BACKGROUND and environment / context of
profile of the person in relation to :
the condition of ‘dignity’ and 'health' in
these people live. What kind of interrelation between
- time, in relation to the chronic
- 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
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
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”.
he has been under
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.
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.
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
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
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:
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.
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
“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.
WORKERS & NETWORK
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
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
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.
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.
Personal factors influencing
In this case there
were some factors that made the intervention
-The existence of "double
stigma" (mental health problems, involuntary
- 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.
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.
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
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.