RITA

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?           

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 54th year old finnish woman who came to Barcelona alone one year ago. She left Finland when in 2017 her mother, her ex-husband and two friends died due to different conditions. Her father, her half sister, her son and her daughter live in Helsinki, she nowadays keeps in telephone contact with her father and half sister. According to her, she has studies of nursing assistant and she worked in France and Sweden, but she stopped working a long time ago. She says she speaks eight languages and enjoys travelling, reading, music… When we meet her she is in a shelter, she abuses of alcohol and she refers she feels depressed, due to this we started mental health attention. There is a previous diagnosis of schizophrenia or schizoaffective disorder and referred past abuse of heroine (from 15 to 27 years old), refers have been linked to detoxification units and have carried out programs of detoxification with methadone and buprenorphine; past abuse of cocaine (from 15 to 27 years old), only punctual consumptions nowadays.

Her relations with other users and professionals in the shelter are correct. Updated documentation and receiving Swedish pension.

   - time, in relation to the chronic situation; Unknown, difficult to define

   - abandonment, in relation to the breakdown of any relationship and link; One year ago she stopped contact with her family in
     Helsinki.

   - refusal , in relation to any institutional offer of care and assistance services She accepts care, shelter, health attention and
     mental health attention from psychiatrist, nurse and PSI.

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, Comorbidity &
    social disadvantage)

Diagnosed as chronic paranoid schizophrenia, (referring auditory hallucinations, self-referentiality, ideation of harm and phenomena of reading, control and insertion of thought ….). She refers multiple psychiatric admissions from several EU countries in the last 15 years for psychotic symtomps. Other health problem: Cor pulmonale, asthma, diabetes, HBV and positive HCV. Have epileptic seizures in the context of brain neoplasia years ago. She refers been diagnosed with narcolepsy.

Alcohol dependence disorder, smoker. Refers to heroin use parenterally from 15 to 27. It refers to cocaine use parenterally from 15 to 27 years. Subsequently intranasal use and currently punctual consumption. She says several months ago that she does not consume because she does not have accessibility. - Consumption of LSD and amphetamines in youth.

   - influence of the health condition on the lifestyle of a person; During the time she was in the shelter she used to put herself in
     danger due to alcohol abuse and repeated episodes of intoxication. She is also an important smoker and this worsens the
     respiratory situation.

   - history of interruptions and resumptions of medical services provided to the person; After entering the subacute mental health
     unit, she was discharged due to transfer to pulmonology and from this ward she was given medical discharge to the street, so she
     was urgently located by social services in a boarding house. Finally the mental health team referred her to a mental health
     therapeutic community for a stay of approximately four months, she refers great motivation for physical and mental recovery.

   - orientation and opinions of the medical players in respect to the person; A person with several serious health conditions who
     accepts help but the process has been interrupted several times due to extern causes. There is also the need for a long term plan
     to ensure the potential physical and mental recovery she is trying.

   - 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 person’s first contact with the mental health team is addressed by the shelter where she lived, she demanded this first visit, which facilitates the therapeutic relationship. The cause was that she felt depressed and she abused of alcohol, there were obvious signs of suffering. There has been no compulsory sanitary treatment since she accepts resources and health attention and makes demand for treatment. During the last months she has been admitted to the shelter, subacute unit, pulmonology, pension and therapeutic community. This process has been torpid. Operational solutions: improve coordination between actors (despite the numerous mails, phone calls and presential meetings, they were not totally effective in the end). The main aim through all the process has been to get a working plan respecting her priorities and maintaining the therapeutic relationship.

   - What kind of intervention – in health + social field - success of non-success depends of …; Chronology of Interventions: weekly
     individual visits or with other team members, first in the shelter, then weekly visits in the subacute unit/pension/therapeutic
     community (coffee, laundry, social procedures…). Also meeting with her half sister and the patient accepts the possibility to
     contact her half sister using the professional mobile. The visits are always made depending on what she demands, she accepts
     visits so we can easily set goals.

   - Highlight the correlations between the objectives to be pursued, programmed interventions and outcomes... The main objective is
     to maintain a good engagement with her and respect her priorities. The outcomes have been hindered by the circumstances
     described above.

  – Innovative practices Meeting of the three mental health professionals with her half sister, who travelled from Helsinki to
     Barcelona, in order to see her again after a year without news from her.

4. WORKERS & NETWORK:     - One or many actors? - Does the networking and cooperation between actors exist or not?
   

     Several actors: public social team and
     public mental health team with three professionals involved (psychiatrist, nurse, PSI), also team from therapeutic community,
     pulmonology team, subacute unit team…
     The networking among the different actors is difficult but keep trying, regular meetings,   etc.

      - What kind of collaboration between public and private sector? Regular meetings, 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 health card available, great difficulties to get it due to administrative
        situation which limits access to numerous resources. Urgent request of a municipal social worker because the referent of the
        shelter gave her the discharge when she was admitted to the subacute unit. She was given medical discharge from the subacute
        unit because she was referred to pulmonology. From pulmonology, she was given discharge to the street because of non
        compliance with treatment. Difficult coordination with some services despite of the efforts (the patient's belongings were
        thrown  in the trash in the subacute unit despite being warned that social services would pick them up).

      - What obstacles could be overcome by “creativity” of the operators in the face of the unhelpful of confusing legislation?
        Not the case.

5. PROPOSALS: What proposals of possible and innovative interventions when the solution of complex situations seems impossible?

   - What pathways, what specific priorities could be taken for priority recommendations? The main recommendation would be
     taking into account that she is a homeless woman and that it is not ethic to give someone medical discharge (from any medical
     ward) to the street. Her main priority is recovery and the failures in the procedure have made it difficult.

   - Make the proposals as concrete as possible and avoid generalities. Proposal: Orientation towards person: institutions should take
     into account her vulnerable situation before making decisions about her situation and take into account the whole situation.
     Outreach approach by administrative services to solve administrative issues, for instance, the health card. Lack of protocols in
     institutions related to homeless people’s circumstances, for instance, protocol to keep their belongings for some time and phone
     professionals related to the case before throwing the belongings away.

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 situation of being homeless and with mental
        health problems seemed to create a stigma in professionals of pulmonology ward because of which she was given unequal
        treatment and discharge to the street with the argument of non-compliance with treatment (since she is homeless and mentally
        ill she will not be able to make compliance with treatment).

      - sources of stress and burn-out for assistance workers; Inefective coordination between the different resources despite of the
        efforts. Medical discharge to the street several times. Possible unequal treatment due to the homeless and mental health
        situation.

      - changes in staff during assistance process; clashing cultural aspects. There were no changes related to health professionals:
         the relation with the health team was not good in the shelter but it significantly improved when we could accompany her
         through the next steps of the process (subacute, therapeutic community…) Cultural aspect: Not the case.

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; The person’s condition has improved since the mental health team met her
      until now.

    - final thoughts, free.

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

DIVERS: ....