To be homeless, in most cases, means to have multiple needs that require multiple answers to be coordinated and that can hardly be met by a single agency: housing, bureaucratic, working needs, physical or mental health problems.
Furthermore, the way most of the homeless persons ask for help is not usually direct and explicit: very often the necessities emerge because the person “breaks” the fragile balance between the social context and his exigencies.
It is significant that third parties mainly convey the help’s requests: ordinary citizens, volunteers, social operators, and police officers.
Being urgent and not specific are therefore two additional characteristics of such requests, although the need that is detected in immediacy is usually of a health nature or to defend the public peace.
We may refer to a typical experience to highlight the complexity of the phenomenon: a citizen sees a person with characteristics easily attributable to a homeless (particular neglect, lack of hygiene, rough clothing, presence of backpacks, bags, cartons) in a severe physical difficulty, probably even in a state of chronic alcoholism or in a state of mental alteration, such as to determine disturbing, dangerous or disruptive behaviours.
In such a case, the first institution involved is usually the health care system, which, once resolved the emergency (mostly a state of poisoning or a psychiatric acuity) tends to avoid, for several reasons, a more comprehensive sanitary takeover of the person.
One of the reason may be represented by the lack of a further level of care in case of a hospitalization, consisting of a response to basic needs: clothing, changing of linens, toiletries, as well as company, encouragement and support, is usually supported by relatives, are missing or absolved in a discontinuous and not exhaustive way by the most various figures (nursing, medical, volunteer).
In addition to the issues strictly related to healthcare, this is often interfered by bureaucratic and administrative irregularities, a phenomenon that is increasingly present as a result of the large migratory flows affecting Europe in recent years: migrants, in fact, compose a significant part of this population.
Going back to the example, suppose that instead of calling for a health emergency to assist the person in trouble, the Social Services were directly involved: in the luckiest case, they will provide a more or less temporary shelter to the person until his recovery, in compliance with the legal requirements and the legal status of the person.
Rarely, however, the matter is exhausted through a solution of the housing order: it is very likely that the same reasons that led to the call, will occur again in the short time and that the situation will be repeated in a vicious circle that makes the failure of interventions an element of deep frustration for the person in need and for those who are in charge
1.2 Actors involved
As seen in the previous paragraph, in a typical situation of an intervention for a homeless person, we may need to refer to the following agencies:
It is interesting to underline that none of these actors is the only and directly responsible for the situation and each of them are therefore in the position to delegate towards other institutions.
For all the above, in some European realities, it has come to the constitutions of networking, that is, of meta-organizations including all the formal and non-formal institutions, which in various ways deal with this phenomenon.
1.3 Networking as a multi-layered approach
Networking is a “process which fosters the exchanges of information, ideas and practices among
Individuals or groups that share a common interest” (https://www.investopedia.com/terms/n/networking.asp).
Networking, in our case, means to optimise resources and competencies and to avoid contradictory or overlapping interventions.
Creating a network may allow to build a better diagnosis of the problem and to design the intervention and share it at the presence of all the involved entities; to organize the intervention in a procedural and organic manner granting the continuity of care; to overcome each institutional limitation and the different timing between organizations; to take part in the difficulties, not feeling to be solely responsible or, even worse, getting out and avoiding any responsibility.
1.4 Structural and operative networking
Talking about a network implies to contemplate two different levels, strictly interrelated: the structural and the operative.
We indicate with structural, the entire range of the organisation participating in a network in an explicit and agreed way. The network may be constituted in this case both by formal and informal institutions, governmental and non – governmental, public and private.
We define operative, the network strictly constituted by the persons, belonging to the different organisation represented by the structural network, directly involved in the specific case management: a front-line level, that designs tailored intervention and follows the process, case by case, on the field.
As said, these two levels should be interrelated, which means that in a certain way, the operative level should be a kind of output of the structural one, the concrete expression of the values and projects shared by the parties.
Reasons for networking:
To be part of a network should be an opportunity to:
2.2 To build a network
To build a network is not a spontaneous process: it underlies willingness and a specific effort and may take a long time and care.
First of all, it is necessary to “detect” the knots of the net, those sharing with us the same “problem”.
It is important to know the role of each “player”: missions, specific competencies, limitations, inspirational values. To deeply respect the identity and values of each participant, even the “free players”, for instance volunteers whose contribution may become really significant but is rendered on chance, for free and out of any structured organization, is the first step of a process that should lead to share common goals and to design appropriate and coordinated tasks.
In this first phase of contacts, the most common feeling may be of fear and suspiciousness: not to be understood or recognised in our efforts or limits; to be those who will receive most of the duties and responsibilities; to lose our decisional power. It is a very delicate moment, in which the aim should be to create the conditions for mutual trust and to build a “win/win” playground.
A “win/win” approach rests on strategies involving: going back to underlying needs; recognition of individual differences; openness to adapting one’s position in the light of shared information and attitudes; attacking the problem, not the people. Where both people win, both are tied to the solution: they feel committed to the plan because it actually suits them.
B. Networking between institutions:
3.1 Networking as a problem
Several issues can undermine the set-up of the proper functioning of a network.
Different values, cultures and languages between different professionals or roles, may represent a barrier in terms of sharing a goal or in the way this is reached.
To be a public organisation or a private, as well as to be an official or unofficial one, can raise the feeling of a power imbalance between the institutions and threaten the identity of the parties.
In some cases, it may occur that the persons representing the organisation to which they belong to, do not have any decision making power, a condition that could weaken the specific role or function.
The number of participants too can represent a problem: being “too many on the boat”, may affect the decisional and operational processes, creating the condition for a role blurring phenomenon.
A poor communication flow, a fragmentation or a lack of information, the absence of coordination between operators, may seriously affect the continuity even of a good plan, but especially of the long-term ones.
Another issue often disturbing the positive functionality of a network is the tendency to convert the role of the “facilitator” of the meta-organization, into a “coordinator” as the only responsible for the integration of the entire process, the only entitled to take decisions or, even worse, the only responsible for the outcome.
On the other hand, the lack of a “case manager”, that should be not the first and last responsible for the person in charge, but the facilitator of a fluent process may cause the collapse of the project, whenever any difficulty is encountered, due to a discharge of responsibility.
In some cases, the gap between the so said “structural” level and the “operative”, may become an obstacle to the agility of the process and the good results of the outcome. The structural level should be a frame, that grants the awareness to be in the position to overcome limits otherwise insurmountable, thanks to the presence of other institutions. Whenever the structural network prevails through requests of bureaucratic commitments, power struggles, lack of a co-working culture, lack of a common training, this may become a severe threat to the whole functioning of the net, in particular may affect the operative level whose main duty will become to be a function of the structural level, instead of being an efficient enactment.
Last not least in a list that might be longer due to the complexity of the subject, is the handling of all is related to the personal data protection (General Data Protection Regulation, UE 2016/679) a complex matter to manage, being many the agencies involved and the data shared between different professional figures and agencies.
3.2 Preventing difficulties
Building a network, as seen, is a process that foresees several steps.
The mutual knowledge of the parties, as a first step, not only is a necessary, but is also a very delicate phase: it is mainly about building relationship and any initiative that has to do with the promotion of social situation, is highly recommended in order to meet and better know each other, even in an informal way.
Especially for what concerns the so said “operative networks” it will be a must to plan meetings with the attendance of all the parties, to organise the activities and be debriefed on the developments of the different cases. A detailed follow up of the activities is also necessary, in order to check achievements, monitor results, share difficulties and implement recovery plans.
It may happen to have “extra – meeting”, due to the urgencies that arise dealing with human “material”: to be flexible is always a good way to cope with difficulties and complexity.
A good communication, based on shared Information is the basis of the network functioning: not only to provide the updates on every single case that the network is caring for but also to have common access to the information and the resources shared in the net.
Communication and commitment should follow the top - down and bottom – up way, and this is also why it is necessary that the persons in charge for each organisation, should have the decision-making power of the institutions they represent and feel in a peer to peer condition.
It is a good practice to agree on a Memorandum of Understanding, which should not sound like a strict and mandatory contract, but as document fine-tuning each entity, duty and responsibility.
The more the mutual understanding develops, the more will become a necessity to make experience of joint training, which means for instance to visit the places in which each member of the networks and operates: on the street for nurses, doctors, social workers; in some “war room” for the coordinators of the outreach team; in hospital wards or clinics; inside the houses of our clients; in some soup kitchen or shower service; in some government office, etc. etc.
To experience in real life and real time the way the other partners work and the problems they have to deal with daily increases the mutual understanding and tolerance and improves the esprit de corps.
In the light of the above, once the network is well structured, and that suspicion of subjugation or dominance by any party have been dispelled, and mutual trust is acquired, to provide a common training could strengthen the links and the mentality of the group.
To share a common space, in which contacts and communication may happen in a fast way, and the intervention may follow in an easier way the possibility to be tailored for the person in need, may be a big challenge for many European realities, but a good solution for many reasons.
4. GOOD PRACTICES
Who to involve:
A concrete example: NPISA in Lisbon
Filipe was a 40-year-old, tall, black, homeless man that had been living in the street for years in the neighbourhood where he had grown up and where his sister and brother were still living in the family house. His parents had passed away. The sister was the only functional member of the family. She was a physical therapist (their father had been a practice nurse), and single-headed took care of a teenage son and two brothers, Filipe and another brother that had been unemployed for years. While Filipe refused to go home and slept on the streets, his brother refused to go out and had closed himself in his room for years.
Filipe was a big concern for all the community of the neighbourhood. He drank heavily and was so careless with himself that was often seen defecating while walking! He was later on diagnosed a long term course of schizophrenia, with significant deterioration.
The staff working at the psychiatric hospital, that was used to have regular meetings (every 2 weeks) to discuss difficult situations with particular concern for the homeless with mental health problems, first heard about him through an outreach team belonging to the city council and therefore started to visit, on a regular basis, also this family.
Also, a local church group was very much involved in the case and tried to help Felipe and his family. They called for the city outreach team which eventually also asked us to evaluate Filipe's brother since nobody understood why he was isolated at home. So our team, a psychiatrist and a psychologist, paid a visit to their home. We had the chance to talk to his sister and Filipe' s brother. He was also an impressive tall man (he had worked as security), although he talked to us while lying down in the bed. His room exhaled a strong smell, and he talked very little as he was evidently suspicious and tense. His sister told us he refused to eat any of her food and didn't take a bath for a long time. We got out of this visit with a strong suspicion that Filipe's brother was dealing with a psychotic breakdown, and talked with his sister about her options.
Right after this visit, we heard that Filipe had surprisingly accepted to go to sleep in a small nice shelter downtown, with very good conditions and staff. The ladies of the church that had been looking after him for years, together with an outreach team, had managed to persuade him to leave the streets. Everybody was happy and hopeful.
But this joy didn't last for long. After a few days, Filipe became violent at the shelter, breaking a lot of windows. Amid his rabid outburst, he managed to hurt himself, by falling and breaking a leg. He was sent to a big general hospital in the city, where he was taken care of his leg and psychiatrically examined. Within a few days, he was discharged back to the shelter.
The staff of the shelter was quite scared of Filipe coming back so soon after he was admitted to the hospital and felt that the opportunity of giving proper psychiatric care to Filipe was not being used. So the responsibility for the shelter called the head-director of our service, which was also the psychiatrist who had visited Filipe's home. They planned that Filipe would come directly to our service after being discharged from the other hospital. So he did, by taxi!
Filipe stayed as an inpatient in our service for three weeks. During this time he was diagnosed and treated for schizophrenia, exhibiting a very discreet, peaceful behaviour that caused no problems whatsoever at the unit. At the same time, the social services found a nursing home specialised in serious mental health problems. So, when the time came to get out of the hospital, a nice solution had been found. We must say that the costs for this nursing home were a little higher than usual, but the social services managed to obtain special permission to go a little higher than the regular budget because they were conscious that Filipe needed specialised care.
A few weeks later, our team paid him a visit at his nursing home. He was more communicative (in his deficient kind of way), greeted us, and showed us his new home. We found out that his sister was visiting him regularly, and that he was going out daily from the nursing home to the neighbourhood, without trying to escape.
This was a very difficult situation that seemed impossible to change for many years. With the cooperation of several partners (family, local community, outreach team, social services, psychiatric hospital, nursing home) that were able to put together their efforts and expertise, a synergy of actions converged for a final outcome that was much better than previously was thought to be possible.
This case highlights the fecundity of joint action and reflection.
Regular meetings to discuss difficult cases between professionals of the social and mental health sectors can be fruitful and change situations that have been stuck for years.
At the same time, it is important to have the means to intervene and the trust between partners. For example, in this case, the trust that social services would support the patient once he was discharged from the hospital, enable the psychiatric team to open the doors and admit him as an inpatient (without the fear of having no other solution afterwards). Similarly, the social services were not afraid to find unusual and expensive solutions (nursing home) because they trusted that the mental health team would continue to give all the necessary support and felt that this was an adequate solution from the technical point of view.
Five main ideas from the Profile:
characterises the behaviour of a system or model whose
components interact in multiple ways and follow local
rules, meaning there is no reasonable higher instruction
to define the various possible interactions.
someone who helps a person or organisation do something
more easily or find the answer to a problem, by
discussing things and suggesting ways of doing things.
Meta – organisation:
is defined as organisations which are formed of other
organisations, rather than by individuals
A process which fosters the exchanges of information,
ideas and practices among Individuals or groups
that share a common interest.
the “win/win position” is about changing the conflict
from adversarial attack and defence, to co-operation. It
is a powerful shift of attitude that alters the whole
course of communication: I want
to win, and I want you to win too.
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