News

An eccentric older man provokes suspicion, setting Jez Millen and Lesley Wallman-Durrant a difficult task to support and protect him. Graham Hopkins reports.

The names of all service users mentioned in this article have been changed.

Case notes

Practitioners: Jez Millen, social worker and Lesley Wallman-Durrant, community psychiatric nurse.

Field: Community mental health team for older people.

Location: Nuneaton and Bedworth Council.

Client: George Villiers, a man in his early 60s, lived alone in his own house. He was previously unknown to social services. He had developed obsessional behaviours following his retirement and many considered him “eccentric” owing to his manner, behaviour and appearance. He wore a prosthesis - having lost a leg when he was six years old.

Case history: In spring 1998, Villiers was arrested for shoplifting. He was distressed, aggressive and unable to communicate verbally in a rational way, so police had to call for an appropriate adult to be present. Charges were not pressed but Villiers (under the Mental Health Act 1983) was admitted for assessment to an in-patient ward for assessment and subsequently detained for a short time. His diagnosis was of a mental health problem probably caused by frontal lobe deterioration, which reduced his ability to follow conventional social customs.

Dilemma: Villiers’ behaviour, although innocent, could be misconstrued and could further aggravate local hostility to him.

Risk factor: Remaining in his own home, Villiers faced risks of worsening self-care, arrest and potential violence.

Outcome: Villiers remained in his own home for a few more years, although he deteriorated mentally. He now lives, contentedly, in a residential care home.

The word “eccentric” comes from the Greek “ekkentros” meaning “out of centre”. And while we might warm to notions of mad professors, everyday eccentricity can be uncomfortable and unnerving.

Although he was unknown to social services, George Villiers was living his life increasingly out of centre. And then he was arrested for shoplifting. This new experience left him traumatised, incoherent and aggressive. He was sectioned but following assessment was permitted to return home with the support of the community mental health team.

“Our assessment showed that Villiers had little understanding of shoplifting and tended to take things he needed from shops,” says social worker and keyworker Jez Millen. “His behaviour included writing out recipes every afternoon, and sometimes in going out for more paper he’d forget to pay for it.” A one-time self-employed draughtsman, Villiers would copy out recipes from cards: “They really were works of art,” says Millen, “He had ringbinders full of recipes. He saw it as productive work.”

“He didn’t have an obsessive compulsive disorder,” adds Lesley Wallman-Durrant, the community psychiatric nurse who was monitoring his medication and mental health. “He had an almost autistic profile. He looked the part. He looked eccentric.” Villiers tended to fiddle with his artificial leg around his groin area when it became uncomfortable - as it often did. This offended people who thought he was masturbating.

“He had been doing the same things at the same time everyday for 10 years,” continues Wallman-Durrant. “Up at 7am, out at 8.30am. Pork Creole for lunch at 12. At 4pm he had corned beef sandwiches. At six he would watch the first of four videos. Bed at 10.30pm.”

Villiers also preferred to hide rather than pay his utility bills, risking not only being cut off, but also further legal action. Millen helped set up direct debits for him, ensuring future hidden bills would be paid.

Once, convinced he had won the Reader’s Digest draw, Villiers set off to see Tom Champagne, the prize draw manager. “But because he was determined to get back at 4pm for his sandwiches,” recalls Millen, “he got on the wrong train, and eventually got arrested by the transport police. We contacted the train firm - and not only did they reimburse his fares but also advised their conductors on how to deal with him.”

For a year, Villiers lived successfully at home. “We sorted his garden out”, adds Millen, which had been another bone of contention with his well-heeled neighbours, “made sure his bills were paid, made sure he kept his hospital appointments and made regular shopping trips (sometimes accompanied), and then we had the call from the head teacher of the nearby primary school.”

It transpired that Villiers was outside his gate waving at children as they went to and from school. “That upped the ante,” says Millen. “And that’s when we had to weigh the risks carefully - not just to him but presented by him.”

The head teacher was supportive, as she knew Villiers. Parents, however, were less understanding, thinking him - in his raincoat and brightly coloured bobble hat - a pervert who should be locked up. Millen continues: “They were worried. So we thought we’d arrange for home carers to go in at the crunch times, to help with personal care and to give him something else to think about.”

One of the parents, a police officer, said they had seen Villiers masturbating outside the school. “This seemed extremely unlikely to us because of his leg problem, but we had to take it very seriously,” says Millen. As there was no history of problems or behaviour from children’s services, police or his GP, and because parents were always there, child protection concerns were allayed.

With all the support in place, including a community support worker, it was agreed that Villiers should remain at home. “We thought the people who were antagonistic about him needed to understand him,” says Wallman-Durrant. Most of his behaviour started after his retirement, his lifestyle changes being supplemented with ritualistic behaviour. There was no evidence that that his behaviour would escalate into something sexual or become dangerous.

Villiers did manage to stay in his own home for another year or so. However, his deterioration escalated because he began to be bullied, threatened and picked on by a gang of youngsters. “They stole from him and set fires in his house. It was all interfering with his lifestyle too much. Whereas he used to be able to shut his door and have his privacy, that wasn’t there anymore,” says Wallman-Durrant. Villiers moved into a care home, where fortunately he adopted the home’s routines and rituals. “He now feels safe,” she says. And, indeed, centred in his world.

Arguments for risk

- By working hard to support Villiers to remain in his home and maintain independence and control over his life, the mental health team sought not only to maintain his quality of life but also to meet his expressed wishes. Villiers loved his cooking, walking, writing out his recipes, watching videos - and he continued all these activities.

- By staying at home Villiers was being monitored daily by a combination of social worker, community psychiatric nurse, home carer and social work assistant, so any difficulties would be picked up quickly.

- Villiers had a clean history and all his behaviours had stemmed from his retirement. There was no evidence that his behaviours would escalate to put children or himself at unnecessary risk.

- The best part of this case, says Millen, is its “multi-agency strength” -  the way

different strands of service pulled together to ensure that Villiers’ wish to stay in his home was realised.

Arguments against risk

- The behaviour of Villiers outside the school was clearly a worry. Although it always happened in front of parents, and no “grooming” of particular children was attempted, it was concerning that he did not understand how parents or children themselves might perceive this. The groundswell of parental anger - calls for him to be “locked up” and so on - could potentially explode into violence.

- Villiers’ lifestyle did not convince that he would manage his own care well. There was concern over his eating habits - such as cooking and then reheating pork each day.

- There was a strong risk that his behaviour could lead to another arrest, which inevitably would disrupt his routines and cause him acute agitation and distress. Local people might be alerted to his lifestyle, but those who did not know him could still accuse him of committing an offence.

- Villiers was vulnerable to verbal and physical attacks from those who found him eccentric.

Independent comment

The case of George Villiers is interesting given that his medical, social and psychological history before retirement appears to be largely unremarkable, writes Dr Eric Davis.

The responses of Jez Millen, Lesley Wallman-Durrant and others are to be applauded. The assessment evidence suggests a frontal lobe-related difficulty for Villiers. Retirement, or other significant life change, is known to trigger or exacerbate brain-related difficulties. Presumably Millen and Wallman-Durrant would have arranged a psychological or neuropsychological assessment for Villiers.

Typically, frontal lobe damage can result in some or all of the following difficulties: problems in getting started on tasks; problems in being aware of your own thoughts or behaviour; problems in stopping behaviour - “perseveration”; problems in being able to plan, consider and reflect - “reduced executive function”; impairment in social cognition, - “a reduced understanding of how others think and feel”; and acting in ways that are considered unconventional.

It is possible that Villiers is suffering from frontal-type difficulties. He is most likely to be a danger to himself, not through active self-harm, but through passive self-neglect. He is most unlikely to pose a danger to others, given his problems in being able to plan ahead.

From a pragmatic view, supported residential accommodation appears the best option for Villiers.

Eric Davis is consultant clinical psychologist at East Gloucestershire NHS Trust.