1. BACKGROUND and environment / context
G. is a 43 year- old female
G. is a 43 year- old female who was born and raised in Athens. She
is illiterate and has no social insurance.
She visited the Day Center for Homeless of the NGO PRAKSIS in
Piraeus in May 2012 for the first time and her initial
request was the use of sanitation services (shower and clothes). At
that time she “stayed” at the port of Piraeus with her mate L. She
had been involved with L. for 8 years and had two children, but they
had been removed from them by the Social Services. Concerning her
she was getting her food either from the municipality of Piraeus or
from the church.
She has two older sisters that are married and have children, but
they all share the same house not far from their parent’s house, who
are street scavengers. G. lived with her parents all of her life.
She describes her father as a violent person-mostly verbally-who
doesn’t like her mate and keeps humiliating him. She seems to be
afraid of him (her father) but at the same time very attached to
While she was living in her parents’ house and having an affair with
L., she gave birth to two children (a boy and a girl). But soon
afterwards, the two children were removed from them.
The initial cause was when L. was accused of abandoning the baby boy
in a taxi (although he strongly denies that). The taxi driver took
the baby to the police station and after long investigation; L. was
prosecuted and was taking to the court. The judge
ordered the social services to intervene. Therefore,
a social worker visited G.’s home a few times. Her report was
hygiene/sanitation conditions were very inappropriate as there were
many useless things, dirtiness and waste in the house. In addition,
there were clear signs of inadequate maternal care and neglect.
So, the court ordered for the children to be given to foster
families and L. was sentenced to a suspended prison sentenceAfter
that G’s father told her either to break up with L or leave the
house. She decided not to break up with L. despite their frequent
fights and strong disagreements, so she found herself sleeping in
the port of Piraeus.
While she and her mate were staying in the port of Piraeus she got
pregnant again and gave birth to another baby boy in 2016. This baby
was also removed from them right after his birth and was sent in a
hostel for abandoned children. But unlike their previous experience,
they have the right to visit the baby until it goes to a foster
family. This makes them feel very happy and proud.
HEALTH: physical and psychic conditions.
During G’s first meeting with the social worker of the Day Center
for Homeless (NGO Praksis) she referred to visual and auditory
hallucinations, so she was sent for a psychiatric assessment and a
medical check-up. After that, she was diagnosed with schizophrenia,
mental deprivation and hypothyroidism.
she has been under
The nurse from the Day Center for Homeless, made all the proper acts
in order to supply free medicines, as she is still uninsured. At the
present time she can take her medicines from a psychiatric hospital
of Athens and the NGO Medecins du Monde (MdM). But, the main problem
remains; she cannot take her medicine by herself (as she is
illiterate and mentally deprived). L. is willing to help her, but he
is illiterate, too. So, the nurse of the Day Center for Homeless
gives her the daily dose in separate envelopes and in different
colors (e.g. red for the morning dose and green for the evening)
after few explanatory sessions. This seems to work pretty well and
helped them build a relationship of trust and continuity with the
Another problem is that G., due to bad sanitation conditions and
her reluctance to cooperate with the doctors’ instructions, suffers
urinary tract infections.
3. INTERVENTIONS description
During G.’s last pregnancy, she and L. were hosted in a protected
apartment of NGO PRAKSIS under the supervision of the coordinator of
the apartment and the social worker of the Day Center for Homeless (D.C.f.H.).
It was a temporary solution (about a year) in an effort to help them
organize their life with their newborn child. However, there were
many problems, as it was very difficult for them to follow the rules
and the daily care of the baby, despite their efforts and the
staff’s of the Day Center. As a result, the baby was agreed to be
sent to a special hostel where they can visit it in regular basis.
At this point, the D.C.f.H. started cooperation with the association
“Society of Social Psychiatry and Mental Health (SSP&MH)” in order
to provide more efficient and integrated services to homeless people
with psychosocial problems. Therefore, a psychologist from SSP&MH
had a weekly presence in the D.C.f.H.
With this setting, the social worker of the D.C.f.H. and the
psychologist from SSP&MH along with G. and her mate started having
regular sessions. The intervention aimed at two levels:
To help G. with her personal hygiene and the daily housework. Since
she needs constant coaching and support for cleaning the house,
cooking their meals or even wash her hair, we have attempted to
build a personalized therapeutic and psycho-educational program for
her and her mate under the social worker’s supervision. That was a
step-by-step program with
a combination of “reward and punishment” methods
in order to help G. succeed in one goal before stepping to the next
one. Every month there was a special session with the social worker,
the psychologist, G. and her mate, where there was estimation
(re-evaluation if necessary) and setting of the next goals.
Although it is difficult for G. to keep to the program, she is
committed in doing this
mostly because of
the strong emotional bond that has been
structured among her and her therapists (the social worker and the
To help her have a less dysfunctional relationship with L., as he is
close to her and willing to support, but at the same time he is very
disappointed by her unstable attitude towards him. As a result, he
becomes angry, gives up on helping her and they have constant
disagreements and fights. On the other hand, L. has asthma and
drinking problems and G. is very worried about his health. Through
their regular sessions with the psychologist, they realized that
despite their difficulties they love and need each other. Expressing
also their feelings they gradually focused on themselves instead of
constantly blaming each other. It also became clear that they have a
certain pattern in their relationship; G. expects L. to take care of
her and she acts like a child. L. finds it irritating and tiring,
but at the same time he enjoys being the “adult” in their
relationship. From their personal stories it has been obvious that
they both were neglected and abused by their parents.
Despite all the difficulties that were analyzed above, this
intervention helped G. (and her mate, too) to restructure her life.
She started also having separate psycho-education sessions with the
psychologist apart from the sessions she had with L.
In these sessions hygiene issues and contraception were discussed;
also her feelings due to her separation of her children. It was
obvious that G.’s attitude was that of a child and not of an adult
woman and mother of three children. She was very happy showing
photos of her infant boy, but she could not understand how serious
the situation was. She used to say that she was able to take care of
this boy but when practical things and details of everyday life were
discussed, she was so stressed that she couldn’t follow the
discussion. She was laughing, saying something irrelevant or asking
permission to go to the toilet. When that was underlined by
the psychologist and she was told that although she loved her
children, she couldn’t raise them properly, she felt relieved.
That was the time she decided to sign for the third child’s adoption
and to do
sterilization (tubal colonization)
Gradually, her clinical situation was improved, her attitude became
more stable and she gained self-esteem. She and her mate managed to
keep their apartment and
themselves clean and tidy, whereas
they applied for a social allowance, collecting all the necessary
supportive documents required, with the help and guidance of the
social worker. The allowance was approved and this will allow them
to save some money over time and rent their own house.
hospitality period in the
ended in August 2017
and they had to leave. Since they didn’t have the money to rent a house by themselves
nor the ability to take care of it without the
support of the therapists, the social worker helped them to be
registered at a temporary shelter of NGO MdM
When they moved to the shelter G.’s clinical situation deteriorated.
She was not willing to follow the rules of the hostel; she neglected
hygiene and was aggressive to L. In addition, she had difficulty in
waking up in the morning and despite her claims that she had lost
her appetite, she gained weight. That happened because she only ate
croissants, cheese pies and drank soft drinks late at night as she
sleep. The main reason for her “regression», as it became clear
from the sessions, is that she was separated from L. They were in
rooms and they were not allowed to sleep together at night. So, G.
had lost the guidance, company and care of L. and had felt helpless
Through the therapeutic sessions she gradually felt better, but
things didn’t go very well for her mate. Since he lost
responsibility for G., L.
started drinking heavily again and neglecting his appearance and
personal hygiene, too. He was jealous of G. and he constantly
the sessions that she didn’t show him love and affection anymore.
Despite the efforts of both the social worker and the psychologist
to support him, he kept lying on them about his drinking problem and the
issues he had in the hostel. Consequently, after a serious incident
(a fight he had
with some other beneficiaries) he was expelled from the hostel and
now he is back to the port. Although he was actually the victim of
caused by three other male mates, because of his previous
provocative behavior (he was caught drunk in the hostel, he had
and violent incidents with some other residents) he was expelled by
the administration. So, G. has been left alone in the hostel,
without having proper care.
This unfavorable outcome was
frustrating for the therapeutic team, but also a hard lesson for G.
and L. They now seem to have realized that whenever the therapists
expressed their concerns they were not exaggerating.
G. revealed that she
is very nervous because her mate drinks heavily again. However, she
is afraid of expressing her feelings to him. We support and
encourage her to discuss this issue. We empower them and we focus on
the positive things.
L. is now willing to attend a special rehabilitation programme for alcohol addicted and both of them agreed to be more careful with the money they spend.
4. WORKERS & NETWORK:
As it has been already mentioned, this particular intervention
became feasible through the cooperation
of the Day Center
for Homeless people of NGO Praksis
and Society of Social Psychiatry and Mental Health. Additionally,
there was collaboration with other NGOs (e.g. MdM), public hospitals
and other public services as well, but it was not official or
In addition, despite our efforts there was no feedback from the
intervention by the other actors.
For example, in the shelter for homeless of the NGO MdM there isn’t
a psychologist or a social worker, so they generally don’t accept
people with mental health problems. They accepted G. and L. in
exception and for a limited time. Unfortunately, as it was
underlined above, there wasn’t possibility for continuous
intervention and follow up from our side. Consequently, when they
had problems with L. they didn’t inform us, so he ended up in the
streets again without any previous warning. That was frustrating for
Our experience shows that the most vulnerable people among homeless
face a double stigma and exclusion. Not only they face social
exclusion, but also they face institutional exclusion, due to
bureaucratic barriers, ill-coordination of services, legal and
institutional gaps. This means that homeless people with mental
health problems have less access to (proper) services than homeless
and mentally ill!
Complex situations require person centered interventions which do
not pose a particular methodology that is followed in all cases.
Solutions are hard to find, however the priority should always be
the high lightening of subjectivity and the hard effort from our
side in order to facilitate on the recreation of each person’s
Therefore, a specific long term rehabilitation programme should
be set with the active participation of the beneficiary so
he/she could be under a stable and continuous follow-up.
The combination of “Housing First” model
and assertive community treatment (free floating services,
mobile units, day centers etc.) would be the most sustainable
solution for this couple. In particular, a semi-protected
apartment with regular therapeutic support would be ideal, but
there is no such provision in the health and welfare system in
Greece. All the existing protected apartments are either for
people with psychosocial problems or mental deprivation. There
is no project for homeless with mental issues and alcohol abuse.
This situation reveals the gaps and barriers that people with
multiple needs face in their access to services. People with dual
diagnosis (mental health problems and drug/alcohol abuse) are facing
difficulties to enter the health and welfare system. Homeless people
with mental health problems are often excluded from services both
for homeless and for mentally-ill. Their right of equal access to
services is violated they cannot claim their rights.
Therefore, we suggest that apart from the obvious need for
integrated services and networking between existing services, we
should empower the services and shift from advocacy to
Finally, in cases like that in which the relapses and the
frustration are usual, a multidisciplinary team, good coordination,
staff training and support is necessary.
6. Personal factors influencing
In this case there were some factors that made the intervention more
- The existence of multiple needs and diagnosis made the
coordination of intervention difficult, as the service of reference
(which had the role of case manager) had to coordinate different
interventions but acting in an informal way.
- The existence of children is always a very sensitive issue and it
is very stressful for the assistants to implement the interventions
having in mind that all these will affect at least the child that
this couple was visiting in the hostel.
-The idea of Psychologically Informed Environments and Trauma
Informed Care seems to be very crucial for people like this couple,
who have faced multiple traumas and were neglected or abused as
7. Overall assessment of the case:
During this one-year intervention many things were improved in G.’s
life, but there are many more to be done. We worked with her on the
relationship with her mate, expressing her feelings and taking care
A further aspect of our approach had to do with their financial
management as they spent all the money of their first allowance on
shopping (clothes and mobile phones) and entertainment. Although we
understand their needs we are afraid that without saving any money
they will revert to homeless status. Counseling goes on, as there
are many unresolved issues.