Over the last ten years, I have worked as a clinical psychologist providing a psychological service to elderly people, both directly and through staff. Often referrals are made when a difficult behaviour escalates and becomes so distressing to staff or relatives that the caring relationship or placement is threatened; some patients show cognitive impairment, although this is not the major problem; often there have been major recent changes in health, circumstances and relationships; there is sometimes a recent history of multiple losses; sometimes carers hold the opinion that the problems are deliberately caused by the patient; some are referred only after having been seen by several other professionals.