment of a client with a severe hoarding problem, feces from 24 cockatiels and three small dogs coated sections of the carpet, walls, and even the ceiling. In some areas of the home, the cleaning people were unable to remove the feces entirely, even after considerable scrubbing. In this case, the property owner and city health officials decided that conventional cleaning was inadequate and they condemned the home. Insect and rodent infestations are a particular problem in apartment buildings where infestations can spread quickly to neighboring units. Fumigation and clean up may be sufficient to eliminate pests such as ants and cockroaches. However, condemnation of the property may be the only viable intervention to protect the client and other residents from serious diseases or injury from the collapse of a wall that termites have damaged and weakened.

This next section describes legal and medical arrangements, including conservatorship and advance directives typically used to protect the rights and interests of an individual when she is no longer able to do this for herself. Clinicians may benefit from becoming familiar with these legal arrangements and, in particular, when assisting frail older adults who hoard and who may not be able to care for themselves. In addition, hoarding behavior can co-occur with other serious psychiatric conditions that contribute to self-neglect (e.g., dementia, schizophrenia) and conservatorship can serve as a safety net for the client to avoid homelessness and financial ruin.

That was the situation for Albina, who had to move in with her sister after she lost her home through foreclosure because she could no longer pay her monthly mortgage payment. Albina was retired and lived on a small fixed income. She had thousands of dollars in credit card debt because of her compulsive spending. Albina’s sons worried about her financial well-being and where she would live if her sister asked her to move out. Albina’s sons petitioned the court to become conservators for their mother. Albina agreed to have her retirement checks mailed to her sons and they then sent her a portion to live on. With the rest of the money, they worked to pay down her debt and contribute to a savings account.

A conservatorship (or guardianship in some areas of the United States) allows one person to make health, financial, and legal decisions for another person when authorities have deemed that he is no longer able to care for himself. The objective of conservatorship is to protect people who are at high risk of injury or financial loss, or who require someone to make legal, financial, or medical decisions on their behalf. A client may be eligible for conservatorship if there is evidence of diminished capacity. A county authority would have to evaluate the client and conclude that his mental or decisional capacity consistently renders him unable to safeguard his own health and safety. A severe hoarding problem in and of itself does not usually satisfy the definition of diminished capacity, as many people who hoard still take care of their daily needs like bathing and eating. Individuals with severe hoarding who are also gravely disabled or who live in squalor are more likely to qualify for conservatorship.

Courts grant conservatorships and appoint conservators. Typically, courts grant conservatorships for 1 year and the courts can terminate conservatorships at any time. Conservators can be a family member, friend, Public Guardian, or a private agency or professional (attorney, accountant, or mental health provider) (Wilber, Reiser, & Harter, 2001). A Public Guardian typically becomes the conservator by default when there is no willing or qualified loved one or when the conservatee cannot afford a private conservator.

Once the court appoints a conservator, the conservator determines the arrangements necessary to provide the conservatee with her basic needs. These include food, clothing, shelter, and medical treatment. Conservatorships can be limited to protections over specific domains and not others. For example, conservatorships can focus on ensuring that the person is clothed, fed, and housed, or alternatively can focus on protecting the estate, which involves managing money and assets.

People have mixed attitudes toward conservatorship. Some people see conservatorship as a benevolent safeguard protecting the best interests of an individual. For example, a conservatorship may help a client live independently in her home longer, thereby postponing a move into an assisted-care facility. Conservatorships can also provide a means to increase social support for the client as well as a means to monitor her safety through routine visits to her home. Thus, when used thoughtfully and with the best interests of the client in mind, conservatorship benefits some clients. Other people, however, see conservatorships as highly intrusive and demeaning to the conservatee since the process removes fundamental and constitutional liberties from adults (Wilber et al., 2001). Procedures for conservatorship vary by state or region. Clinicians may learn more about conservatorships by contacting the local department of aging or adult protective service.

Fulfilling conservator responsibilities can be quite stressful for family members and professional conservators alike. For one, the role of conservator requires a substantial time commitment and may involve court appearances, bookkeeping, direct care giving, and managing additional caregivers (Wilber et al., 2001). Conservators often have to balance and manage scarce economic resources to ensure quality care for the individual. Keeping other family members involved increases the demands on a conservator, particularly when the conservatee requires substantial monitoring and care, as is the case when the physical and cognitive abilities of the conservatee is deteriorating. This latter situation is particularly difficult for an individual who is both a family member and conservator of a loved one in decline. When a family member assumes the role of conservator, it can take a considerable emotional toll on both the client and the family member. Even professional conservators and Public Guardians are not free of the stress of caring for the conservatee, particularly when his family members are difficult and challenging and have attempted to exploit him prior to conservatorship (Wilber et al., 2001).

Clinicians can serve an important role for family members who wish to pursue conservatorship for a client. Clinicians can provide emotional support both to the client and to his family throughout the long and often distressing process of seeking conservatorship. Clinicians can serve as a liaison between the client, the court, and other professionals involved in the petition for conservatorship, particularly during the early months when the client and family are adjusting to their new roles.

Many people with severe hoarding have received eviction notices (Rodriguez et al., 2012). Eviction notices typically inform the resident that he has a certain number of days to vacate the premises (see Appendix 3). The notice does not usually describe the specific complaint, nor does it describe what the resident can do to avoid eviction. Typically, by the time a client receives an eviction notice, the property manager has likely delivered to the client multiple written complaints and verbal warnings.

Most clinicians who work with clients with severe hoarding will encounter the eviction process. Clinicians who have a general understanding of the process are better able to provide effective support during this very difficult process. Again, I recommend clinicians encourage clients who have been served an eviction notice to seek legal consultation and to connect them with appropriate legal resources.

Eviction based on behaviors associated with hoarding disorder or other psychiatric conditions which include hoarding behaviors may constitute discrimination under the federal Fair Housing Act (Fair Housing Act § 42 U.S.C. §§ 3601–3609, 1968) (the Act, see 42 U.S.C. §§ 3601–3619 for the entire Act and 42 U.S.C. § 3604 (f)(3) for the section on discrimination under the Act). The objective of this Act is to promote equal access to housing and to prohibit discrimination based on race, national origin, religion, skin color, sex, familial status, and disability, including mental disability. To ensure that those with a disability have equal access to dwellings, the Act requires that housing providers make reasonable accommodations in their services, practices, rules, and policies for such individuals and families. A housing provider may not deny a request for a reasonable accommodation unless it imposes an excessive financial or administrative burden. Private property owners may have more limited resources than public housing providers. Therefore, reasonable accommodations may differ for private and public housing providers. Nonetheless, the Act determines that all housing providers will work to reach an agreement with the person requesting an accommodation.

In order to evict a tenant, the property owner or property manager must file an unlawful detainer lawsuit with the court. Before filing the suit, however, the property owner must first present an eviction notice to the resident that specifies the length of time until eviction. The property owner cannot evict the tenant until the end of the period specified in the eviction notice. The outcome of an unlawful detainer case centers around three questions: (1) whether the tenant committed a nuisance, (2) whether the tenant suffers from a disability, and, if so, (3) whether the tenant requested or the property owner offered a reasonable accommodation for the disability.

The first consideration is whether a nuisance exists. A nuisance is a serious inconvenience or threat to safety that exists on the property. The fire or building inspector is often the person who determines whether there is a nuisance. Even mild or moderate hoarding situations can result in unsanitary or unsafe conditions that violate the terms of the lease. Nonetheless, the Fair Housing Act is clear that housing providers who fail to make a reasonable accommodation are guilty of discrimination based on a mental disability.

The next factor, disability, pertains to whether there is evidence of a medical or mental health illness that impairs the tenant’s ability to correct or repair the nuisance. If the tenant has a disability and the property manager has not offered reasonable accommodations, the tenant may file suit against the property owner for violation of the Fair Housing Act. If a tenant is facing possible eviction, she must provide to the court evidence of a disability. Usually, this includes a written report (see Appendix 4) with a diagnosable psychiatric condition conducted by a qualified professional. Clinicians with expertise in hoarding are well qualified to conduct evaluations and generate a report that describes severe hoarding and its associated challenges.

Finally, unlawful detainer cases consider whether the property manager offered the tenant a reasonable accommodation for her disability. For severe hoarding cases, a reasonable accommodation is typically for the property manager to grant more time to the tenant to correct the situation. A reasonable accommodation may also include assistance in referring the tenant to appropriate psychological and pharmacologic treatments to address the hoarding problem. If the tenant does not comply with or adhere to the recommendations for accommodation, such as treatment, the tenant loses her protections under the law and the property owner or municipality can move ahead and evict her.