SAN DIEGO – Vicky Wittorff's cozy, rustic home is full of antiques – but not too full. Each piece is carefully placed, whether it's on a side table, wall or windowsill. Everywhere you look, something odd and interesting catches your eye.

It wasn't too long ago that the house was too full, with boxes and bags stacked almost to the rafters. The only way to move around was via a narrow path carved from the clutter.

"Clothes, paperwork, toys, shoes – you name it, I had it," Wittorff recalls.

Wittorff and her husband, Bob, a cabinetmaker and firefighter, built the home in 1973 on an acre of land in Jamul, California , a rural town roughly 20 miles east of San Diego . Wittorff kept a tidy home – friends would comment on how beautiful it was, she says. Then on Mother's Day in 2002, her youngest daughter, Janelle, was shot and killed by a friend in the Wittorffs' driveway. The friend had been struggling with alcoholism and depression, and Janelle, 18, was trying to help her.

Overwhelmed by grief, "I gave up," says Wittorff, 67. She and her husband started buying things to fill the void left by their daughter's death.

Wittorff stopped inviting friends over, too ashamed of the mess. Things got worse when Bob fell ill. The night he died, in March 2017, a friend came over to check on Wittorff and saw the condition of the house. "I'm not judging you," the friend told her, "but we need to help you."

Vicky Wittorff holds one of the last photos of her youngest daughter, Janelle, who was shot and killed on Mother's Day in 2002. After Janelle's death, Wittorff and her husband started buying things to try to fill the void. (Brett Ziegler for USN&WR)

It's estimated that around 2% to 6% of the U.S. population suffers from hoarding disorder, which is marked by an inability to discard items of little use or value. Research suggests the number of older adults living with hoarding disorder is actually higher.

Changes that come with aging – like cognitive decline, downsizing to a smaller living space, or the loss of a spouse, family member or friend – can trigger or exacerbate hoarding behavior, says Catherine Ayers, an associate professor of clinical psychiatry at the University of California–San Diego who's studied hoarding disorder for 15 years.

Hoarding, in turn, can create significant health and safety risks for seniors. Clutter can cause falls or fire hazards. An inaccessible kitchen can lead to problems with nutrition and food contamination. Medications are easily lost. In severe cases, hoarding can lead to eviction and homelessness.

Through her research, Ayers developed a unique approach to treating hoarding disorder in older adults. Called CREST (Cognitive Rehabilitation and Exposure/Sorting Training), it combines exposure therapy – encouraging someone to face whatever is causing them distress – with what's referred to as "compensatory cognitive training" to address deficits in memory, concentration, decision-making and problem-solving.

In 2016, through a contract with San Diego County's Health and Human Services Agency, Ayers created a mobile, in-home program using CREST's treatment approach. The county's Older Adult Council, a volunteer advisory group, had identified hoarding as a growing problem that was putting low-income seniors at risk of eviction. Funding for the program came from California's Mental Health Services Act . Passed by voters in 2004, the act levies a 1% tax on personal income over $1 million. So far, it's generated about $15 billion for mental health treatment and services.

Over 26 sessions – more if necessary – CREST participants work with a case manager who helps them set goals, create to-do lists and schedule tasks. Several sessions focus on strategies to improve memory and organization. After eight weeks, participants are introduced to exposure training to help them ease into the process of sorting and discarding items. If they need additional assistance, Debbie Lynn, a peer specialist who's been through the program, will sit with them to provide emotional support and encouragement as they go through the decluttering process.

"They may think we're going to get in there and be heavy-handed and just throw out their items," Ayers says. "We don't do that at all."

Rather, the process is gradual and participants work at a pace that's comfortable for them, Ayers says. A workbook that guides them through the program urges participants to "think of your efforts as a lifestyle change and not a 'quick fix.'"

Gardening is a therapeutic activity for Wittorff. Hummingbird sculptures adorn her garden in honor of her daughter Janelle. (Brett Ziegler for USN&WR)

Data from CREST's first two years underscores the threat hoarding poses to housing stability. Nearly two-thirds of the more than 20 initial participants reported being pressured by others – like property managers or city officials – to clean up their home or apartment. Half said they'd been homeless at some point in their lives or had not had a home of their own, and another 43% said they had nowhere to go or no plan for where to stay if they lost their current housing.

Data also shows how intractable the disorder can be: Roughly half of program participants in 2017 who completed 26 sessions needed more treatment. In 2018, the county received additional state funding that allowed CREST to expand from two clinicians to six.

Ayers says CREST routinely gets referrals from property managers and code enforcement officers. Initially, only people who were uninsured or on Medicaid could participate in the program, though it now can serve Medicare patients as well.

"Many (participants) have eviction notices or 30 days to rectify code violations," Ayers says, "so we try to figure out a plan to keep a person in their home." She says all of the CREST participants who were facing eviction prior to joining the program have been able to stay in their homes.

Since hoarders often isolate themselves, CREST staff also coordinates with agencies and organizations that might come in contact with someone in need of help, like animal control and Meals on Wheels.

"We're all around town giving talks and presentations," Ayers says. "We flyer all over the place. We do provider trainings."

Liza, a program participant who asked that only her first name be used, doesn't remember exactly how she found out about CREST.

"But I should remember," she says, "because it was like the clouds parted and a ray of sunshine came down." At that point, she was 59 and living in a part of the county not yet covered by CREST. Staff took down her contact information and said they'd give her a call when she became eligible.

"When they called, I was so excited because it was just so dreadful. I was so stuck, I couldn't move on in life," she says.

Liza, now 61, meets weekly with Lynn, CREST's peer counselor. With Lynn's help, she's cleared out her living room, kitchen and a downstairs bathroom. On a recent afternoon, boxes of paperwork were stacked on the kitchen table, awaiting a sorting plan Liza was working on with Lynn's assistance. There were still her bedroom, garage and two storage units to tackle.

Liza, like Vicky Wittorff, once kept a tidy house. An environmental planner, she prided herself on being organized. "I could open any file and I knew right where things were," she says.

But after a series of health issues, her mother's death and a car accident that left her son with a traumatic brain injury, Liza found herself struggling to make decisions and follow through with basic tasks like paying bills. She was the executor of her mother's estate, left to deal with a house in Arizona and another in Ohio that had been in the family for 200 years. Her mother was a collector – "except she was very neat," Liza says – and Liza couldn't bear to part with her mom's things.

Friends would come over to try to help Liza sort through everything, but she'd become frustrated by their efforts.

"I lost all those friends," she says. "I just didn't know why I couldn't do this. It seems like I should be able to go through stuff and throw some out, put some away. But it was like being in quicksand."

She says CREST helped her develop a system for discarding items. "They gave me tools so that I would know what to do with stuff when I went through it," she says.

She remembers the moment when everything clicked. She was trying to decide what to do with a chipped bowl.

"Do I really want to spend my time fixing this little thing?" she recalls thinking to herself. "Do I need it? I'm 61. Do I really want to spend my time that way?"

Making the decision to discard the bowl "was really freeing," she says.

A statue of an angel, in honor of her late daughter, Janelle, stands outside Vicky Wittorff's home in Jamul, Calif. (Brett Ziegler for USN&WR)

When Vicky Wittorff's friend put her in touch with CREST, she'd moved out of her house and into a trailer on her property. A leaky roof had led to a mold problem. Phillip Salas, one of CREST's licensed therapists, first visited Wittorff in October. He took photos of her house so they'd be able to track her progress.

On a recent afternoon, Salas and Wittorff sat at her kitchen table as he scrolled through the photos.

"No light coming in, right?" she reminded him, pointing to a large window that had been almost completely blocked by stuff.

"It was bad," Salas agreed.

"He saved me," Wittorff says of Salas, who helped her not only sort through her possessions, but also the grief and trauma that had triggered her hoarding. He brought in a contractor to fix the roof and, through a fire prevention grant program, had San Diego Gas & Electric come out to clear dry brush and vegetation from the property. From there, Wittorff took over, finding people willing to remove the trailer she'd been forced to live in and a broken-down van. She traded a truck for a new staircase for her home.

CREST's grant runs out in June. Connie German-Marquez, a behavioral health program coordinator with the county of San Diego, says county leaders will need to decide whether to continue the program and how to fund it.