PROFILES   of  PEOPLE   -   2017  

                                 home-less & health-less permanent situation                             Related image protocol  
 

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?   
 

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     1.   BACKGROUND and environment / context  of  GERALD   50y old Portuguese origin              1 / SP 1

 

1.   BACKGROUND and environment / context  of  GERALD   50y old Portuguese origin,

(family constellations/relationships, nature of relationships)

This is  a 50y old of Portuguese origin, come to Barcelona at around 5yrr with the mother and a sister  which died in a strange situation according to him. .. He refers mother could be alive and living near Barcelona but doesn’t know. No family contact. Seems his father lived in Lisbon and in one occasion, he travelled to Lisbon to try and search for him.

According to him has primary and secondary studies, and seems he started other studies, which didn’t finish.

Only known relationships is with a person that on occasions will visit him and spends time with him. He refers he worked as a waiter in the past, but stopped work a long time ago. No updated documentation.


Enjoys painting and says that people buy them, as means to get money.

-   time, in relation to the chronic situation;

     More than 10 years.

-   abandonment, in relation to the breakdown of any relationship and link;

    NO clear link with any breakdown as source of current situation.
-   refusal
, in relation to any institutional offer of care and assistance services

    Refuses all offers of care,  seems he could have had a negative  past experiences with psychiatric services.


2.    HEALTH:  physical  and  psychic conditions.

(Co morbidity & mental health, other health problems  Co morbidity & social disadvantage)

Diagnosed as a Psychotic disorder unspecified, (referring auditory hallucinations, and energetic currents, also talking to himself), diag done from contacts   We objectify repetitive conjunctivitis but does not complain.

All additional information on the health situation,  information on hypothetic or declared diagnoses  including:

-  interaction between mental and physical condition; 

influence of the health condition on the lifestyle of a person;
    Usually remains In the same area, due to “energetic currents..”, refuses help due to suspiciousness.

history of interruptions and resumptions of medical services provided to the person,

   After 4 years of  follow up , we manage  to refer him to a first appointment with another team of council SS in order to  obtain a pension, but not related
   to mental health, despite the coordination with the SS, the social worker didn’t  follow our recommendations and therefore  stopped the appointments
   with SS, and “ disappeared” from  his usual  place , and after a month when again appeared he was more suspicious.

   Another interruption was when a professional was changed

orientation and opinions  of the medical  players  in respect to the person; 

   A person with a psychotic illness, with a difficult approach due to his suspiciousness A perception from the professionals of not being an acute
    situation, and needing a long term plan., to stablish a good engagement with him.

interdependence of psychosocial distress in cases where two people of the same family circle are involved

   Not the case.


3.      INTERVENTIONS  description  :  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!! Operational solutions)

The most important intervention and a baseline would be engagement issues. Referred by SS due to chronic situation In the street with possible psychotic symptoms in the street (shouting, vociferous) and signs of suffering. With the aim to stablish a working plan.

-   What kind of intervention – in health + social field - success of non-success depends of …;

During our time with the person, any situation could be a source of promoting any change, and more than what type of interventions, focus is placed on what he demands, and when…

Chronoly of Interventions: weekly visits individual or with other team members, coffee…, accepts professionals telephone number,  accepts lunch together, taking into account his work demand he was empowered to go work agency, and coordination with other SS team and org a meeting…… relationship breakdown….. re-establish relationship, with another professional, accepts intervention of social worker to help with the washing

-   Highlight the correlations between the objectives to be pursued, programmed interventions and outcomes...

Again our main objective is to stablish a good engagement  with him to use any situation as a source of interventions

–    Innovative practices

Coffee, both bringing a coffee and having a coffee in a terrace, lunch together.


4.      WORKERS & NETWORK:

One or many actors?      -  Does the networking and cooperation between actors exist or not?

3 actors,  Public social team , Public  mental health team, and . Poor cooperation and networking between actors, despite regular meetings.

-   What kind of collaboration between public and private sector?    Regular meeting, joint visits, telephone coordination

-   What kind of multidisciplinary performing synergies between social, health services and... Others?  The same.

 What kind of co-working and co-responsibility between Institutions - Associations - Administrations?

The case is shared between the different institutions. And actions were also shared according to the demands or needs of the person, without appointing actions.

What are the institutional and legal barriers and limitations to providing adequate assistance (cumbersome, poorly
     defined procedures, “vicious circles”; resources and financing).

NO  personal / health documentation available, therefore a lot of resources could not be organized. Refused to be supported to update his documentation in the embasy, for the health card etc..

-   What obstacles could be overcome by “creativity” of the operators in the face of the unhelpful of confusing legislation?

There were possibilities to overcome unhelpful or confusing legislation, but did not cooperate


5.      PROPOSALS: 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?

His main priority was work; we therefore suggest a service that could facilitate work accessibility taking account his context.

Make the proposals as concrete as possible and avoid generalities.

Proposal: Offering a job prior to the documentation.

-  Work in exchange with needs. ( could exist but is not accessible for us)

Outreach approach by administrative services


6.      Personal factors influencing the launching and continuation of assistance process:

(stigma, prejudice,  orientation towards person, cultural aspects)

possible stigmatization of person taking charge or applying for assistance;

The social worker believed that the chronic situation could not be overcome

sources of stress and burn-out for assistance workers;

Since the social worker was not very collaborative, the mental health team could not access a lot of resources. and was very limited in his actions.

changes in staff during assistance process; clashing cultural aspects.

Changes in both the social and mental teams occurred, and delayed/stopped  outcomes of the process


7.      Overall assessment of the case: strengths and weaknesses of the support net and/or interventions provided;

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;

   Objectively remained unchanged, but the engagement with the mental health team has improved.
-   final thoughts, free. 

 

2.   Profile of  G. a 43 year old  woman                                                                                                           2 / GR 1

 

1.  BACKGROUND and environment / context  of  profile  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 nourishment, 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 him.

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 clear: The 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.


2.  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. Since then she has been under medical treatment.

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 Day Center.

 Another problem is that G., due to bad sanitation conditions and her reluctance to cooperate with the doctors’ instructions, suffers from frequent
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:

1.       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 psychologist).

2.       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. Unfortunately, the hospitality period in the protected apartment 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 herpersonal
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 couldn’t
 sleep. The main reason for her “regression», as it became clear from the sessions, is that she was separated from L. They were in separate
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 and angry.
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 complained to
 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 an attack
 caused by three other male mates, because of his previous provocative behavior (he was caught drunk in the hostel, he had strong arguments
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 institutional.

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 the team.

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! 


5.   PROPOSALS:

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 social identity.

Ø  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.

Ø  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 self-advocacy.  

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 complicated.

- 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 children.


7.   Overall assessment of the case: tr

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 of herself.

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.

 

 

3 / PL 1

1.      BACKGROUND and environment / context  of     Arthur, 43 years of age.

Arthur, 43 years of age. Educated  confectioner. In the past worked in a butchery. Brother emigrated, A. would like to have some contact to him. Parents live in other part of Poland. A. contacts them sporadically, accepts some material support from them but otherwise does not miss them or is not willing to return to them. Two daugters of 21 and 11- not contactes for several years now. Daughters either from a wife or a partner – no info. Homeless from 2005. From 2013 in Caritas shelter. 


2.      HEALTH:  physical  and  psychic conditions.

  Physically seemingly healthy – according to hospital tests in 2013. Brain tomography (2013) – correct. 6 stays in psychiatric hospitals in Warsaw in 2013, including one stay at a detox unit.

Diagnosed with:

-          Alcoholic delusions

-          Mixed personality disorders

-          Dissociative disorders

-          Adaptive disorders

  Prescriprions: Pernasyne, Pridinol, Neurotop, Hydroxizinum, Convulex, Deprexolet, Propranolol.

Arthur stops taking drugs shortly after leaving hospital. At the shelter the alcohol addiction diagnosed by addiction therapist.  A. took alcohol for the first time at the age of 6 (vodka). Longest period of perpetual drinking – 5 months. Multiple detoxications. In 2013 he drank after 22 weeks of abstinence , because he “heard voices”.  In 2014 judged as handicapped for 3 years. Entitled to a monthly benefit for the time of “work incapacity” – 120 euro. In the meantime he took temporary jobs like cleaning, arranging wares at supermarkets. In 2015 attempted stable work and resigned the benefit. Gave up work after few weeks. Returned to benefit.

Arthur functions correctly in the shelter. Accepted by inhabitants of his sleeping room despite his long hours of sleep and the fact that he speaks loudly while asleep. No close relationships with other inhabitants. Does not communicate if not accosted. Sits alone in the smoking space, watches tv, works in the kitchen and in the public showers run by the shelter. From time to time spends a few days in a roll in bed claiming “being ill”.


3.       INTERVENTIONS  description  :  

 While in the shelter Arthur has never shown any initiative towards returning to independent life. Once in a while the social worker tried to mobilize him and facing failure asked again and again the shelter psychologist and addiction therapist to find a way. To little avail. Arthur is a difficult client. He mostly shunned the interviews with psychologist, and refused to go to the psychiatrist claiming that the drugs prescribed for him by psychiatrists in the past have only harmed him inducing psychotic experiences (like “voices”). Social worker suspected simulation on Arthur’s part aimed at obtaining the benefit and avoiding paying alimonies for his daughters’. In 2016 another psychiatrist  on a visit to the shelter did not diagnose any concrete psychiatric ailment. Arthur complained at the time to suffer visual and listening hallucinations. Arthur did not drink alcohol since 2013.  Presently Arthur goes to visit the psychiatrist not alone but attended by psychologist – whose role is to support him on the way and make meaningful communication possible betrween the two parties. First visit occurred in September 2107, second in October. Arthur abandoned taking the first prescribed drug – Pernasyne – after 2 weeks claiming it causes frightening hallucinations. He was then visibly agitated, running in and out of the shelter, but always returning. Next drug he was prescribed is Olanzapine. We are waiting for the results. The positive change is the fact that the attended visits are taking place at all and that the psychiatrist agreed to the presence of psychologist during the visits. Arthur is not at all disturbed by the psychologist’s presence. We plan to make some psychological tests on Arthur  and have him tested with brain tomography. The psychiatrist seems now to concur with psychologist on possible diagnosis – paranoid schizophrenia.


4.      WORKERS & NETWORK: 
 

Networking has always been the weakest aspect in assistance given to Arthur. After leaving the hospital he was left to his own devices and then to the assistance from the shelter staff with little knowledge of what happened during the hospitalization. The only thing at their disposal was the excerpt Arthur was given when leaving the hospital. He refused to take drugs or to go to the psychiatrist while at the same time causing few problems and being cooperative as far as practical functioning in a shelter went. Thus he avoided being much seen or heard of and stagnated as a result. His positive attitude to make now assisted visits to the psychiatrist may stem from the fact that he lacked money after the benefit ceased to be paid in March. In the psychologist’s opinion his inability to gather necessary documents and reapply for the benefit is indicative of the genuineness of his sickness.


5.       PROPOSALS: 

 It seems necessary to continue the visits to one psychiatrist, to do the tests and complete the dossier on his state of psychiatric health. He will probably obtain the handicapped person certificate and the benefit, but it will not solve his problems. At the moment Arthur seems unable to leve on his own. The family is reluctant to take him back, and he himself is not seeking contact with them Just recently he refused to see his mother who has come a long way to Warsaw to visit him while having precious little to offer. Perhaps some form of protected housing would meet his needs and capacities  – protected meaning with regular support.  Also employment in his case would have to be “protected” in some way. He is capricious in this respect. Just recently he goes eagerly to arrange the wares at the building supermarket. Perhaps because the present colleagues suit him. He has a problem with taking drugs but it takes so long to really diagnose him and prescribe something adequate without too much side effects. Having stated the longevity and at times randomness of the help he received so far we cannot forget that at the shelter he got rid of his more acute symptoms, has a day structure, something to do, and a rather positive human environment. There is at the moment practically no better place for him to be. 
 


6.      PERSONAL FACTORS INFLUENCING the launching and continuation of assistance process: 
-  possible stigmatization of person taking charge or applying for assistance; 
-  sources of stress and burn-out for assistance workers; 
-  changes in staff during assistance process; clashing cultural aspects.


 

SMES-Europa - Secretary   Tel. / fax: (+) 32.2.5385887 -    mob; +32.475634710       -   E-mail: smeseu@smes-europa.org