When the solution of complex
situations seems impossible: how to listen for a
deepest understanding ?
When the body speaks through his silence and his
wounds: who will
listen and hear before intervening?
and environment / context of
profile of the person in
relation to : the condition of
‘dignity’ and 'health' in
which these people live. What kind of
interrelation between these dimensions:
in relation to the chronic situation;
- abandonment, in relation to
the breakdown of any relationship and link;
- refusal , in relation to any
institutional offer of care and assistance
MARI 31y old woman, known to our
team since 2008, previously, described in one of our
profiles in a workshop in Copenhagen in October
Removed from parental home at age
5, an lived in children’s care homes till she was
placed in a foster family at age 12. After some
years living years she was taken back to care homes
due to serious conflicts with her foster mother,
then moved to supported flats till age 18, when
transferred to homeless team.
1- Pre HF Once 18
and transferred to adult care, referred to homeless
team due to her accommodation instability, failing
to stay in shared flats for more than a few months,
as well as briefly sleeping in the streets.
2 - PreHF
Institutionalized from a young age, her
relationships have been “professionalized” and not
fully nurtured. Only contact kept with biological
family is an uncle meeting on very brief occasions.
On few occasions tried to regain contact with a
foster mother, but she totally rejects getting in
touch with her.( even contacting police when Mari
called her).Mari considers the neglect by this
foster mother as one of the most traumatic factors
in her live.
Very frail social relationships,
and putting herself in risk very often.
period , looses her appointed SW ( due to change of
programme, and during the period her case manager
has a sick leave.
3 - PreHF Always
been offered care , that she has accepted, but has
had difficulty in the follow up, due to lack of
compliance with medication as well as difficulty in
Detreriorization of relationship with the health and
social team. Approach is more complicated than in
HEALTH: physical and
All additional information on the health situation,
information on hypothetic or declared diagnoses
- interaction between mental and physical
(Comorbidity&mental heath, other health problems
- Comorbidity &social
- influence of the health condition on the
lifestyle of a person;
- history of interruptions and resumptions of
medical services provided to the person,
- orientation and opinions of the medical
players in respect to the person;
- interdependence of psychosocial distress in
cases where two people of the same family circle
1 - 2)
a young age, visited by child and adolescent mental
health team, by psychologist, and also on small
doses of medication. Probably family history of
schizophrenia and drug abuse. No evidence of any
other medical condition. Smokes hashish on a social
Diagnosed with Paranoid
Due to her mental health illness,
has great difficulties in adapting to certain
settings, her voices and delusions when unwell make
her believe, people in the streets are talking about
her, hears voices through the walls, has
difficulties in concentrating, and difficulties in
containing her emotions. On occasions acting on
these phenomena, and therefore causing disturbances
on the flats she rents, such as braking furniture.
drug intake, and use of other types pf drugs, with
an increase I her deterioration.
3) PreHF Whilst referred
to our programme, never interrupted contact with us.
On occasions would be missing for some weeks but
never completely interrupted.
more irregular and difficult contact, also lost some
of her social relationships
4) PreHF Has a very good engagement with all
the professionals working with her.
engament with HF team, and deterioration in her
relationship with case manager.
5)Not the case
presentation and evaluation of
the history of interventions with their
difficulties, successes, failures, including the
circumstances of the person’s first contact with
the organized assistance; clarification of the
objectives of the intervention in its various
stages; description, if needed, of specific
operational solutions; stating the reasons for
compulsory sanitary treatment .
(circumstances giving rise to the
first contact,clarification of interventions on
various stages, compulsory treatment, reason!!
What kind of intervention – in
health + social field - success of non-success
depends of …;
Highlight the correlations
between the objectives to be pursued, programmed
interventions and outcomes...
– Innovative practices
1),2)PreHF Referred to our team due to severe
behavioral problems, and difficulties in the shared
flats she was renting, becoming very suspicious with
her flat mates, and braking furniture on occasions.
Been admitted compulsory to hospital on several
occasions, mostly due to periods were not taking the
medication properly and increasing the abuse of
hashish, and displaying all the symptoms described
Referred to a case manager, to
individualize her treatment plans.
Referred on several occasions to
different professional training skills programme,
but unsuccessful. On occasions, it was a need
detected by professionals, but not her choice, and
when her choice she would leave when felt
An appointed social worker with a
very good engagement
Been accepted to the housing first project, with new
professionals working with her. Had to leave
Moved from several houses due to
neighbor complaints about her disruptive behavior,
braking furniture and shouting in the middle of the
night, as well as slamming the doors. And in one
occasion her flat was squatted. During the time her
flat was squatted the only option offered was to go
to a shelter home, which she refused.
Difficult to follow up due to her
unstable mental state and her chaotic way of living.
There is always evidence of a degree of residual
negative symptomatology present.
The objectives of the mental
health team and the HF team were not allways in the
( perspectives of how to carry
out her follow up, whilst in the housing first
project, is slightly different between the mental
health team, and the housing first team. The HFT
are carrying out a very paternalistic approach, in
the way that for them the housing is not the aim,
but the means to carry out a rehab scheme).
Currently been discharged from HF
programme, and waiting for a SW to be assigned.
Mari is currently in hospital
WORKERS & NETWORK:
One or many actors? -
Does the networking and cooperation between
actors exist or not?
- What kind of collaboration between public
and private sector?
- What kind of multidisciplinary performing
synergies between social, health services and...
- What kind of co-working and
co-responsibility between Institutions -
Associations - Administrations?
What are the institutional and
legal barriers and limitations to providing
adequate assistance (cumbersome, poorly
defined procedures, “vicious circles”;
resources and financing).
- What obstacles could be overcome by
“creativity” of the operators in the face of the
unhelpful of confusing legislation?
1)PreHF, Many actors involved , trying to
work in a joint way
and more difficulties in networking
2)PreHF The mental health
team is from a service provider paid by the Catalan
health department, ”, and the social worker is still
from a different service provider paid, by the town
The professionals from the housing fist team are
from the same service provider as the mental health
team, but from a different “Branch”.
3)PreHF Joint meetings of
SW mental health team an d mari predominantly in SS
office, except case manager visiting at home or
in community. , and in these meetings agree on
how we would distribute the different
responsibilities between all the professionals,
making sure that Mari had a saying in all of this.
We agreed on the frequency of visits, and the tasks
we had to carry out.
Same as before
but predominantly at her flat or surroundings
responsibility between different agencies
according to actions taken
Same as before.
5)PreHF When she lost a
room in a flat, social services would pay for a
hostel, and on occasion that could give rise to
economical problems , because lack of resources
When the house
was occupied the programme did not contemplate an
adequate response., leaving her un supported
What proposals of possible and innovative
interventions when the solution of complex
situations seem impossible?
- What pathways, what specific priorities
could be taken for priority recommendations?
Make the proposals as concrete as
possible and avoid generalities.
Rethink the follow up model, Team/individual follow
up. When a team member is ¨¨of¨ another known team
member con continue.
Revise housing first project, The procedures in the
Housing first project (Barcelona) are not properly
defined since it is a very new project, and some of
the allocated professionals are nor experienced
enough, all of this giving rise to on occasions
doubling actions, poorly defined responsibilities,
and badly addressed solution to problems that arise.
Wider spectrum of solutions to concrete problems
E.G when house is squatted, possibility of
transferal to another location
the launching and continuation of assistance
(stigma, prejudice, orientation
towards person,cultural aspects)
- possible stigmatization of person taking
charge or applying for assistance;
- sources of stress and burn-out for assistance
- changes in staff during assistance process;
clashing cultural aspects.
some of the professionals of HF Project there was
evidence of judgmental opinions.
being seen as a rehab instrument, that can be
applied to overcome the needs assessed by the
professional , rather than a right in the process of
recovery and dignity.
Problems regarding changes of staff, were observed.
Overall assessment of the case:
strengths and weaknesses of the support net
- synthetic judgment: the person's condition
has improved/worsened or remained unchanged?
(in relation to the assumed objectives
relevant ethical issues related to the work;
- final thoughts, free.