H O U S I N G

Exchange   for  changing

 H O M E   SOCIAL HEALTH R E C O V E R Y STAFF Training & Care NET-WORKING O U T R E A C H

 

1.      Introduction

 
Why is housing important?

Housing constitutes an important part of the assistance that needs to be offered to a homeless person with mental health support needs.  Housing has two aspects of vital importance to any human being. The first and more obvious one is the mere roof over one’s head – with its amenities (appropriate temperature, running water, electricity, adequate furniture and equipment). Such structure provides conditions for the physical survival and physical well-being of a person. The second aspect also concerns the invisible reality of a dwelling place, the general well-being of its inhabitant. This aspect, in contrast to “house”, can be called “home”. “Home” necessarily is based on “house”. “Home” is a “house” expanded with inhabitant’s participation. “Home” contains “house” and more. It is in “home” and through “home”, through the feeling of being “at home”, “chez soi” that a person realises his/her need of belonging, privacy and intimacy, of feeling at ease and free. These needs are rooted in the dignity of each human person. It is within a “house” raised to the status of a “home” that the space for outer and inner safety, dignity and freedom is provided. All this being true for humankind and having a home of one's own is critical for a person who is homeless and who also has mental health support needs.

It is through “having a home” that essential conditions exist for the person to be enabled to recover from a mental health illness [u1] and while not an absolute given mental health supports can often be more effective when a person is living in a home.
 

2.      Main ideas

Housing as a right

Many EU countries have enshrined in their constitutions the right to “shelter” and right to “home of one’s own”. This in itself is not a guarantee that those who need a home will be provided with one, and indeed the interpretations in some countries tend to be limited in their effectiveness. However, it is important and consequential for practitioners to start to think about housing in terms of a person’s right. It changes the way we view the problem and invigorates advocacy. The CHARTER OF FUNDAMENTAL RIGHTS OF THE EUROPEAN UNION states in article 34.4: In order to combat social exclusion and poverty, the Union recognises and respects the right to social and housing assistance so as to ensure a decent existence for all those who lack sufficient resources, in accordance with the rules laid down by Union law and national laws and practices.

Adopting a Rights-Based approach has its implications:

Immediacy. The notion of right defies barriers. People should be housed as quickly as possible (be it temporarily). Housing should be available for people who present with multiple support needs - meaning that the threshold to accessing housing should be as low as possible. This may concern rules about couples or pets staying in the facilities or more importantly the issues concerned with harm reduction.

Choice. The person we are supporting should be given a choice. This is certainly true for long-term housing. Simply offering an option of “take it or leave it” while not being respectful of the person’s preferences is not conducive to promoting his/her well-being and in particular his/her mental health. Even when the choices are very limited, the service user must be facilitated through a process where he/she is involved, fully informed and owns the decision making process. The person must also be “allowed” to change as time passes, as his/her situation can change also.

Practice Example: The SLI Nua Apartments operated by the Midlands Simon Community in Athlone in Ireland provides homes for people that have experienced homelessness and who also need visiting supports to maintain their tenancies. Prior to moving in the service users come to view the apartment, they get time to ask questions, and they have a period of days after visiting the apartment to reflect on if this is suitable to their needs. Even if the service user is living in a hostel and has no other realistic options of a home, this process is followed, and one of the reasons it is followed is the belief that engaging in this way will have a positive effect on the service user’s well-being.  In 2018  Taoiseach  Mr Leo Varadkar T.D ( Prime Minister of Republic of Ireland) and Mairead McGuiness M.E.P  First Vice President of the European Parliament visited a new housing with support project in Longford Town (which is funded by Department of Housing, Community and Local Government and Longford County Council) where 10 people with a range of support needs  and with an experience of long terms homelessness were offered a home of their own; critical to this model is that people are seen as active participants in their own care and not passive recipients of a service and the belief in the right to housing drives this methodology.

Support. There is no proper housing without proper support, adapted to the needs of the person, especially the person with mental health problems. On this depends on the success in housing. Support should be based on the care plan developed with the service user and operate[TO2] d as long as the service user needs it. Support should be case managed and include different disciplines pertaining to the particular case,  i.e. mental health, addiction, social care, other health professionals, housing officer, a lawyer. Support should be open-ended meaning flexibility and adaptation to the changing needs of the service user and not time limited. A major challenge is to have the courage to let the person we are supporting “ to set the pace”. This means the steps that are taken from the street to home and how fast this journey progresses is the prerogative of the service user. This is a challenging position to take, especially when funding of services are often subject to attaining certain targets. It is difficult to square the targets set by funders with the pace that a service user wishes to move with. However, it is vital for the wellbeing and recovery of a  person who is homeless and who has mental health problems to be trusted to make his/her own choices at his/her own pace.

Practice Example: Project Udenfor in Copenhagen outline that their core ethos is to “give assistance based on the individual’s needs of the moment, with no strings attached. This means that we do not demand any particular behaviour, nor do we require any specific results from our users.” Preben Brandt (Founder of Project Udenfor) outlines in his book “Udenfor – Erindringer fra et liv pĺ kanten” that this way of working not only is a respectful and rights influenced intervention, it also leads to sustainable and lasting change.

Quality of accommodation. The quality of homes that are offered to people needs to meet appropriate standards[i]. Psychologically[u3] [TO4] [EB5]  informed housing services (service that takes into account the past traumas and psychological problems of users) should also take into account the physical environment of the shelter, hostels, day service or home. The physical environment of the home or service needs to convey welcoming and empathy as opposed to being functional, cold, impersonal or institutional. At the very least, the housing offered should not re-traumatise people we are seeking to support. Thus often when someone with mental health support needs moves into their new home, there should be a welcome pack, welcoming and appropriate soft furnishings and everything is done to convey warmth, welcome and safety.

Prevention. Prevention must have an important role in any housing strategy, as it is probably the most efficient way to secure people a home.


Check List for using a Rights-Based Approach:

·         Have service providers formally adopted the value that people have a right to a home?

·         Is there a process where housing options are explored and explained to the service user?

·         Are professionals supporting service users participating in training in anti-oppressive practice?

·         Once a service user moves into their new homes is the support open-ended?

·         Are the homes offered to people meeting minimum standards for leasing?

·         Is there a code of conduct for professional standards which people supporting service users are
    obliged to adhere to ?

.         Is the home welcoming and emotionally warm, i.e. is there a welcome pack for new residents?


Importance of staff training

A key factor in offering relevant support is staff training. A rights-based approach requires training in person-centred interventions. For this staff should be able to demonstrate a high level of empathy and capacity to engage with emotional warmth and have a high competency in active listening. Knowing when to advise and direct when needed but always being able to communicate understanding, unconditional positive regard and emotional warmth. These skills also require reflective practice, f and opportunities to reflect under supervision with a supervisor with the necessary skills and qualifications 

Professionals wishing to support people who are homeless or at risk of homelessness and who have mental health problems should participate in training in anti-oppressive practice[EB6] . This training would ensure there is awareness about how some of one’s own beliefs and values can impact negatively on the quality of support offered to service users.


Check List for person-centred intervention:

·         Are staff working with service users briefed/trained in using person-centred interventions?

·         Are staff competent in basic listening skills?

·         Has staff been trained in anti-oppressive practice?

·         Is there a reflective practice and opportunities for staff to reflect on this methodology?

Assistance to people with mental health problems should specifically take into account the possible past traumas experienced by them. This is what is often referred to as the trauma-informed care approach. Peter Cockersell, writing the FEANSTA magazine “Homeless in Europe”( Winter 2017) gives an illustrative account for the trauma experienced by people who are experiencing homelessness. He states: “Anybody who has worked with long-term rough sleepers and the chronically homeless knows that a large proportion of them have experienced very difficult lives, often starting with early childhood experiences of abuse, neglect, parental separation, death or  alcoholism, often followed by difficult school histories, maybe trouble with the police, with violence, or drugs, or alcohol, or mental health problems (often undefined), and sometimes with all these things. They then in adult life face social exclusion and the dangers and challenges of rough sleeping. This understanding among homelessness workers of the clear link between compound trauma and long-term or repeat homelessness has been confirmed by a range of academic studies in Britain, Europe, and across the world “(Maguire et al., 2009; Cockersell, 2011).  Cockersell argues not to pathologise or psychologise homeless services but rather that people working in homeless services and supporting people with an experience of homelessness should have a  competent awareness of the impact of trauma and gain better insights into how to support the victims.

 

Checklist for having Housing service that is operating from a Trauma Informed Care Model

·         Are Staff[EB7]  trained in the model?

·          Do houses and shelters have a standard for letting that is psychologically informed?

·         Are the external environment gardens and common areas well maintained?

 Training should be offered to staff in:

·         the processes of change,

·         the impact of trauma,

·         ways of motivating,

·         involving and supporting people;

There is also a need for regular (at least monthly) formal reflective, practice sessions for staff.[u8] 

 
Home triangle

 There is a “hard”, and a “soft” side to the support offered to a person. Both are indispensable, complementary and intertwined.  There is this impersonal, objective, unbending aspect to assistance as well as personal, subjective, adjusting itself to individual circumstances. Both are very visible in housing and very important to take into account when we deal with a person with mental health support needs Hard assistance would be the actual architecture, medical indications, prescriptions, deadlines, social assistance in its official, documentary aspect. Soft assistance would be the space and possibilities for personalisation within given unbending context -  human aspect of the interaction between the user and social worker, doctor, psychiatrist, psychologist, social worker etc. This human dimension enables meaningful exchange with a user, fuels mutual relationship, stimulates the user to come into contact with oneself, really make his/her own decisions. “Soft” assistance induces participation on the part of the user. Participation is an indispensable factor in making a  house to a home. It is by participation that one starts owning the place where he/she lives. It is owning the place that changes a house into a home. We can picture it in the shape of a “home triangle.”

       House

 


 

                                                Support                     Participation

Participation on the part of the user is to a large extent the function of support given to him/her by care-workers.

Housing continuity of care

Let us follow the real world manifestations of housing for homeless persons. While the description progresses from the simple to the more complicated, it should not be understood as preferred chronology for the individual case. Indeed the basic assumption of Housing First, for example, is to defy the chronology. Assistance should not be measured out in schematic ways but be a relevant response to the present day needs and capacities of a person. It is the task of the support worker to make the best use of the available resources for the benefit of the specific person.

Pre-housing. There are in the real world situations where the notion of a “home” is or can be conveyed. The fact that this is not housing yet does not mean these manifestations are not useful or meaningful in the process of housing a person.  The first hint of a home may come in the shape of a street-worker offering a cup of coffee. A warm cup of coffee as a modest token of safety and human closeness invokes that safety and human closeness which constitutes a home.

There are soup-kitchens and drop-in centres. No housing, but already wider space for communicating “home”. It comes with a smile of someone ladling out the food, with the quality of food itself, with opportunity to have one’s clothes washed and washed in a way that reminds of home (the smell), with invitation to a festive meal at Christmas, with site’s welcoming aura, with the possibility to spend time in “one’s own” corner. Such unobtrusive, informal, flexible hints of home, warmth and welcome are especially in demand in contact with persons with mental health problems.

Emergency housing. Emergency housing mainly ensures survival. This is especially true for the night-shelter providing roof overhead at night with an obligation to leave for the day. Night-shelter may however also serve an important purpose of connecting a person living in the street with more sophisticated forms of assistance, including housing. That depends on the range of services deployed at the facility (e.g. psychiatrist, social worker), engagement of the personnel and functioning referral pathways. 

The day-and-night shelter is the first representation of housing potentially able to contain meaningful doses of a home ingredient for users. The shelter is often looked down upon as an inadequate and obsolete way of dealing with homelessness. While criticism may be justified on the grounds of a typical practice, what is really questionable about shelter has more to do with the way it is run than with the institution itself. Certainly, no form of emergency housing should become chronic. But shelter may play an important role in ensuring physical and psychological survival and stabilisation of a person and in allowing the workers and the user himself to assess his/her actual state and further options. Ideally, the stay should be short but in real life, owing to the scarcity of other possibilities, and also to the user’s attitudes, the delays may prove substantial. It has to be mentioned that some persons seem to fare quite well in a shelter. Structured day, tasks to take care of, elements of discipline, manifold interactions with other people – all these things characterising shelter may be in shorter supply in individualised housing. Loneliness, pressure of everyday problems, unwelcoming or harmful environment – shelter protects from this.

There is a right tendency to move towards ever-improving standards of living in a shelter. Ideally:

·         Each person should have access to their room without having to share it;

·         Showers and toilets should be shared at the maximal ratio of 2:1;

·         Users should be consulted about the meals provided and their dietary requirements;

·         Users should be allowed to access their rooms 24/7.

Higher standards, however, should not deprive users of incentive to live more independent lives, which is a risk especially in the situation where more independent, long-term housing options are in short supply.

 Long-term housing. The dilemmatic choice between – to put it in simple terms - housing conditions with little privacy and housing conditions with little company can be solved by flexibly shaped forms of supported housing. This is where the home triangle can be fully and creatively played out to suit the capacities and needs of a homeless person with mental health problems. We can have many solutions based on a threefold muster:

·     A centralised block of apartments for individuals or couples with private quarters allowing for privacy, and common spaces for socialisation, where care-workers are present on a workday basis;

·     Big, individual apartments, normally dispersed within a town or a city, where every person lives in a separate room, with common sanitary, kitchen and socialising spaces; such apartments may come in all sizes, and they are characterised by a quasi-familial community of life between the users;

·     Individual apartments for individuals or couples.

Support may also come in a threefold muster:

·     On the spot support by care-workers present on a daily basis (most suited for the block of apartments as described above);

Support by various relevant care-workers  (most suited for the “communities of life”);

·     Case-managed support on an individual basis with the case manager and the use of generally available services.

There are of course all kinds of possible mixes both as far as living structure, and support structure is concerned. Generally, both living and support structures above musters go from more to less support and control. Whether a person attains any such housing following the line of gradual progress or just “jump in” at the later stage is of secondary importance  - only a function of individual needs and capacities as well as objective possibilities and constraints.

Practice Example: Sophia in Ireland has a centralised service in Dublin where it provides homes for 18 couples who had a history of long-term homelessness. These couples would typically not be allowed to access homeless services as a couple and would have been sent to live in different services. Many of the couples have significant and on-going addictions and mental health support needs. The couples are offered a home of their own without pre-conditions with on-site 24-hour support staff. To date of the 36 people that moved to live there in 2015, 32 of the people have successfully maintained their homes.

Housing First. Housing First is an intervention that proposes that people experiencing homelessness should be supported to access a home of their own as quickly as possible and without the pre-conditions of having to be sober or compliant with treatment. Housing First is a paradigm shift in that instead of following a linear model where people progress from the street to a hostel to transitional housing and eventually onto a home of their own, and people are supported as soon as possible into a home of their own. In short, people that are supported through a Housing First service don’t have to prove they are housing ready; rather their need for housing is what predated being offered a home. Housing First is especially relevant for people with mental health problems.  Of course, “Housing First is not housing only” stresses Dr Sam Tsemberis, (lead international expert on Housing First).  In his pivotal work “Housing First[ii]: The Pathways Model to End Homelessness for People with Mental Illness and Addiction” Dr Tsemberis outlines in detail the methodologies and interventions that are required to support people with mental health support needs to successfully progress out of homelessness. There is a substantial body of international research that supports the model as leading to positive and sustainable housing and health outcomes for people with mental problems and experience of homelessness[iii]. While this manual doesn’t allow for a full treatise on the Housing First Model, service ethos and values can be summarised as:

·         Housing as a basic right

·         Respect, Warmth and Compassion

·         Support is there for as long as needed

·         Scattered site housing

·         Services leasing and in turn sub-letting to the service user

·         Recovery Orientation

·         Harm Reduction

·         The Art of the Home Visit

The experience of the practitioners that implement this model argues that Housing First excels as an intervention when there is an investment in all the multidisciplinary interventions needed such as a psychiatrist, mental health nurse, housing officers, support workers, addiction specialist, peer specialist.  

Some issues of importance

Home visit. A home visit is one of the key interventions in a supported housing hosing with support or housing first model. It is where the person offering support meets the service user in their own home. While it is casual in setting it is focused and is one of the key therapeutic interventions in Housing First as well as any supported housing.

The following points are critical to the successful home visit:

·     The visit is scheduled in advance and not an unexpected call;

·     The support worker needs to arrive prepared and have the clinical notes read in advance of the visit;

·     It should be relaxed and not rushed;

·     There needs to be an emotional, warm and authentic tone communicated verbally and non-verbal body language.

·     The home visit allows the support worker to monitor the user’s well-being. Often the support worker should bookmark their observations and not be expected to raise every observation with the service user.

·     The home visit allows the support worker to monitor any repairs and maintenance that needs to be followed up to make the service user remain a comfortable home.

To conclude this section a summary of the home visit by Dr Sam Tsemberis: “The home visit, both in its form and content provides a wealth of information about the client, the client living conditions, the staff, and the conditions of the treatment relationship. It is a microcosm of the entire program. Most of the work of the program takes place during the home visit, the teams continue to visit their client, and they bring them caring and questions “How are you?”, “How can I help you ?”….to foster trust team members must convey acceptance and concern-not judgement (Tsemberis S, 2010 P86/88).

Discharge from hospital, prison or other institutions. This best practice manual proposes that clear protocols be developed between the discharging institution and homeless services to plan discharge and consequent admission into homeless services, so that discharge into the street is prevented.

Women and men in housing services. There are good sides to co-habitation of users of both sexes and varying degrees of deficits and skills in homeless facilities, notably shelters. They complement and help each other. Mutual acceptance dissolves stigmatisation. But there also must be among workers a high level of awareness of the needs and vulnerabilities of both groups. Women’s vulnerability, especially within emergency facilities and their experience of gender-based violence means that essential work needs to be done to ensure women feel safe and secure[iv].

Building bridges between users. It is important to introduce the co-habitants of the housing facility based on a degree of collectively (be it a shelter or community of life) to the difficulties of some of the more problematic users in the way that facilitates constructive relationships.


3.
      Difficulties

Increase in house prices[EB9] : House prices rose by 4.3% in both the euro area and the EU in the third quarter of 2018 compared with the same quarter of the previous year. (Source Eurostat) Thus having an impact on affordable housing for people experiencing homelessness.

The lack of affordable rent proprieties[EB10] : An EU wide trend is the lack of affordable housing and the trend of local government to withdraw from being an active player in building social homes.

Besides the scarcity of living spaces available typical difficulties to cite is prolonged bureaucratic procedures necessary to obtain them, lack of variety in available spaces in the face of very varied needs of the users-to-be. Most probably there will also be other underprivileged groups and their representatives competing for what is available. It is difficult to work in a person-centred way when there is little choice we can offer to the person.

Housing process poses constraints of time. On the one hand, there may be a lot of waiting to go through, on the other some things, especially to do with documents and legal transactions have to be completed sharply on time. This may be especially difficult for some of the persons we focus in this manual on.

There is a tendency to regard a housed person as “done[EB11] ,” i.e. the end-result achieved – “homeless person no longer homeless.” Even if we are aware of a person’s persisting need for support, some services may be less readily available.  It is a delicate turning point in the person’s situation when he or she is all of a sudden expected to do much more for him/herself than before. This moment requires special attention from the support worker.

The possibility of stigmatisation and rejection on the part of the neighbours is also a problem to be reckoned with.

 

4.      Good practices

 This best practice manual proposes that the ideal model is based on a Service Users right to choose if they want a home of their own such as is ascribed by the principle values of the Housing First model. [u12] 

The ultimate goal of housing is to achieve the home triangle – to put a person into an adequate living space – a house - and to induce with the support given a degree of participation that will make this space his/her home. It sounds simple; in reality, it is an open-ended process in which the support -worker is not the only and not unconditioned decision maker. The Support -Worker is rather one of the actors, important, but having to reckon with other people’s decisions (notably the user, perhaps other persons close to him/her, neighbours, other services, actual architecture etc.). That’s why the role of the care-worker is best described by two notions: balancing and flexibility. First of all, he/she has to strike a balance between the user-to-be and the architecture while architecture to some degree presupposes the mode of living. As described in the previous chapter we can have a block of apartments; we can have a community of life within bigger apartments, and we can have individual apartments. We have users-to-be with all their traits, strong and weak points, particularities, deficits, idiosyncrasies. Our actual housing options are almost always restricted. Now we have to strike a balance! Use the available architecture for the best benefit of the person(s) before you. Deliver yourself and/or procure from other services the support needed. No easy act of balancing, the sole comfort is that we can strive for the ideal and achieve only the possible. One suggestion concerning housing where interactions between inhabitants play a big role – especially in communities of life – is to bring together people with differing characteristics. Strong points of one person fit well with weak points of someone else. People who fit together well tend to mutually take care of each other in many small ways, which is meaningful additional support on the top of the professional one. Such mutual, every day, peer-to-peer support is, by the way, an important ingredient of a home — a family of sorts, a company which is a common need among humans.

Striking balance in other forms of housing (individual, a block of flats etc.) is no easier. Everywhere the same wise and well-known principles apply of:

-     Prevention. It is better to foresee a problem than to quench the fire. A good example for housing is negotiating and planning discharges from hospitals and other institutions to have housing – be it only a short-term one – for the person ready when the time comes.

-     Reaching out. This takes in housing mostly the form of the home visit, but the question is not the form but the content. How much reaching out in the home visit? How much real contact and dialogue?

-     Networking. It is good to have partners in striving for goals. All kinds of services are eligible as partners in housing – health services, social assistance, occupational centre, employer, police – but especially desirable are neighbours of the housed person. A coalition with neighbours prevents stigmatisation and rejection. It requires, however, reaching out to neighbours.

-     Person-centeredness is the very centre of meaningful assistance in housing and elsewhere. In practical terms, it means that among all service providers for the housing user there is at least one for whom this he/she is in the centre as a whole person — subject, not an object of assistance. The formal embodiment of person-centred assistance is case-manager – a very appropriate form of service in housing, especially for individual apartments, and especially for the Housing First model.

Being so often faced in the realm of housing with various constraints and scarcity of solutions available, we are asked not to add inflexibility of our thinking to the inflexibility of the reality around us. In general, all good practices are expressions of agile perception, hard and often unorthodox thinking, bold decisions and action making the best of circumstances encountered.
 

5.      Case Studies

Best Practice Service

Flat Zero – Arrels Foundation – Barcelona

Low-demand temporary housing for the homeless

Flat Zero is low-threshold temporary housing for people who are chronically homeless in Barcelona. The project aims to provide an alternative way to ensure access to housing; it caters for ten people each night. It is deliberately a small service to respect privacy and build on relationships of trust with Arrels Staff. 

A conventional flat was renovated and transformed into a “street flat”, it is geared towards people who have rejected other shelter options, the 20% of people that do not adapt to the Housing First model or are unable to adapt to some of the rules they impose regarding behaviour and communal living. The flat has been designed as a half-way spot between the street and home. Service Users can access the flat with dogs, drinks and the bags and packages they normally carry with them. 

One innovation worth pointing out as a benefit to the organisation is that the flat becomes a reversible space that acts as a collective dwelling at night and during the day, is used for training Arrels Foundation volunteers and advocates. 

They have adapted the space to meet the needs of those they support; they do not aim to change a person in order for them to fit a model, rather they adapt for the person. Aligning it with key elements of best practice, creating a person-centred service, that brings dignity and security to their service users. 

Flat Zero Links: 

https://www.arrelsfundacio.org/piszero/

https://youtu.be/favwHgzwZjY

https://youtu.be/_OtmYhwVdp0

 

6.      Case Studies

Housing case history/profile

Jack was a 34-year-old man from Newcastle, a city in the North East of England, who had developed a severe psychotic illness in his late teenage years. He had lived in London, on the streets and in large hostels, for around ten years before he met our team. He moved into a flat in one of our first-stage projects, improved greatly with a small dose of antipsychotic medication and support, and then moved to a long-term high support flat a couple of miles down the road in Bermondsey, a traditionally working-class area in South London. He seemed to be settled in his flat, which was one of 12 grouped around a courtyard, with housing staff on-site 12 hours per day.

However, one day he was talking to his key worker and said that he had been thinking of moving back to Newcastle – in fact, he had thought of just catching the train the following week. He had not made any arrangements but was sure that things would “be alright” when he got back to Newcastle, which he clearly saw as his home town. After some conversation, his keyworker persuaded him not to go back without any kind of preparation but started to help him make arrangements. Over the next few weeks, he managed to contact the Housing Department in Newcastle, a flat was found for him, financial benefits were arranged, and the local community mental health team agreed to take him on.

Before he made the final move, he and the team agreed that it would be good to go up to visit the proposed flat and meet the mental health team in Newcastle. So, Jack, his key worker and the psychiatrist (myself) went up to Newcastle for the day. Now arrangements had been made; he was looking forward to the move.

We got off the train and took a taxi to the flat that had been allocated. It was in good repair but absolutely bare. Jack also did not seem to recognise the geography of the city. We then went to the mental health team, introduced ourselves and had a very positive meeting. After lunch in the city centre, we got on the train back to London. I was aware that Jack had been rather quiet during the several hours we had spent in the city and, after an hour or so, his keyworker asked him if something was wrong. He said, “I don’t think I want to go back to Newcastle”. He had not felt comfortable there as it had changed so much since he left. In addition, although he had tried to contact his family, they wanted nothing to do with him. So, he had not recognised the place from his past, and he had no relationships or social network left there. The visit had brought home to him the reality of the situation.

So, he stayed in the flat in London, where he was able to stay indefinitely. For myself, it was so helpful to go with him. A lot of time and energy had been invested in his move, and it would have been easy for my team to have felt irritated, or at least disappointed, by the fact that all their work had resulted in – no change. But, being there with him, his sense of disappointment and discomfort was so obvious. It would clearly not have worked for him. And so the relationship between Jack and the team continued on a positive basis.

 
Profile : Mr D  (team : Infirmiers de rue)

We met Mr D in June 2010.

At that time he was 45, homeless, living in the street. He was nearly always under the influence of alcohol and was sometimes aggressive. It took us some time to get his confidence and to be able to open some rights for him (income, medical care,…).

Still, it was very difficult to imagine any solution in terms of housing for him since he was most of the time not accepted in the emergency shelters or temporary housing facilities, and housing first was not developed at that time in Brussels.

In 2015 we managed to propose him a place in our housing first program, and he was very glad to enter his first apartment for nearly a decade. In the first months, it was all well; he had stopped drinking and was investing his new life with enthusiasm.

But then he started again to drink, and the following two years were a nightmare, both for him and for us. We were very worried because we found him often heavily drunk, nearly in a coma, in his home, without any surveillance. Several times he tried to stop drinking, whether alone or in a detoxification program in an institution. The only positive points in these two years were: that his confidence and the relation with our team was never affected, on the contrary, it improved; that he wanted really to continue in an apartment, he was very motivated ; and finally that he choose himself to move to another apartment, smaller (which he liked more, the other seemed too big ) and cheaper : he was again in state of making his choices, really.

And then, finally, after one more hospitalisation, he told us that he had realised that it was not good for him to be housed alone. So we proposed him a nursing home, for which he was too young, but where he was accepted, and which he accepted! Since two years that he has been there, he has not drunk any alcohol, and he is happy. He is continuing his progress because now he is thinking about finding another collective housing project where he could be with people of his age.

Questions:

-     What strengths and risk factors do you identify in the interventions described?

-     What could be the critical moments in the process?

-     Starting from your experience can you imagine a different intervention? If yes can you describe it?

 

7.      Glossary

Active Listening

Is to fully concentrating on what is being said rather than just passively 'hearing' the message of the speaker. It is listening attentively while a person speaks, reflecting back what they said and without judgement or advice.

 Housing

Housing, with regard to it being a social issue or human right, can be defined as a house, other dwelling or shelter which gives safety and warmth as well as providing a place to rest. It is one of the most important components of living a secure life.

 Housing First

Housing First, is an approach to ending homelessness that focuses on moving a person from homelessness to a home of one’s own as quickly as possible.  It is recovery orientated with additional supports and services given as needed.

 Housing Officer  

Manages housing and related services on behalf of housing associations, local authorities and NGOs. The role involves managing housing and keeping in regular contact with Service Users, looking after rental income and dealing with repairs and neighbour nuisance issues. Housing Officers often work in a team which includes tenancy support officers, case / key workers etc. 

 Interventions[u13] 

Intervention refers to actions taken by services to support service users in their recovery journey. These can be extremely wide-ranging and often involves providing less dramatic means of helping an individual.

 Psychologically Informed Environments

Psychologically Informed Environments are services that are designed and delivered in a way that takes into account the emotional and psychological needs of the individuals using them. It is a complementary approach to service delivery for people with complex needs with Trauma Informed Care.

 Person-centred care

Person-centred care means putting Service Users at the centre of decisions and seeing them as experts, working alongside professionals to get the best outcome.

 Being compassionate seeing and making decisions from a Service Users point of view and being respectful are all important. Consideration is given to a person’s values, social circumstance and lifestyle when making shared decisions with Service Users.

Rights-Based Approach

A rights-based approach places an obligation on Service Providers to ensure that their services uphold and promote European and international human rights standards. Such an approach places the focus on the right of an individual rather than the need.

Under a rights-based approach, the plans, policies and processes of development are anchored in a system of rights and corresponding obligations established by international law.

For example, Article 25 Universal Declaration of Human Rights states that: Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

Service User[u14] 

A service user is a generic term for any person who uses a homeless, health or another social service

Trauma

Trauma is an emotional response someone has to a negative event. The effects of trauma can interfere with an individual’s ability to live a normal life. Someone who has suffered trauma may develop emotional issues such as anger, sadness, anxiety, PTSD, survivors guilt etc. They may develop on-going problems with sleep, physical and emotional pain and have trouble with their personal relationships. People who have suffered a major trauma are more likely to have an addiction support need.

Trauma Informed Care

Trauma Informed Care is an approach which aims to improve awareness of trauma and its impact on Service Users, to ensure that the services provided offer effective support and, above all, that they do not re-traumatise those accessing or working in services

Anti-oppressive practice

Is a method and model for challenging actions of both individual and institutions that have an impact of being oppressive of individuals and groups in society and these discriminatory actions are based on prejudicial and invalid attitudes and values.

 

8.      References


[i] Note for example the Housing Regulations 2017 Statutory Instrument SI No 17 2017 the Irish Department of Housing, Planning and Local Government. In terms of supporting people with mental health support needs who have experience of homelessness, standards set out above can be seen as a minimum

[ii]  Tsemberis S (2010) Housing First The Pathways Model to End Homelessness for People with Mental Illness and Addiction. Hazelden USA

[iii] Tsemberis S, Gulcur L, Nakae, M (2004) “Housing First, Client Choice, and Harm Reduction for Homeless Individuals with Dual Diagnosis” American Journal of Public Health 94 (4), 651-656.

[iv] Hutchinson et al., 2014; Sznajder-Murray and Selznick, 2011.


 [u1]I would add this and leave the rest out. It is not fair to equal shelter and hostel with the street.

 [TO2]Operated instead of operate

 [u3]I have no problem. Sounds universal.

 [TO4]There was some feedback from parners in Barcelona that we sgould remove a speific reference to a standard. Yet I think it is usdeul but I am open to guidance and feedback on this

 [EB5]This sounds fine to me.

 [EB6]Nice!

 [EB7]Question: Are or Is staff...?

 [u8]I could delete that as it is laconic and general and in effect does not say much new

 [EB9]Perhaps this point  could be inserted in the section of difficulties

 [EB10]Also a difficulty

 [EB11]Good point

 [u12]I think this sentence is out of place here. The segment below argues for flexibility of solutions, the sentence prioritizes HF solution. HF  is best – in some cases  – in other  cases not.

 [u13]do we have to explain that?

 [u14]do we have to explain that?

 

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