Strange ways

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.