YORBA LINDA, Calif. — Wet rag in hand, the older woman was trying to clean her filthy, packed garage to comply with a warning that she was violating city codes. As two officials approached to check on her progress, she proudly pointed to an open box in which she had placed two dead rats.
For maximum display, she had perched the box atop one of the garage’s many dense, waist-high piles: bins overflowing with clothes and cans, a bicycle frame, a mildewed mop.
Darren Johnson, an inspector with the Orange County Fire Authority, and Mary Lewis, a city code enforcement officer, smiled encouragingly. They maneuvered into the woman’s townhouse, its passageways blocked by the detritus of a troubled life. Both are members of the Orange County Task Force on Hoarding, trained not to gag at the stench, even as their shoes squished on newspapers slippery with rat urine.
Mr. Johnson, who with Ms. Lewis accompanied a reporter into the woman’s home on the condition that she not be identified, shined a flashlight over tangled electrical cords and ancient magazines. If a fire broke out, he told the woman, “my guys would have a tough time getting inside.”
“So we’d have to get you out through the window,” he told her. “But it would be hard for you to climb through this stuff to get there.”
The fire inspector added softly, “Can you let us help you clean this up, to save yourself and not put everyone else at risk?”
An estimated 3 percent to 5 percent of Americans suffer from hoarding, which was officially recognized as a disorder this month in a psychiatric diagnostic manual. But the impact of hoarding extends beyond the afflicted individual and relatives in the home: the behavior can also put immediate neighbors at risk, by creating perfect conditions for explosive house fires and infestations of vermin and disease.
Across the country, local officials like Mr. Johnson and Ms. Lewis have begun grappling with hoarding as a serious public health hazard. More than 85 communities — from San Jose, Calif., to Wichita, Kan., to Portland, Me. — have established task forces, hoping to stave off catastrophes and help hoarders turn their lives around.
The task forces on hoarding are finding their mandates daunting. With each case, officials must weigh when their authority to intervene trumps an individual’s right to privacy.
“The nature of the disorder demands multiple resources,” said Christiana Bratiotis, an assistant professor of social work at the University of Nebraska, Omaha. “No one discipline has all the expertise needed.”
The task forces typically include people from support as well as enforcement perspectives, added Dr. Bratiotis, a co-author of “The Hoarding Handbook,” an intervention guide. “There is value in the carrot-and-stick approach.”
Hoarding disorder is poorly understood, complex and often recurring: over decades, cases wax, wane and become chronic. It is distinct from cluttering or insatiable collecting. The self-soothing need to acquire, coupled with a paralyzing inability to discard, significantly impairs one’s ability to function.
Over the years, a hoarder’s health and hygiene become dangerously compromised. Because stoves, sinks and tubs are used for storage, cooking and bathing become impossible. Sleep becomes a relative term. When the queen-size bed of a rocket engineer Mr. Johnson tried to help became buried under mounds, the man simply hoisted a twin mattress on top. In 2010, a Chicago couple was found buried alive under years of possessions.
The possibility of a hot, hungry fire increases over time. First, utility bills become buried under snowdrifts of paper, so people forget to pay them. Electricity is turned off. Then residents use candles for light and gas burners for heat, inches from swaying towers of cherished trash.
In October 2011, a couple died in a fire in Dana Point, Calif. — a home that officials had tried for years to get cleaned up. Last October, a fire in Old Greenwich, Conn., destroyed a home that officials called inaccessible, leaving a woman critically burned.
In November, a Chicago man was burned, five of his dogs died and a neighbor’s home was scorched. Pat Brennan, a chief with the Chicago Fire Department, told reporters at the scene: “He was a hoarder. It impeded our progress.”
And the problem is not confined to the United States: a 2009 study found that the homes of hoarders accounted for 24 percent of preventable residential fires in Melbourne, Australia.
Task forces are also confronting another public health threat: infestations. After water is shut off, residents may urinate in bottles and defecate in the yard. Bacteria invade. Maggots feast. Vermin burrow.
In September, a woman who was trying to clean up a hoarder’s house featured on a reality TV show contracted a rodent-borne hantavirus. When a home shares walls with neighbors in an apartment building or a condo complex, contagion spreads.
Traditional methods for confronting hoarders are increasingly considered draconian and ineffective, creating new problems. Municipal cleanup crews or family members would throw the hoarded contents into a Dumpster, as the homeowner watched, traumatized. Officials would seek civil or criminal penalties.
In extreme cases, a hoarder’s home — floorboards weakened, waste pipes neglected, mold growing deep inside walls — would be condemned. Evicted homeowners and tenants, mentally ill and often estranged from relatives, became homeless.
A pilot study last year led by Carolyn Rodriguez, an assistant professor of psychiatry at Columbia University, found that of 115 clients who sought help from a New York City nonprofit organization to avoid eviction, 22 percent had clinically diagnosed hoarding disorder. In Boston, representatives from MassHousing, a nonprofit group, try to prevent evictions by showing housing court judges that tenants who hoard have a disorder and are receiving help.
Each task force is a loose amalgam of agencies and, depending on what resources they can muster, their goals may range from educating one another and the public to collaborating on cases. But some uniform procedures, and problems, are emerging.
Many task forces around the country use a standard checklist to rank homes. Those rated at levels 1 through 3 may need intervention but may not have descended into squalor.
“I’ve never seen a level 5” — the highest — “be cleaned up for less than $20,000,” said Mr. Johnson, the inspector, who travels among 23 cities in Orange County and says he sees between 60 and 80 severe cases a year. In some cases, public funds may be available to help cover the cost.
After evaluating a home for fire hazards, he may call in pest control, social workers who specialize in older adults — whose hoarding may have gone undetected for decades — and cleanup crews affiliated with the county’s task force. He will enter notes in a database for first responders, so that if there is a fire or other first-aid emergency at the home, they will be warned which entrances are blocked and to wear additional protective gear.
But even for a comprehensive task force, hoarding cases present harrowing, poignant obstacles, chief among them the homeowners’ fervent resistance to intervention.
Over the years, they increasingly withdraw, terrified of losing their possessions. Mr. Johnson has fended off vicious dogs and faced down armed hoarders. He spent two years trying to clean up one household. He leaves his card, returns every few weeks, brings sandwiches and intercepts residents outside the home.
Another challenge is the stigma of hoarding, dissuading many from seeking help. Some task forces have considered renaming themselves. The Wichita and Sedgwick County Hoarding Coalition offers a “What a Mess Workshop” and a “Clutter Cleaners Club.”
One impediment is whether officials have the right to gain access to a hoarder’s space, particularly to private dwellings. Although landlords and condominium property managers have the right to enter residences, those who do not share walls enjoy greater rights to privacy.
While each municipality has sanitation and building codes, enforcement is discretionary and selective. Even when neighbors complain of unsightly yards or noxious fumes, once those issues are addressed, compelling a homeowner to tackle the interior is problematic.
In egregious cases, said Capt. William Cummins, a fire official in Shrewsbury, Mass., task force members have gone to civil court for an administrative warrant.
But even after a home is rendered habitable, relapse is likely, especially if the underlying causes are not resolved.
Years ago, the woman in the Yorba Linda townhouse had gotten the courage to fill a Dumpster with hoarded materials, although there was plenty left.
“A therapist told me I should at least throw out my papers, but I couldn’t,” she told Ms. Lewis, the code enforcement officer, during the site visit. “There were checks in there somewhere,” she said.
Ms. Lewis learned of the woman’s situation from the complex’s property manager, after a crew came to fix an interior leak that was making one of her walls collapse. To get more information and gain her trust as they inched their way through her home, Ms. Lewis and Mr. Johnson gently chatted her up.
Did she need food? Medication? Since Ms. Lewis had already extended the stick of code enforcement, they now both offered carrots for the cleanup.
Mr. Johnson had a friend at a vermin-control agency who could help. Ms. Lewis had a list of cleaning crews, mentioning that the woman might be eligible for a grant to defray costs.
Mr. Johnson wondered if he might stop by to install smoke detectors. The woman looked relieved. She promised to attend a therapist-led group in nearby Buena Park.
“I didn’t come into this world a hoarder,” she said. “I’m 76 now. I’m not leaving as one.”