REPORT on the 1st COURSE
LISBOA  16-18  March 2017

ERASMUS +       ANNEX II - KA2     Ag. Nb.:  2016-1-PT01-KA202-022970


REPORT 1st Course






1.   BACKGROUND and environment / context   C Man - Dublin 2

C aged 54 grew up in the midlands with his mother, father and siblings. C had 3 children who had very little contact with. From the travelling community, and due to C’s family history, C faced a lot of disadvantages and stigma growing up. After the death of his son due to addiction, C got involved in crime to feed his heroin addiction, resulting in him being in and out of prison over a 20-year period. On release from prison, C would return to his family home. But after the death of his parents, the family home was sold. C was left sleeping rough on benches and abandoned houses on release from prison. Due to the stigma attached to his family’s name it proved extremely difficult to get a landlord to accept C into private rented housing and for C to receive adequate supports. C entered emergency accommodation in MSC where he stayed for 15months. Recommendations for emergency accommodation is maximum 6months, but this was extended due to the complexities involved. C thrived in this environment where there was 24/7 support. He moved into long-term supported housing from here, where he stayed for 4 months. This broke down due to anti-social behavior and C’s difficulty to say no to visitors that were causing serious risk to himself and others. C withdrew from mental health services and stopped taking his medication as his addiction worsened. C shortly after returned to prison, he has since been released and again is sleeping rough. 

2.   HEALTH:  physical  and  psychic conditions.

C was diagnosed with paranoid schizophrenia when in prison. This was as a result of C experiencing some of the common side effects such as delusions, hallucinations, self-harm behaviour and after numerous suicide attempts. During his sentence in prison C would take medication daily and engage with psychiatrists. On release, C was referred to a local mental health service which he attended monthly for a depot injection and met a psychiatrist approximately every 3 months. When C’s addiction would worsen, attending these appointments proved very difficult and would lead to C disengaging with supports. This was seen upon moving to supported accommodation where C had to travel 30mins to engage with mental health supports.

C was also linked into Community Alcohol and Drugs Service (CADs) when in the emergency accommodation where he was on a methadone programme. The emergency accommodation had to advocated for a local pharmacy to dispense this daily to C as due to C’s previous convictions, the closest pharmacy that would accept him was located 30minutes away where C would have to travel to daily. There was very little communication between the mental health and drug services, only updates key worker in the homeless service would provide to each. Both services felt that his addiction was hindering his mental health and vice versa, requesting C work on the other before effective treatment could be done to help him.

    INTERVENTIONS  description  : 

With the support of C’s probation officer and MSC completing the assessment in the prison, C successfully entered emergency accommodation directly on release from prison. Whilst this presented challenges in the community of the emergency accommodation due to stigma, this was managed through monthly community meetings were any issues were managed i.e. community feeling there was an increase in crime since C’s arrival, without any evidence for this. C had a successful placement and was linked into mental health and addiction services showing a vast improvement in his addiction and management of mental health diagnosis. It proved extremely difficult to secure private rented accommodation but by working with homeless service, C moved onto supported housing. Due to lack of easily accessible support services, C disengaged. Due to his personality and vulnerability, he also found it extremely difficult to control visitors, which lead to unauthorized visits out of hours causing risk to himself and others.

Case conferences were initiated by the homeless service where the majority of C’s support services did come together to support C to get the best possible outcomes. And whilst this was successful and a positive, this was not ongoing and was mainly to address C’s accommodation needs at the time. Support services did not engage in this long-term and not all support services were involved including the mental health service.


4.   4.   WORKERS & NETWORK:

 There was multidisciplinary work between the homeless service, probation officer, regional resettlement service, mental health service and addiction service which did result in some positive outcomes for C. What we feel was lacking, was direct communication between mental health services and addiction services. C’s dual diagnosis proved so complex that when one aspect deteriorated, it would affect the other. Without the collaboration of both services and local support, this had significant effects on C’s outcome. Whilst there were various individuals supporting C, there was no multidisciplinary team where all support services worked together on the same care plan.



·     Mental health services and addiction services to work closely together in supporting people with a dual diagnosis. A multidisciplinary team to be established where all services work together and meet weekly/monthly.

·     Mental health services to be more flexible in supporting service users locally i.e. if finding it difficult to attend appointments, to meet in the community or home (community support).

·     Accommodation to be provided by the local authorities to people who are experiencing difficulty renting from landlords due to their history or ‘name’.

·     Long-term secure housing facilities staffed 24/7 for people who need extra support to live independently.

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

C’s family history and social network made it very difficult for C to disengage in anti-social behavior and change his lifestyle. This was seen when C’s progress would deteriorate when socializing with old acquaintances, leading C into a cycle of addiction and crime and ultimately into a homeless ‘cycle’. 

Agencies such as the Local Authorities working with C who were not from a social care background did not show the same level of understanding re. C’s situation as C’s support workers in homeless service. This caused many barriers when advocating to get C the supports and outcomes that he deserved. This caused stress for workers who had seen the significant progress C was making with the right level of supports.


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

When the appropriate supports were in place, C made significant and very positive progress. The lack of multidisciplinary work and community support when C’s mental health and/or addiction would deteriorate resulted in C relapsing to his old lifestyle of crime and addiction. This has resulted in him sleeping rough on the streets once again. C is currently trying to source accommodation, but is facing the same challenges as he did in the past.



1.        BACKGROUND and environment   of  MARY  - Dublin 2

 Mary is 36 years old and is a member of the travelling community. She has been in and out of homelessness for almost 16 years due to family breakdown and addiction. Mary has 7 siblings, 6 of them are also homeless and in addiction. She has 3 children who are all in foster care. 2 of the children were with her while she experienced homelessness. When her children were taken in to care she fell deeper in to addiction. She began accessing emergency homeless accommodation and sleeping rough as she could not maintain a house. She feels let down by the county council as she states she was treated unfairly when houses were taken from her. She feels tricked by the social workers who she says conned her in to giving up her children. She finds it difficult to trust professionals and struggles to move on from the past. Mary lives with her partner in Dublin city. This is not where she is originally from and she hates living there, she also feels that she was tricked in to moving there by her previous support worker. Mary is diagnosed with depression and this presents itself as severe highs and lows. Her current living situation has a detrimental effect on her depression and mental health. Mary is an ex heroin user. She is on methadone and abuses street tablets (benzodiazapines)


2.   HEALTH:  physical  and  psychic conditions

AMary is diagnosed with depression and is on medication for this. No other health concerns.

Mary’s depression influences her lifestyle by her becoming withdrawn and/or very heightened and aggressive. Mary will have extreme verbal anger outbursts but will then shut down and disengage from support. This is very draining for Mary. She feels guilt after these outbursts and struggles with her feelings around this. She has also attempted to take her life during one of these outbursts.Mary is prescribed her depression medication by her drug treatment center and it is rarely reviewed. This center does not have a mental health specific professional on their team.

After her most recent depressive episode, Mary was brought by staff to the local psychiatric hospital. After this visit she was put on a day programme for people who require psychiatric support. Here she linked in with a psychiatrist and a counsellor and they managed her medication. When they found out she was linked with a drug treatment centre, there was some confusion about who should be her primary carer. The day programme were happy to do this, however the drug centre requested that she remain in their service. They promised the same level of psychiatric care and Mary agreed to this. However, since her day programme came to an end she has received no further support around her mental health.


3.       INTERVENTIONS  description  : 

Support sessions working on how to manage emotions. Staff being aware of how she presents and how to manage the presenting behaviours. For example, it is important to give her some time away before checking on her after an outburst. Doing prevention pieces, noticing the signs that a depressive episode may be on its way. She will often appear very happy and overly excited before an episode of depression. Episodes are less frequent and behaviours are more easily managed due to ongoing staff support.

Support worker and service manager have been in touch with her drug treatment centre in an attempt to work together to provide her the best care, however her doctor is very difficult to communicate with and has previously said that she not his issue despite the fact that he demanded he be in charge of her care.


4.        WORKERS & NETWORK:

There are many agencies involved in her care. Social workers, drug workers, housing, support worker.

They have all raised concerns about her mental health and in the past have blamed her current living situation. However the staff where she is living currently offer her the most support. Other agencies are afraid of upsetting Mary rather than helping her work on her presenting issues and so they pass the responsibility on to someone else. This has been frustrating for the staff as there is no positive relationships among the agencies despite attempts to develop them and all work together to support Mary.


5.        PROPOSALS: What proposals of possible and innovative interventions when the solution of complex situations seem impossible? Separate her psychiatric care from her drug treatment. The drug treatment centre do not have the resources to best work with Mary to keep her mentally well.

She should be linked in with a mental health team who will look after her medication and ensure that she is on the right treatment. Be able to do regular reviews of her illness and also have information on or access to other supports such as counsellors and support groups.

Personal factors influencing the launching and continuation of assistance process: Marys distrust of professionals is a barrier to care. Because of her outbursts, it is possible that staff in services will not engage with her.

Issue of addiction and mental ill health. No service that will deal with both effectively.


7.       Overall assessment of the case: strengths and weaknesses of the support net and/or interventions provided;
Mary receives a lot of support from her housing provider and she seems to have learn how to better manager her emotions. Her main goal is to move out and live independently, however other services involved in her care need to take some responsibility to ensure that community supports are available/in place so that she can do so safely.



Profile Maurice   Porutgal1

1.       Background and environment

Maurice is a 52 years old man, born in Senegal, who has been in Portugal for approximately 5 years, supporting himself with short, temporary jobs in the construction industry as a painter. Unemployed for over a  year he was known to live in an abandoned building before being hospitalized for convulsive  crisis into a general hospital and after that  transfered to a psychiatric hospital.

He refers to have been born in Senegal, where he supposedly has his mother,  brothers, wife and children. He reports to have completed high school and to have been a professional football player in Senegal, Italy, France…

2.       Health: physical and psychic conditions

Before being hospitalized, Maurice was known  to abuse alcool and was exhibiting strange behavior: he would talk to himself, he would gesticulate in a manner that scared people…

In the General hospital he showed a syndrome of   “hyperactive delirium”, urinating and defecating in inappropriate places, walking endlessly in  and out of the hospital, interfering with the activities and the patients, while at the same time he was hard to understand , appeared confused and showed  behavior suggestive of alucinatory activity.

In the Psychiatric hospital, Maurice showed a more calm, friendly behavior, speaking fluent French (just a few words of Portuguese). Yet he appeared not to be oriented in time, place, his age and at times seemed to be confabulating.

For example, if he was asked where he was (that is, in a hospital in Lisbon) he answered that he was in Dakar, in a catholic school, and justified his presence here as a construction worker painting a wall.

Submited to a psychological evaluation he showed a syndrome of cognitive deficits, with major impairment in the functions of orientation,  recent memory, and a diminished reasoning ability, suggestive of a an alcoholic dementia (korsakof syndrome) 

3.       Interventions

 There was some informal intervention by people living in the area of Maurice that put some pressure for his hospitalization. Yet there is no one as reference to articulate with the hospital team in finding solutions.

 4.       Workers and network

 At this point he is still hospitalized and we are trying to discover and build a network besides the hospital team. The social worker of the hospital team has made contacts with an International Migration Organization in order to help establish the location of family members in Senegal.

 5.       Proposals

 If he has a reliable family network in Senegal he could be helped returning home.If not, he might integrate a residential unit in the Hospital since he will need suport and care after discharge from the hospital since he has no capabilities of autonomy to live by himself.

 6.       Personal factors

 Although Maurice has a nice contact and is easy to live with he presents a serious impairment in his cognitive functions.

 7.       Overall assessment of the case

 This case joins together being a migrant, with no family network in Portugal and an uncertain network in his country of origin, yet to be confirmed; and being seriously impaired in his cognitive capabalities which makes him very vulnerable to live in the worst conditions as a homeless. In order to prevent that, a solution has to be found acknowledging  his deficits of autonomy and need of support.



1.        BACKGROUND    of  John  - Portugal 2

John has lived on the streets of Lisbon since 2004 until 2017.

He has been discharge from psychiatric hospital, in 2004, with a double schizophrenia diagnosis and alcohol dependence. He missed a psychiatric consultation booked on March 13th 2004 and for many years he disappears from the health services, living closed to the largest football stadium of the country, always refusing to leave from that place.

One important world football match put him in a psychiatric emergency room for a couple of hours, but the psychiatrist of the general hospital decided not to use the compulsory psychiatric admission and he returned to the street.


2.        HEALTH:  physical  and  psychic conditions.

John suffered from schizophrenia and also had alcohol dependence and high blood pressure.

He had a delusion that 1000000 of women belong to him and had no insight for his disease. Always in a quiet and peaceful way, he refused any type of health help.

3.   In 2016 it has been tried multidisciplinary interventions, with social and health professionals (public  and  private sector) and the Health Authority, in order to promoting  compulsory conduction for evaluation in a hospital leading to a probably compulsory psychiatric admission.

Still, for administrative reasons he remained in the street for months, because he was never in the place of sleeping when the police arrived to conduct him to the hospital.


4.        WORKERS & NETWORK:

Many different professional from social, health, municipality, belong to multiple institutions (hospitals, health centers, social security, municipality, police, health authority, multiple associations for homeless), public and private, were insufficient to solve the situation.

It was only when a psychiatric report has been made, that things begin to move, in a slowly way. And only when the psychiatrists and psychologists from the psychiatric hospital, who never given up, insisted with the Health Authority (who join us in a visit to the place were John were living) that it was possible to have the homeless psychiatric patient admitted in the hospital.

5.        PROPOSALS:

He never learn about counting in euro money. He believed that he has many houses and one million women.

On 20th September 2017 he entered in a “Housing First” program, but he has been there only for one day. He has returned to sleep in the streets, but accept the psychiatric admission again.

One month later, on 16th October, after 150 days of psychiatric admission (in an acute psychiatric acute unit for 16 days!) he went again to a house of “Housing First”, where he still remains.

Personal factors influencing

For many years this situation has been very stressing for most workers, for many reasons: he was always calm, non-aggressive, some psychiatrists (of the general hospital) don’t wanted to activate the mental health law for compulsory admission and even after this has been possible the police never find him!

7.       Overall assessment of the case:

The joint work of many professionals allowed that, at the end, he has his own house. On 19th October he was clinical well, attending our Psychotherapeutic Open Group and psychiatric consultation, and finally our work in the way of a better life for him was going on.

 GR  1 

  1. BACKGROUND 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: 
    -   time
    , 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 services

N. was born in 1967 in Chios (Greek island), but when he was two years old he and his family moved to the USA. He is single with no children. He has a younger brother. His mother died 15 years ago; his father has been remarried and lives in the USA.

N. graduated secondary school and lived in the USA until 2014. After his mother’s death, with whom he was very close, he started behaving in a deceptive manner. He wanted to become rich and independent, as he thought that if his family had money his mother wouldn’t have died. But soon afterwards he was arrested for drug possession and use and was sentenced for 4 years. When he came out of prison he tried to find a job in his uncle’s restaurant but he was not paid enough and he quitted. He started doing illegitimate things again and consequently he passed another 6 years in prison for carjacking and undeclared labor. When he was released, he was expelled from the country as he had no American citizenship. He didn’t inform his father or his brother about that because he was embarrassed and this is how he ended in Greece, sleeping in the streets.

N. visited the Day Center for Homeless (D.C.f.H.) of NGO PRAKSIS in Piraeus in June 2015 for the first time and his initial request was the use of sanitation services (shower and clothes). At that time he was sleeping at a shelter of UNESKO. He was also under legal advisory and support by an NGO for ex-prisoners named “Epanodos” (=Comeback).

While he was a beneficiary in the Day Center for Homeless of the NGO PRAKSIS in Piraeus he also visited the Day Center for Homeless of the same NGO in Athens, although this is not allowed. When this was discovered he was asked by the social worker in Athens to leave. He got furious, started accusing the staff that they intended to harm him and finally he had a violent outbreak; he hit a beneficiary in the head with a tether and threatened that he would kill them all. He locked himself in an office and took one of the beneficiaries with him as a hostage. As this was not the only violent incident, the staff called the police and he was taken first to the police station and then for involuntary admission to a psychiatric hospital.

HEALTH:  physical  and  psychic conditions.

During his hospitalization N. mentioned to the doctors that he was brought and left in the borders of Greece by agents of the FBI. He also expressed paranoid thoughts and aggressiveness. Consequently, he was diagnosed with ”Severe psychotic syndrome, drug use inclination (sisha and cannabis) and  aggressive behavior-verbal and physical”. Since then he has been under medical treatment.

After a few weeks in the psychiatric hospital, N. returned to the hostel of UNESCO under order to be   followed up every month.  Additionally, he was under the support of Day Center for Homeless of NGO PRAKSIS and PRAKSIS Polyclinic as well. Unfortunately, soon afterwards he had another violent outburst, in the D.C.f.H. in Piraeus.

But this time, with the intervention of the male nurse and the social worker of the Centre he was persuaded to go for voluntary hospitalization. In the hospital he admitted that he didn’t take his medication, therefore auditory hallucinations and paranoid thoughts were still troubling him.

Due to his attitude (he had a few violent episodes in the hostel and an unstable behavior) he was expelled from the hostel of UNESCO and ended up sleeping at the port of Piraeus. Fortunately, he had built a strong relationship of trust with the male nurse of the D.C.f.H., therefore he accepted taking his daily dose from the D.C.f.H. and having a follow up by the volunteer psychiatrist of the Center. In addition, thanks to the nurse’s continuous and genuine interest, N. eventually started feeling safe and expressing himself.

At this point, the D.C.f.H. started cooperating 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.  

2.    INTERVENTIONS  description 

With this setting, N. started having weekly sessions with the psychologist from SSP&MH (May 2017 until today), aiming at his psychological support, empowerment and guidance. His clinical situation was gradually improved due to combination of counseling and medication. Therefore, he became less aggressive and paranoid whereas he was more “open” to talk about himself.

Although he didn’t visit the Day Center in regular basis, he was there on time for the sessions and he was looking forward for them. He said that it was the only reference point in his life and made him feel resilient.  In one of these sessions he said that he also used to visit a psychologist during the prison period and it was very helpful for him.

Meanwhile, with the support and guidance of both the psychologist and the social worker, N. got his Tax Registration Number and applied for a social allowance. This will help him to save money and rent an apartment. These adjustments relieve him, as in the past he was robbed twice while sleeping at the port. Unfortunately, during our intervention he was robbed again for the third time. They stole his bag of painting materials forcing him to stop painting and selling them. This theft led him to despair and he “returned” to drug use.

Thanks to the trust he had to the staff of the Center he told them about the drug use and they in turn informed the psychiatrist; he modified the dose in order to help him overcome his anxiety and despair.

In addition, the psychologist suggested N. to have daily presence at the D.C.f.H. and a few extra sessions with the social worker, as he needed extra care and the psychologist was at the Centre only once a week. He seemed relieved by this proposal. For the first time in his life he was taking care of instead of being punished. This coordinating effort from all the members of the multidisciplinary team created a safety net for N. The team became the family he never had. So he started feeling better.

But this didn’t last long. As he was flashing back to his life and regretting for his mistakes he believed that nothing could change in his life; A feeling of despair overwhelmed him and he admitted that he had suicidal and self-destruction thoughts. Therefore, the psychiatrist modified his medication again and the psychologist proposed to N. two things:

1.    To visit the Day Centre in daily basis and have a brief session with either the social worker or the nurse. In case of intense suicidal and self-destruction thoughts he was advised to inform the staff immediately.

2.    To start painting again in daily basis despite his lack of inspiration and his feeling of despair. He could paint whatever he wanted without thinking about the esthetic outcome. In the sessions he could discuss about these paintings and his feelings. As a result, he expressed his anxiety and despair and gradually they were replaced by feelings of hope and determination.

His words from that period are characteristic:

·         “Prison is better than homelessness. There you could sleep and eat…However, prison affects you physically and mentally. You feel that you are under a sheet and this keeps you “down”. You “forget” you have a body. For this reason, I acted regular exercise”.

·         “The most valuable thing in life is to have a key and open the door of your home… In different case, you feel “lost”. Everything seems to be in vain”.

·         “I want to do something for my life. I can’t wait for the allowance to be approved. I have to find a job, to have my own money”

It was then that he decided to go to Chios and work there as a street painter/artist. He said that he had relatives there and he believed that they could support him. He was encouraged to search for more information about his relatives before going to the island, so he started searching for his mother’s brother, who lives in the USA permanently but visits Chios every summer.

At the same time the social worker was trying to find him a temporary shelter. For this reason, the psychologist along with the social worker went to Unesco to meet the social workers there. They reassured them that N. had made huge steps since last time he was staying there. He was not aggressive anymore; he was taking his medication steadily and made plans for the future whereas he had stopped using drugs. Drugs were his effort to help himself reduce the anxiety and the psychotic fear he had, so he didn’t need them anymore.

Meanwhile, N. participated in a street fiesta that was organized by the D.C.f.H. under the umbrella of the municipality of Piraeus and during the fiesta he painted in front of the audience. The painting was so good that the municipality bought it for 200 euros. That made him regains his self-confidence and start seeing himself as an artist instead of a homeless and hopeless person. On the other hand, it convinced the social workers of Unesco that he had changed so they accepted him back as soon as they had a spare bed.

The first night in the shelter N. was very anxious and was unable to fall asleep. After a year sleeping at the port he found it difficult to sleep in a closed space.

At the present time, he is organizing his first personal exhibition with the help of the staff of Unesco and he is excited about this project. Additionally, his allowance has been approved and our concern has to do with his financial management, as he is inclined to spend without planning. Consequently, a joint management with the staff support on the use of the allowance is necessary, at least for the beginning.


As it has been already mentioned analytically before, this particular intervention and the fruitful results became feasible through the cooperation of the Day Center for Homeless of NGO Praksis and Society of Social Psychiatry and Mental Health. Additionally, there was collaboration with other NGOs (e.g. Unesco, MdM), public hospitals and other public services as well (e.g. social services for his social allowance), but it was not official or institutional. As a result we didn’t have a continuous and systematic collaboration; despite our efforts it was not possible to receive feedback from the intervention of the other actors.

This also means that due to institutional barriers, no service was really responsible for N. and certainly no service alone could meet his multilevel needs. In addition, this poses the burning issue of the lack of specialized interventions for the most vulnerable group among homeless people. The paradox is: Mental illness is strongly related to homelessness. Despite that fact, mentally ill homeless people fall between the lines and do not "fit" to the bureaucratically organized services…Neither the services for homeless can accept them if they have a disturbing behavior nor the services for mentally ill can reach them, as the housing services for people with severe mental health problems are designed for people who are discharged from psychiatric hospitals.

4.        PROPOSALS:

The best intervention for homeless people with mental health problems is the combination of Housing First and Assertive Community Treatment (e.g. off-site mobile service), as we have to ensure housing before designing and implementing any other multilevel interventions.

Lockers in every Day Center would also be a solution for many people who live in the streets and they are often robbed.

Additionally, through the Greek network for Housing Rights it could be developed coordination among the NGOs in this field, in order our interventions to be more efficient. Our case did show that the model of networking and joint intervention can be proposed as a good practice.

Coordinated and complementary interventions through networking of services would be the only sustainable solution at this period of time. It is difficult to push for more services in a period of austerity measures (although we keep on trying); however a realistic solution would be better coordination to the existing services using all the available community resources.

Furthermore, the implementation of the National Operational Plan - continuum of services is now more necessary than ever. This action requires coordination of Ministry of Health and Ministry of Labor and Social Welfare.

Finally, promote Advocacy, mainstream human rights in the provision of services for homeless people and eventually promote self advocacy should be also taken into consideration.

5.      Personal factors influencing

In this case there were some factors that made the intervention more complicated:

-The existence of "double stigma" (mental health problems, involuntary hospitalization, prison)

- The stressful situation of suicidal thoughts; that was difficult to be addressed by the everyday staff in the Day Center, which poses the question for the need to support and supervise the assistants.

- The idea of Psychologically Informed Environments and Trauma Informed Care seems to be very crucial for people like N. who have faced multiple trauma, exclusion and punishment instead of an integrated and stable support.

6.      Overall assessment of the case:

In this case there was the coordinating intervention by two actors with great experience in two different fields:

·         NGO PRAKSIS has great experience in working with homeless people and people living in extreme situations (poverty, refugees etc) and

·         SSP&MH has great experience in working with severely mentally ill people in order them to avoid hospitalization and be treated in the community.

Therefore, integrated services and personalized intervention were achieved and N. didn’t have another hospitalization; Next step was then his empowerment, development of his self-esteem and control of his life. The question he had to answer was: How do you see yourself in the future? As homeless and hopeless person or as an artist with potentials?

Since N. is very fragile and he falls from enthusiasm to anxiety and hopelessness very easily, we have to be very cautious and supportive to every step he makes and be there for any possible relapses.

What did work in a very fruitful way in this case was the initiative and motivation of the staff of the Day Center for Homeless of NGO Praksis and the favourable condition of the pilot collaboration with Society of Social Psychiatry and Mental Health that offered the time of a psychologist once/week. This interdisciplinary team collaborated also with the team of UNESCO shelter and managed to offer stable, long term and multilevel support and thus to meet the health and housing needs of N.

Conclusively, we argue that networking, integrated services and good coordination among services can be proposed as a good practice in order to meet the diversity of needs of homeless people who also face mental health problems.



1.        BACKGROUND 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: 

(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.
All additional information on the health situation,  information on hypothetic or declared diagnoses  including:
-  interaction between mental and physical condition; 

(Comorbidity&mental health, other health problems

Comorbidity &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.

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.




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. 



OPTIONAL:   Complementary elements on the situation of gradual degradation in terms of both physical and mental health

DIVERS: ....








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