INDEX  of  PROFILES 
of  homeless  people with  mental  health  problems

1.     HISTORY and CONTEXT

Mrs. R.D., a 50-year old psychiatric patient and Mr. M.D. her 30-year old son – living together in a flat owned by Mrs. R.D.'s brother. They recieve mental health treatment for 16 and 14 years respectively. Their husband/father passed away 8 years ago. They take care of themsleves mostly on their own, being occasionaly visited by Mrs. R.D. brother, who lives in Germany.

Over the course of their psychiatric treatment history they both experienced frequent hospitalizations resuting in weakening of most meanigful social and familly relations. It was caused both by prolonged absence from daily life and by mental disorder stigma which basiclly excludes patients from the society. Mrs. R.D. refusal to recieve institutional assistance is invariable and is directed mainly at psychiatric treatment. Her son Mr. M.D. goes through cycles of acceptance/rejection of institutional help.

2.     HEALTH:  physical  and  psychic conditions 

Mrs. R.D. has a diagnosis of paranoid schizoprhenia dating with a hypothesis of personality disorders having significant impact on her psychological well-being. In addition to psychiatric diagnosis, she also suffers from a acute form of rheumatoid arthritis. Her son, Mr. M.D. is diagnosed with paranoid schizophrenia, obesity. There is a hypothesis of mental and behavioral disorders due to the use of tobacco. 

3.     INTERVENTION

Intervention is home-based – both Mrs. R.D. and Mr. M.D. recieve a antipsychotic medication therapy and psychological assistance. They are visited on regular bi-weekly basis by a psychiatric nurse and psychologist. Psychiatrist visit them on less regular basis.

The main difficulty of the intervention is changing willingness to cooperate – both Mrs. R.D. and Mr. M.D. tend to vary between acceptance of their mental disorder and need for treatmnet, and denial/rejection of intervention.

Success of the intervention is mainly found in decreasing number of hospitalizations – both Mrs. R.D. and Mr. M.D. spend much less time in mental hospitals than they used to.

Under such conditions failure is mainly found within intervention group itself – mental fatigue of our workers tend to distance them from patients, occasionaly causing decrease in quality of our services. 

4.     WORKERS  & NETWORK:

There is no collaboration between public and private sector. All services available to Mrs. R.D. and Mr. M.D. are provided by state run agencies and hospital.

In addition to community-based mental health treatmnet, our patients recieve help from social services. However, there is institutional lack of collaboration and even communictaion, leading to both systems providing separate and uncoordinated services. 

5.     PROPOSALS:

Mrs. R.D. and Mr. M.D. being mother and son are interdependent in their mental health problems.

An intervention aimed at separating them – like offering Mr. M.D. a place in a hostel, or protected

accomodation - would be desirable. It would allow designing completely separate

intervention/therapy plans for both mother and son.

Mr. M.D. could then be offered place in day ward or/and an assisted work place. That would enhance his social interaction which at present – being assisted at home by his mother – he vehemently rejects.

Mrs. R.D. would be able to receive therapy outside mother-son context which presently is the the source of diffrent tensions and stress.

Context and history   :   Belgian citizen of Rwandese origins

• Arrived in Belgium in 1992 in order to pursue studies in electrical engineering. Received his diploma in 2001.

• Never went back to Rwanda but witnessed the massacre of some of his family members.

• From 2001 to 2003, was a teacher for electrical engineering lectures in a secondary school in Brussel

• Following a certain mental instability, was preventively institutionalized in a psychiatric hospital three times from 2003 to 2009. Was diagnosed bipolar with psychotic symptomatology.

• Still lived in a private apartment in Brussel, until late 2011, early 2012. Since then, has lived for 3 straight years on the street (mainly in the train stations of Brussels.

• Severe alcohol consumption was developed during this period. Also tended to avoid contact with any kind of institution (our mobile team included).

• On November 2014, a contact was finally able to pass through and a link was established with our institution. From then on, he accepted being sheltered in our center. Our PMS team was able to start a follow up of his situation.

• From November 2014 to late April 2015, he was sheltered in our center, was closely follow-up by our team. Diverse administrative procedures were put in place (social revenue, property manager, medical stabilization) and a physical accompaniment was necessary throughout the whole period to ascertain its positive development (everything was made with his full consent).

• On May 2015, he entered a social apartment at a social housing institution. He has been there since then, is regularly seen his psychiatrist (1x/month) for his medication and mental health evaluation.

  Never went back to Rwanda but witnessed the massacre of some of his family members.

Health:

Mr F was diagnosed with bipolar disorder, with psychotic symptomatology. Beside this diagnosis, an alcohol consumption problem was observed by our team during his stay in our center. This alcohol consumption tended to aggravate his symptoms, his mental and behavioral instability, and disturb the psychiatric treatment that was put in place.

Intervention and development :

At first, our intervention consisted in trying to establish a link, a stable contact with Mr F with our mobile team. When we were finally able to bring him back to the Samusocial, a global evaluation of his situation was made by our PMS team. Medical and psychiatrical evaluations were made (in order to assess the full extent of his mental illness). Contacts were made with the CPAS and Brussels city hall, in order to put his administrative situation back in order (obtaining identity papers + social income + medical coverage). 

Several difficulties were met during this period. First of all was the mental illness that played a central role in Mr F’s instability (behavioral troubles were frequent). Our first priority was to put a psychiatric treatment in place, in order to stabilize the symptoms. Even though he never expressed proper refusal, Mr F was not very compliant for taking the medication at first. Nevertheless, after several efforts and changes in medication, positive effects started appearing, such as an improvement in socializing with others, more stable emotional states, better accountability for his social procedures and a more down-to-earth personal expectations.

A second difficulty was the fact that Mr F showed a certain degree of alcohol consumption, which tended to alter the medication therapeutic effects. This also tended to exacerbate his behavioral aggressiveness. Also, when his social income was obtained, he tended to drink up all his money. Severe measures had to be taken (one night exclusion and close searching of his personal belongings for alcohol, administering and safeguarding his income). It must be outlined that progressively, his alcohol consumption went considerably down.

Another difficulty was the fact that we had to start from scratch with his social situation (considering that it was the same for the medical situation). Mr F didn’t even have identity papers anymore, didn’t have any administrative address, we had to help him recovering all these basics elements. A personal accompaniment had to be put in place, because he was unable to do it all by himself.

After many efforts, teamwork and network collaboration, we were able to put a property manager in place (as a safeguard measure), to reobtain all of his social rights, put his administrative situation in order and obtaining him a social apartment at a social housing institution. He now has his own apartment and has the support from the institution team to face any difficulties he might encounter. He keeps a medical follow-up with his psychiatrist, in order to perform a psychiatric evaluation and to keep his medication in check. His objectives (as well as ours) were finally met. This would have not be possible without close teamwork between our different services (social, medical and psychological), as well as close collaboration with different social collaborators (social assistant from CPAS, the team from the social housing institution, the property manager, etc). His stability today is still dependent of the network collaboration.

 

3.  Profile of  Tavernello, by   Silvia Raimondi  IT - ASL RM E Roma      silviaraimondi@fastwebnet.it

1.     A STORY CASE  :   J. is 54 years old and comes from Africa.

J. was officially intercepted, at the very first time, in Genova: this matter, joint with some spots of his story-telling, suggests he landed by ship in our country, with regular I.D.. It is highly predictable that, due to an unrecognized psycotic breakdown, J. was pushed to an increasing situation of social emargination. For years he set up his surviving in the “Ponte Milvio” area in Rome, where, due to his always being drunk, he was named and known as “Tavernello”, the cheapest wine label you may buy in Italy.

In this period several attempts were implemented by Traffic Policemen , Policemen  and Sanitary Services to help J., but  lack of networking between these entities and J.’s deny to accept any protection made all our attempts vain and useless.

J. used to go back to his immovable dwelling, in an unconfortable steep corner of the public gardens, drinking wine and feeding himself by the garbage cans.

2.     HEALTH

At his very first hospital admission, the psychiatric diagnosis  describes a severe schizophrenic status (ICD10: 295), with a complete “self” disintegration: contact goes through echolalic and imitative mode and  psychic regression implies inability to sphincter’s control.

Reviewing J.’s story, it is possible to elaborate a second dyagnostic step, where schizophrenia seems to be a reaction to heavy traumatical events, possibly linked to loss of any social-familiar relations and to the exposure to duties perceived  as forced orders (patient often imitates military characters dictating orders to imaginary troupes, in a “falsetto” tone).

We may therefore desume a “defensive/retiring” symptomatology and a positive prognosys, whether it would be possible to re-establish adequate and contenitive social  and familiar contacts.

3.     INTERVENTION

Under the Mental Health Department coordination, an integrated intervention between different services was planned: jointly with policemen, volunteers and sanitary operators a mandatory sanitary treatment was executed at San Filippo Neri Hospital, Psychiatric Department. In this case, a special agreement with the hospital was planned: it is a fact that the acceptance of this kind of patients causes a stress to italian health public structures: diagnosis and therapy psychiatric services aren’t ready to accept patients whose behaviors are potentially able to bring contagious pathologies, with the relevant necessity of a special prophylaxis process, and protected, isolated and dedicated departments.

Furthermore, it is also necessary a specific assistance which usually is delivered by relatives within the hospital: change of clothes, purchase of medical devices and accessories, overall support in order to reactivate a “normal life”, and accompaniment during the first walks out.

All the above must be kept and handled on a mere voluntary basis.

The admission, which was then agreed both with the hospital and the volunteers,  went on for a period of 10 days, on a volountary basis and this allowed a pharmacological therapy to take place, which still continues at low neuroleptic doses.

After mandatory hospital admission, all the next interventions were proposed and accepted volountarily, according to J’s psychological status.

J. spent a couple of months in part of the state run health care psychiatrc clinic but in this situation he wasn’t a “regular” patient: J. didn’t have any I.D. with him, which is a necessary pre requisite in order to have access to those cures which cannot be considered “first aid” and it was thanks to the good will and the direct responsability of the owner of the Clinc, that this issue has been overcome.

Infine, J . was transferred in the homeless residence hanlded by Santa Teresa di Calcutta nuns, where he still is hosted.

All the actors involved in the various locations where J. was admitted, had, as a common target, to improve his social integration and skills, starting with the recovery of his body functions’ control and basic personal care.

In the last two years it has been possible to identify J. and we are currently trying to get in touch with the family in Ghana – J.’s homeland he left 27 years ago – and with his sisters’s who we suppose are living in U.K.

J.’s current psychiatric conditions are fairly satisfactory: he actively collaborates with the nuns in carrying on the different duties and needs of the homeless residence, he has good interactions with other guests and with us and leaves the residence for just very short periods, but always gets back.

4.     OPERATORS AND NETWORKING

All actions were possible only after a collaboration network was set up between institutions and services.

Up to then, all the above were called on chance, with great dissipation of energy and were unable to deliver concrete solutions for the claiming citizens, nor for J., still damned in a unhuman, timeless condition.

So, sinergy was established between social services, volunteers organization and health structures.

In Italy, in these cases, no networking between institutions and services is foreseen, while each structure’s autonomy and mission inhibites the set up of a coordinated operational network, thus generating waste of precious energy and frustration in the involved operators.

Coordinating actions, defining responsabilities, assigning clear duties, was at the end extremely efficient under the “concrete results” point of view, with no extra budget compared with previous availability.

5.     THE METHOD

In a public mental health service, the interventions related to homeless people, generally urged by citizens, volounteer’s associations, public services, social operators, policemen or others, follow undisciplined procedures, mostly unefficient, because all of the organizations involved relinquish responsabilities and duties one each other, in a total lack of coordination and rules.

Summirizing we can shortlist the main bottlenecks:

• Lack of coordination and rules;

• Difficulty in personal identification of patiensts, due to the absence of the  persons in charge of this task

• Lack of dedicated areas in the health structure

• Lack of compliance of the homeless

With the aim to overcome part of these isssues , we built a project focused on the integration between all the various entities, public, private, volunteers, sanitary, involved and operating in the activities related to serious emargination contests.

Starting on september 2010, our public mental health service has created an integrated group, whose purpose is to orchestrate the shared paths, following the social-sanitary emergencies and the specific competencies of each organization within the group.

This group on a be-monthly  basis meeting tries to perceive three main targets:

1)   to monitor an area including roughly 100.000 inhabitants, in order to be updated on the presence and needs of such a specific population (homeless with psychiatric injuries);

2)   to mantain a strict contact with these patients, whereas volounteer’s associations help them to remain   in touch with our service;

3)   to detect new cases and define appropriate solutions.

We are now on the way to formalize this integrated method, which resulted extremely inexpensive and efficient. Last, not least, this approach implies a significant reduction of frustration and conflcts for the operators, by reducing the risk of failures of all the efforts and diligence given.

 

4 .  Profile : FILIPE    by: Elias Barreto   Serviço de Psiquiatria - Lisboa    eliasbarreto2004@yahoo.com.br    PT

 1. Background and environment

Filipe was a 40 year old, tall, black,  homeless man that had been living in the streets for years in the neighbourhood where he had grown up.

In fact, his sister and brother were still living in the family house. His parents had passed away. The sister was the only functional member of the family. She was a psysical therapist (their father had been a practice nurse) and single-headed took care of a teenage son and two brothers, Filipe and another brother that had been unemployed for years. Altough Filipe refused to go home and slept on the streets, his brother refused to go out and had closed himself in his room for years.

Our team, working at a psychiatric hospital, first heard about them through an outreach team belonging to the city council. We had recently started regular meetings (every 2 weeks)  to discuss difficult situations with special concern for the homeless with mental health prolems.

2. Health

Filipe was a big concern for all the community of the neighbourhood. He drank heavily and was so careless with himself that was often seen defecating while walking!  He was later diagnosed  a long term course of Schizophrenia, with significative deterioration.

3. Intervention

A local church group was very much involved and tried to help him. They called for the city outreach team  who eventually also asked us to evaluate Filipe's brother, since nobody understood why he was isolated at home. So our team, a psychiatrist and a psychologist, paid a visit at their home. We had the chance to talk to his sister and to Filipe' s brother. He was also an impressive tall man (he had worked as security), although he talked to us while lying down in the bed. His room exhaled a strong smell and he talked very little as he was evidently suspicious and tense. His sister told us he refused to eat any of her food and didn't take a bath for a long time. We got out of this visit with a strong suspicion that Filipe's brother was dealing with a psychotic breakdown, and talked with his sister about her options.

Right after this visit, we heard that Filipe had surprisingly accepted to go sleep in a small nice shelter downtown, with very good conditions and staff. The ladies of the church, that had been looking after him for years, together with an outreach team, had managed to persuade him to leave the streets. Everybody was happy and hopeful.

But this joy didn' t last for long. After a few days, Filipe became violent at the shelter, breaking a lot of windows. In the midst of his rageful outburst he managed to hurt himself, by falling and breaking a leg. He was sent to a big general hospital in the city, where he was taken care of his leg and psychiatrically examined. Within a few days, he was discharged back to the shelter.

The staff of the shelter was quite scared of Filipe coming back so soon after he was admitted to the hospital, and felt that the opportunity of giving proper psychiatric care to Filipe was not being used. So  the responible for the shelter called the head-director of our service, Dr. António Bento, wich was also the psychiatrist who had visited Filipe's home. They planned that Filipe would come directly for our service after being discharged from the other hospital. So he did, by taxi!

Filipe stayed as an impatient in our service for 3 weeks. During this time he was diagnosed and treated for Schyzophrenia, exhibiting a very discreet, peaceful behaviour that caused no problems whatsoever at the unit. At the same time, the social services found a nursing home specialized in serious mental health problems. So, when the time came to get out of the hospital, a nice solution had been found. We must say that the costs for these nursing home were a little higher than usual, but  the social services managed to obtain a special permission to go a little higher than the regular budget, because they were conscious that Filipe needed specialized care.

A few weeks later, our team paid him a visit at his nursing home. He was more communicative (in his deficitary kind of way), greeted us, and showed us his new home. We found out that his sister was visiting him regularly, and that he was going out daily from the nursing home to the neighbourhood, without trying to escape.

4. Workers and network

This was a very difficult situation, that seemed impossible to change for many years. With the cooperation of several partners (family, local comunity, outreach team, social services, psychiatric hospital, nursing home) that were able to put together their efforts and expertises, a synergy of actions  converged for a final outcome that was much better than previously was thougth to be possible.

5. Proposals

This case highligts the fecundity of joint action and reflection.

Regular meetings to discuss difficult cases between professionals of the social and mental health sectors can be fruitful and change situations that have been stuck for years.

At the same time, it is important to have the means to intervene and the trust between partners. For example, in this case, the trust that social services would support the patient once he was discharged from hospital, enable the psychiatric team to open the doors and admit him as inpatient (without the fear of having no other solution afterwards). Similarly, the social services were not afraid to find unusual and expensive solutions (nursing home) because they trusted that the mental health team  would continue to give all the necessary support and felt that this was an adequate solution from the technical point of view.

 

5 .  Profile de  Caroline  C.    by Pierre Ryckmans  INFIRMIERS DE RUE          pierre.ryckmans@idr-sv.org    BE

1.     BACKGROUND and environment

Caroline is a 46 year old women. She lives on the street since at least 2006. We know her since 2007. She refuses contact with most of the people, especially with people she identify as social or health workers. With them she can be verbally very violent, starting to shout in the street and insult them, puke on them.

She spend the days in the same streets, going in some snacks and cafés where she is known. Nobody knows where she sleeps.

She has been put several time in forced observation in psychiatric hospital, at least in 2006, 2009 and 2013. In 2006, the result was very good, and she accepted to continue to take  injection treatment regularly. She was speaking about getting an appartment. But the treatment was dicontinued because of the absence of the psychiatrist. Since them the contact is very bad. The following forced observations were not long enough (only 40 days) to allow sufficient improvement, and she was released on the street (even knowing she would not accept any treatment)
 

2.      HEALTH

 In 2013 she was put on forced observation because chronic wounds on the legs, which cured completely. At this moment we don’t know if she has the same problem because nobody is able to see her legs. Recently she has little wounds on her face and left hand.

Since she is scratching a lot we suspect she could have scabies, but we cannot check this.

She has no other health problem.

In her stays in hospital she was diagnosed as having schizophrenia, but estimated sufficiently well to go back in the street (because under treatment while in hospital, she is much better) what she asked for.

3.       INTERVENTIONS 

At this moment, she is met regularly by two teams of street workers, but the contact is very short, since she doesn’t accept the contact. Sometimes she starts to shout as soon as she sees the workers.

We have managed to get her an « administrator ». (person who is designated by a judge to take care of the interests of the person), and as a consequence we could obtain some benefits for her. But it was not possible to get her an ID.

For this reason, the judge asked us to ask for a forced hospitalization again,  at least to be able to work out an identity card.

4.      WORKERS & NETWORK

 Two streetwork services working together, alternating visits. A third service, for mental health, doesn’t see the patient but meet regularly with the other services for support and propose interventions. Their psychiatrist was involved in the forced obesrvation in 2013.

 We have build a network of people around her : snacks and cafés where she use to go. They used to offer them meals or drinks for free, but we arranged that they could send the bills to the adminsitrator, and so now they can be paid for the meals they offer, which is a way to ensure that she eats correctly and regularly. It’s also a way to prevent that she loses her benefit (if she doesn’t spend anything it is suspended). This seems to work well until now.

We also told these people to alert us if anything changes : when she doesn’t appear any more, or if she is in a bad condition, especially in the winter. This works also pretty well.

There is an excellent colaboration with the judge, who accepted to do the audience in the street, to get the administrator, and who is now taking the initiative.

5.       PROPOSALS:

 The last proposal, which is  now on its way : to place the patient in forced observation, more on administrative ground (initiative of the judge), because at this moment ther is no sufficient medical ground, and to be sure that she is placed in a hospital where they know her.

Once she will be in the hospital, we will make contact with the psychiatrist to be sure they will take the full story into consideration and keep her long enough to have a good effect with the treatment. In this condition, look for a long term solution : long term residence in protected appartment,….

Questions are : how will she react on the treatment ? will she remain long enough for the treatment to be efficent ? what if she has to be kept in a closed environment for a long term ? what solution on  the long term ? 

           PROFILE of Linda, woman, 44 years old (2008-2015)

1       BACKGROUND and environment / context 

Linda is a Nigerian woman who lived in streets since 2008.

She is tall and thin, masculine in attitude and appearance. She always preferred locations where she could be visible and able to do what she considers a work: asking for charity.

With money she buys low cost alcoholics and gets drunk, then sleeps on streets in awful hygienical conditions. 

Sometimes she is gentle and talkative, more often she is aggressive and enraged, refusing every kind of help people and operators could offer, with the exception of money, covers and clothes.

During these years we managed to understand just a few information about her - we are not even sure of her name and age.

She does not like to tell about herself and when she does she is shallow and unclear about the stories she tells.

Once Linda told that she was rejected by her community because of some kind of “spell” or “curse”, so that she is forced to live alone and in poverty. In seven years Linda changed several locations in the city of Rome, staying in a place then leaving when she felt too much bothered. She is a solitary woman without significant bonds and her trust in people it is given just for a short period of time. Still today the situation is unchanged.

2       HEALTH:  physical  and  psychic conditions;  

Linda seems to be addicted to alcoholics and expresses an attitude that could be related to psychic disease, especially when she is alone and talks to herself on when she is aggressive to other people.

This behaviour is not always linked to alcoholic assumption, because drinking usually makes her sleep.

This aspect could prospect an hypothesis of “double diagnosis” – both psychiatric and addictive.

Despite all these years on streets her physical conditions are not badly worsened, but her mental conditions get weaker and weaker: she is getting more and more expulsive and isolated.

During the short periods of hospitalization - three times in seven years, one week each time - it was not diagnosed any specific psychic disease nor physical pathology. Her only "diagnosis" made until now was "social disease": she is homeless and nothing more.

In 2014 she was conducted in hospital because she could not walk anymore: doctors said it was for malnutrition/alcoholic abuse in a long period of time and that her psychosis was a “general” one. She always refuses medical help and recovery - hospital or shelter.

3       INTERVENTION:  

The difficulties described and the absence of an organized network around Linda made all interventions fail until now. In consideration of Linda physical and psychic conditions, we first planned to organise a forced admitting in hospital (TSO – Obliged Sanitary Treatment, in Italian legislation) to stabilise her health, both mental and organic.

She was admitted in hospital just for a few days so that was impossible to plan any rehabilitation or detoxification program.

When she went out of hospital we offered her recovery into a shelter but she fled immediately and went back on street.

We asked for collaboration to Nigerian Embassy with the hypothesis to make her comfortable to speak about her story but her ever changing conditions interfered with the development of a relationship.

4       WORKERS & NETWORK:

We tried to activate different agencies, both social and sanitary, in order to organize recovery in hospital. We also contacted Police to verify her identity in order to help her acquire documents, but the answer was cold and the stigma of homeless was prevalent over the hypothesis of social and sanitary needs.

Politics were interested into the case when citizens protested for Linda and her critic conditions – she usually leaves garbage and dirt on the streets – and helped to organize admitting in hospital.

Our Mobile Unit (social operators) is still monitoring Linda and her conditions.  

5       PROPOSALS:

Linda's profile is linked to the topic of autonomy.

Sanitary agencies often diagnosed that Linda lives this way because she is homeless, while our hypothesis is that she is homeless because she lives this way.

We think it is not a choice, but a result of different processes. Is Linda really able to clearly choose about her life?

Or is that her needs petrify her in a state of inability? What is the distance between social assistance and social protection? Another aspect to consider is alcoholism.

Usually psychiatric agencies have difficulties to define the border between psychic pathology and alcoholic effects.

On the other side agencies competent for the cure of addiction symptoms work in a vision of self-determination: people must choose to be cured. In the absence of a multidisciplinary analysis of the problem these situations remain crystallized for years and people like Linda live in a inexorable worsening of their conditions.

Eventually we should also consider the presence of cultural aspects.

How predominant are anthropological elements in people perception of disease?

Does Linda thinks she is “cursed” to live like that?

How “cure” and “social assistance” are perceived in her culture?

It could be useful to organize "street intervention teams" composed by social operators, doctors and anthropologists/mediators in order to rebuild a complete vision of situations like the one described.

8.  SP    -   PROFILE of:  Amanda         by: Victor Soto       from :  Barcelona     vsoto@pssjd.org  1.     BACKGROUND and environment:   62 year old Caucasian woman, that is being followed up by our mental health team since Julio 2012 . We do not have any reliable identification data and probably the name we have isn’t real. We also lack almost all past personal and medical history Previously she had contact with psychiatric services in feb.2008 after an involuntary admission. Apparently she attended a  general hospital with different physical complains , such as tiredness , and general bad health , but in that setting she started to express delusional persecutory contents, as well claiming she was working for the royal family. complained of auditory hallucinations, and ended up admitted to a psychiatric ward. There was also the suspicion of alcohol related problems. After 10days in hospital she was discharged on her absence, since she went awol. She was diagnosed as Unspecified Psychotic disorder. She has always been  localised around the  same area, sitting on the floor, with sunglasses, and various layers of clothing independently of the temperature, with multiple bracelets on both her arms and a hand fan. With a very ecric look, due to the colourfulness of her cloths. There was always evidence of a formal thought disorder, with loosening of association, and a delusional content, in relation to the secret services, and as if she was doing some work for them. Always refusing any help, and making it impossible to work with her in that setting. We decided to admit her on a compulsory basis around Feb 2015, organising a planned admission. She was discharged on mid June 2015,since a further stay in hospital was not possible, and a referral to another service was not adecuate due to “lack of criteria”. Her stay in hospital was positive in the way that she became more approachable, her speech was more comprehensible, but still was very deluded and would give us no information about herself. Her engagement with both our team and her social worker from the homeless program has improved greatly.     2.     HEALTH : Physical - psychic:   Re lab results show : VDRL positive, T pallidum positive, therefore past syphilitic infection. Possibility of a  Neurosyphilis . Re CT scan with moderate involutional signs of cortical cerebral parenchima. Nicotine dependency, no evidence of sustenance misuse . First contact with mental health in an admission in 2008 after visiting to A&E due to unspecific complains, she absconded after 10 days in hospital. Diag of  Unspecified Psychotic disorder. Regained contact with mental health team in 2012, with persistent psychotic symptomatology,  disorganized behavior, with  a slightly hypomanic mood with congruent polymorphic delusional contents, and behavioral repercussion, as well as self neglect, and no insight. Re admission to psychiatric hospital feb 2015-July 2015.   3.      INTERVENTIONS: Had been offered hostels, and B&B and meals by social services and refused. The mental health team would be visiting her  on a regular basis trying to engage her, and gradually offering her some psych.  Treatment, but refused. Joint visits of  mental health team and social services were done on a regular basis. Contact with neighbouring shops/bars were done to ask for further information. Planned admission to hospital, due to: psych. Illness, lack of insight, vulnerable situation in the streets , and impossible to treat whilst in the streets. A longer stay in hospital was proposed, (referral to a longer stay ward, )  but not accepted by hospital team. It was also suggested , to continue admission  in a specific unit(more open and near where she used to live in the streets) but not accepted due to lack of criteria, according to the unit. After discharge, a provisional hostel was organised, till a better placement was found.     4.     WORKERS   & NET:  Social worker from the social services (homeless programme), responsible of offering community resources, accommodation, and food, as well as being able to apply for allowances, income etc. Mental health team, which provides with the mental health follow up, seen by nurse and psychiatrist. On occasions seen by voluntary organisations   5.     PROPOSALS:   Gradual discharge plan to the community, with time to gradually find an appropriate place for her.  A time/space for adaptation(critical time). Greater flexibility on referral criteria to specific units. Wider range of accommodation possibilities. Easier access to income, or pension schemes.

72 year old Catalan Caucasian woman, first referred to our program in February 2007 by an ONG which works with homeless people. She had been known to them for several years, but had problems trying to engage with her, due to her constantly moving from one place to another, always around a very bus y and touristic street in the re of Barcelona, and refusing any type of care plan.

When found, she would always be with a lot of bags beside her, covered with plastics, sitting on a bench or wondering around the area.

At the beginning there was little evidence of personal neglect, apart from poor oral and hand hygiene, but her hair was clean, and her clothing was fine even though being in a homeless situation.

She was polite and talkative, with a good rapport, and would tell us she enjoyed reading, and learning about things. Her main themes were about the importance of nutrition, and would  never talk about personal things “my things, are private..”  “it’s enough for you to know that my name is Teresa….”

On several occasions the police would confiscate the bags she would  have on the bench.

When seen she was either having a walk or reading magazines or newspapers. She was very up to date with certain  topics and news.

Due to her mobility and difficulty to be found, she was discharged from our program in March 2010 .

She was then redetected and readmitted to our program on February 2011. Again detected around the same area. 

On this second period of time we managed to know that she had worked with nuns in a meal re, but still would not give any personal information, and would get annoyed when asked.

We tried to provoke conversations about her homeless situation and what she thought,  “there are positive things about living in the streets, people show interest, they give me things to eat, to read…. I can see a lot of things happening . distracting  myself “. She would never elaborate n negative aspects of homelessness.

“ If I wanted to live in a house I would, some people have offered it to me…”

“Everyone chooses the type of life    they want to have…”

The police would continue to come on occasions telling her she could not be occupying a bench all the time and would remove some of the bags she had. She would get very annoyed  “ police should care about me , not take things away from me…”.

Gradually  her engagement with us was better, speaking more with us and expressing her other interest which were religion and religious saints.

She would keep insisting that being in the street was due to a  personal decision “ it’s my decision, because I want…”  “saints used to say a bit of penance won’t do any harm”. She was  always refusing any help we would offer.

During this period of time she had to move from the place she was, due to police pressure, and moved to almost opposite the street, but then again we lost contact for some weeks.

We regained contact  because she was found in another area of Barcelona , in a bench full of plastic bags, also in a very busy street near to a big round about.

She told us this location was very special for her since Gaudi had  died there,  run over by a tram.

During all this time the evidence of self-neglect was becoming more and more evident, as well as a more restricted mobility. Her hoarding of plastic bags  was increasing, and when we would visit her , she was sleeping or sitting between the bags.

We managed to get some personal information from some relatives that contacted the social services, and it seemed that she had been admitted in the past, to a psychiatric unit.

She was offered a hostel near the bench she was in and a place to leave her bags , but declined the offer.

Current situation hasn`t changed, still hoarding on the bench, and not accepting any help, though less oppositional in her attitude towards us, and our suggestions.

2.      HEALTH : Physical - psychic

We have no information regarding her physical health, she has never complained about any diseases, and we haven’t been able to identify any .

Regarding any mental health issue, we have the information from a niece that contacted the ONG, that in  the past teresa  had to be admitted to a psychiatric hospital when younger, after a broken relationship ,  and was diagnosed of Schizophrenia.

3.      INTERVENTIONS:

She is being offered accommodation  and meals on a regular basis, by social worker, which she refuses . The social services by means of her social worker are trying to update her identification papers, but not possible. Lack of collaboration. Therefore lack of possibilities of claiming any benefits.

Our mental health team has contact with her in a regular basis, but doesn`t accept or engage in any plans that we suggest, any possible treatment or admission to a psych ward for assessment.

We suggested on several occasions if she wanted to have a place to stay and come to that bench every day if she wished, but refuses.

We suggested possibility of meeting with the police and neighbours, to be able to negotiate combined actions, but this was difficult and in its place we were asked to provide formal information (report) about her physical and mental state, and a working plan.

Police remove the bags occasionally, depending on neighbourhood pressure.

4.     WORKERS   & NET: 

Referred by worker from ONG, which continue visiting her on a regular basis, offer support, can provide accommodation, meals etc. They are from the voluntary sector. 

Has social worker (SW) from social services (homeless program) can provide a variety of services, visiting her on a regular basis, offering her different resources. The social worker has meetings with his team leader and gets information regarding neighbour’s complaints and police actions.

Mental health team, seen by psychiatrist and a nurse, provide mental health follow up.

These three key figures meet once every 2 months to discuss and organise a care plan.

PROPOSALS:

Case meetings of all key figures to organise interventions (including police, and neighbourhood associations)

More flexibility in the service provision.

Improve SW delivery of care ( more visits, more empathic approach)

5.     PROPOSALS:  

Prioritise housing, the possibility of offering an adequate placement for her.

-         Facilitating all the administrative work, e.g documentation required.
-         Fluent communication between neighbourhood associations, police, social services, and mental health
          teams.

1.   HISTORY and CONTEXT  

Mr B. is an Hungarian citizen. He was born in Budapest in the 3rd August 1958. He has all the Hungarian identity documents. He says that in Hungary he was a dental technician with a regular title obteined in Budapest. He has not health insurance and he has not residence address document. He speaks very well Italian and he sleeps on the road.

Mr B. came in Italy, for the first time, in 1990 in Riva del Garda in Trentino region, where he lived and worked for several years. After he says he went all around Italy untill the 2011 when he arrived in Florence. Since 2011 he has been ever in Florence working like street artist. He says he lived ever on the road, sleeping where he could find an easy shelter in the parks and in the streets in Florence.

He has not family’s relationships in Florence he says he has a doughter in Budapest living with her mother (Mr B.'s ex-wife) but he says he doesn’t have any news from them since several years. He has not friends and he has not any kind of network that can help him . In january 2015 he started to frequent a daily center targeted on homeless called " La Fenice " managed by an NGO.

2.      HEALTH:  physical  and  psychic conditions...

Mr B. is in good phisical conditions. Occasionally he drinks alcohol but it seems not a serious form of addiction. About the psychic conditions he showed, since the first time he met the social workers of the center, an important personality disturb. He says to be controlled by "people" using drones and other technological instruments. He says they can control him using electric impulses that hit him in the brain and leave him in a confused condition. Sometime, when he is sleeping, these "people" put poisoned gas under his nose and when he get up he is confused and he can't do anything. He says they hinder every job he tries to organize and for these reason he left his work like street artist. For the same reasons he doesn’t want to be hosted in the homeless shelters's. In because of his speeches, the social workers of the center have invited him to consult a doctor about his psychic conditions. He accepted but because of his irregular status (he has not health insurance and he has not residence documents) he was not able to enjoy public mental health services. For these reasons the social workers of the daily center accompanied him in to an health service managed by another NGO and he was able to have a mental health medical consultation. The psychiatric, who visited him, believes that he is affected by a chronic delirious persecutory disturb and he prescribed for him a psychiatric therapy based on Riperdol and other psycho drugs.

3.       Description of INTERVENTION 

The staying of Mr B. inside the center it was not easy in the past and it is not easy today. The most part of his personal inner experience remains hidden, we have not many informations about his personal history and what we have is not certain. Mr B. says he left Budapest when the "people" who control him have begun to harass him and they started to make his life not more normal. He says it became impossible having good family relationships and he was forced to leave his family. He went to Scotland and he staied there for 5 years less or more, working like dental technician but the "people" who control him were able to reach him also in Scotland and he was forced to leave. Finally he chosed Florence because he believed to have more chances like street artist (he paints sacred images on the road). But the "people" who control him prevent him to have success and he arrived to the Homeless Center.

In the daily center Mr B. works every days in the artistic workshops, he picks up everything he find in the street (expecially in the trash) and he creates little crafts products. Mr B. partecipates also at the puppets's workshop, he works to the scenography where is able to use his skills in the trash recycling. He speaks with the other guests of the daily center and he has been able to build good relationships with the social workers. He is always helpful every time someone asks him something.

He has often individual motivational interview with the social workers That are trying to work on his esteem and his trust in his self.

4.      WORKERS  & NETWORK 

...

In this moment does not exist any collaboration with the public services because of the irregular status of Mr B. (he has not health insurance and he has not the residence document) . To respond to his needs the social workers of the daily center have built an informal network with other projects ( for example the psychiatric outpatient) managed by the private social organizations . The real problem regards the impossibility to insert Mr B. inside a formal network of mental health services . He is not dangerous he has not acting out with violence and he is not in a severe phase of the sickness for these reasons the emergency services focused on the mental desease are not present . In additions to this it is not possible for the doctor of the private outpatient's project for homeless to take in a formal charge Mr B. because of the few resources available by the project. So mr.Mr B. can have only a occasional therapy and he is not in the condition to leave the homeless's life (for the reasons linked to his irregular status and for the reasons linked to his mental desease )

Quand la solution de situations complexes semble impossible, comment intervenir ?..  
quand le corps parle ...  qui saura l'entendre ? 
 

1.    HISTORY AND ASSESSMENT OF THE CURRENT SITUATION

Mr S is of Serbian origin. He was born in 1943 and arrived in France in the 60s with a 5-year employment contract. When the validity of his contract came to an end, he decided to carry on his life in France. Married with a child when in Serbia, his marriage was « dissolved » in 1974. He got married a second time in Marseille in 1980. In 1981, he was shot at during an argument. The bullet pierced his intestine and stuck into his back (his aggressor was identified and died few years after in jail). Mr. S received no compensation. After being hospitalised for more than two months, he was still suffering injuries; this left him unable to get back to his job. Instead he got various jobs in different fields. In 1991, war in Yugoslavia started. His wife died in 1992. In 1997 his passport expired and renewing it was too expensive. He gave up on renewing it for financial reasons. In 2002, he reached the age of retirement, he asked for a birth certificate in the city town of N-S, now Republic of Serbia. He learned on this occasion that he had been declared dead since 1997! Since then, he has succeeded in proving that he is still alive, but today’s challenge is to prove that he is Mr. S. He is entitled to retirement pension in France, but it is impossible to receive the retirement pension without a residence permit. To get a residence permit, he needs a passport, and to get a passport, he needs to prove his identity.

2.    HEALTH: 

He suffers multiple « somatic illnesses », due to the gunshot injuries and to the years he spent in the street, till now. He uses a stick to walk, and suffers from the pain. He doesn’t sleep well at night. When he learned that he had been declared « dead », it was a tremendous choc for him. He is given psychological help by a team of doctors in a hospital in Marseille.

3.    INTERVENTIONS :

When his French wife passed away, a new phase of difficulties starts. He lost his home, started to live in the street and to spend time in the St. Giniez neighbourhood. He became a well-known figure among the parishioners and local charities. He now belongs to a little network of persons who support him. The local team of SC Caritas France began its administrative support, together with social workers and hospital staff. Three hospitals in Marseille, two private hospitals, city town social service (CCAS), a doctor from the DDASS (Direction of the Bouche-du-Rhone District for Social and Health Security), a legal expert, translation services, the embassy and consulate of Serbia in France, the city town of N-S in Serbia, the regional court and the public prosecutor, all have tried one after the other for more than 10 years to solve this legal and administrative question...

4.    PARTICIPANTS & NETWORK :

A « mobile field team » (AdJ Consolât) of social workers has met him in the street and initiated a long follow-up work. Mr. S had endured difficulty after difficulty, and could not prevent himself from ending up in the street. The public-private network was very efficient in this case; Mrs. SF was his referent. Nowadays, Mr. lives in a social care institution (foyer) that he has known for many years. He receives the support of a social assistant and has a private room. His situation is “fixed”, for two years now. He is a beneficiary (“Ayant droit”) but has still no resource.

5.  PROPOSALS:

To rebuild the fabric of solidarity, revive it and complete the work of the social assistant of Saint Jean de Dieu social care institution (foyer). The social care institution has a capacity of almost 300 places and the follow-up team doesn’t have enough members. The social service of AdJ Consolât is ready, and SC Caritas France’s network too.

1. Biography

The patient comes from a large family – with nine siblings. Patients’ parents divorced when she was 10 years old. Patient’s father used to abuse alcohol. The patient remembers bad childhood. As a child, she was charged with domestic chores, helped her mother, took care of her siblings. In addition, due to her father’s addiction a lot of fights took place at home on daily basis.
Once she graduated from the Primary School, she then moved to the  Vocational School (NVQ in retail sales) which due to health problems and excessive household duties she was forced to drop out from.

At the  age of 16 she ran away from home, she entered the convent where she lived for 5 years. Then he worked for about 12 years, among others, as a manual labourer, ward nurse (cleaner), caretaker, domestic help. At the time, she repeatedly changed her place of residence.
The patient continued her married life for several years. She and her family suffered cruel physical and emotional abuse from her alcoholic husband. The patient has one child - a son, who is currently detained in a correctional facility because of drug trafficking.

2. Physical and mental health

As a teenager she suffered from anemia, ulcers of the stomach and duodenum. In the later period because of the state of her health, including degeneration of the spine, she often visited physicians and neurologists. The patient also repeatedly suffered from problems with her memory, she often felt depressed, resigned and hopeless.

At the age of 25 due to various random events (including the death of her brother) she went to the Psychiatric Hospital, where she was hospitalized for two months. Diagnosis - depressive neurosis. Since then she has been treated in Mental Health Clinic.
The patient’s life history demonstrates her difficult living conditions since childhood.

The patient-as a little girl she had to cope with difficulties inadequate for her age. She has been subjected to enormous pressure in various situations. For many years she has been experiencing strong stress caused by continued violence:
-lack of the sense of security (alcoholic father- frequent quarrels in the family, at home)
-patient took over the role of the parent (patient was taking care of her siblings, she was responsible for running the house)
-lack of parental care (in patient’s childhood - the mother used to work in a different location, alcoholic father).

First symptoms of neurotic disorder probably occurred during patient’s adolescence: Somatic symptoms, emotional disorders, cognitive disorders. As an adult our patient also suffered from severe stress in her married life and in connection with criminal activities of her child. She often changed the place of residence and work. In difficult situations she did not receive support from family or husband. She lived, for many years in insecurity, loneliness, full of anxiety and fear.

3.Interventions

The patient was admitted to Centrum Pomocy Bliźniemu Monar -  Markot in Warsaw, she entered the Program for  People with  Mild Mental Disorders in mid-2014. Upon admission the patient demonstrated depressed mood, she was weepy, tired of her difficult social situation, housing difficulties and problems with her son. In the initial period of stay at the CPB our patient often revealed the anxiety states of increased tension, irritability, depression. In addition, the patient expressed somatic complaints - especially in situations requiring decision making  or situations difficult for the patient – in her relations with other residents.

4.Workers and NET

During her stay in the CPB the patient was offered professional psychiatric , psychological and social support. The patient benefited from social assistance – she received a certificate of disability degree   (moderate) and fixed income. In addition, efforts were made to obtain social housing for the patient – she currently is on the waiting list. Thanks to the support and motivation of the personnel at CPB the patient completed a computer course ICAR in Bródnowskim Stowarzyszeniu Przyjaciół i Rodzin Osób z Zaburzeniami Psychicznymi „ POMOST . Then she took a course for the property security staff at the the Labour Office of Warsaw. For several months now, the patient has been working as a property security guard in one of the  residential areas of the city.

5. Conclusion

The CPB patient is functioning well, she adheres to the rules of the Centre. She is always eager to work, dedicated and reliable when completing all assigned duties. She regularly attends group meetings for people with mild mental problems- where she shows high activity.
Currently, the patient is feeling well, she usually is in a good mood.
Somatic complaints, irritability and depressed mood appear in situations difficult for the patient. The patient also receives help and support from the staff of the Centrum Pomocy Bliźniemu. In addition, she regularly attends meetings with the psychotherapist at the mental health clinic

1.     HISTORY and CONTEXT

Mrs. R.D., a 50-year old psychiatric patient and Mr. M.D. her 30-year old son – living together in a flat owned by Mrs. R.D.'s brother. They recieve mental health treatment for 16 and 14 years respectively. Their husband/father passed away 8 years ago. They take care of themsleves mostly on their own, being occasionaly visited by Mrs. R.D. brother, who lives in Germany.

Over the course of their psychiatric treatment history they both experienced frequent hospitalizations resuting in weakening of most meanigful social and familly relations. It was caused both by prolonged absence from daily life and by mental disorder stigma which basiclly excludes patients from the society. Mrs. R.D. refusal to recieve institutional assistance is invariable and is directed mainly at psychiatric treatment. Her son Mr. M.D. goes through cycles of acceptance/rejection of institutional help.

2.     HEALTH:  physical  and  psychic conditions 

Mrs. R.D. has a diagnosis of paranoid schizoprhenia dating with a hypothesis of personality disorders having significant impact on her psychological well-being. In addition to psychiatric diagnosis, she also suffers from a acute form of rheumatoid arthritis. Her son, Mr. M.D. is diagnosed with paranoid schizophrenia, obesity. There is a hypothesis of mental and behavioral disorders due to the use of tobacco.

3.     INTERVENTION

Intervention is home-based – both Mrs. R.D. and Mr. M.D. recieve a antipsychotic medication therapy and psychological assistance. They are visited on regular bi-weekly basis by a psychiatric nurse and psychologist. Psychiatrist visit them on less regular basis.

The main difficulty of the intervention is changing willingness to cooperate – both Mrs. R.D. and Mr. M.D. tend to vary between acceptance of their mental disorder and need for treatmnet, and denial/rejection of intervention.

Success of the intervention is mainly found in decreasing number of hospitalizations – both Mrs. R.D. and Mr. M.D. spend much less time in mental hospitals than they used to.

Under such conditions failure is mainly found within intervention group itself – mental fatigue of our workers tend to distance them from patients, occasionaly causing decrease in quality of our services.

4.     WORKERS  & NETWORK:

There is no collaboration between public and private sector. All services available to Mrs. R.D. and Mr. M.D. are provided by state run agencies and hospital.

In addition to community-based mental health treatmnet, our patients recieve help from social services. However, there is institutional lack of collaboration and even communictaion, leading to both systems providing separate and uncoordinated services.

5.     PROPOSALS:

Mrs. R.D. and Mr. M.D. being mother and son are interdependent in their mental health problems.

An intervention aimed at separating them – like offering Mr. M.D. a place in a hostel, or protected

accomodation - would be desirable. It would allow designing completely separate

intervention/therapy plans for both mother and son.

Mr. M.D. could then be offered place in day ward or/and an assisted work place. That would enhance his social interaction which at present – being assisted at home by his mother – he vehemently rejects.

Mrs. R.D. would be able to receive therapy outside mother-son context which presently is the the source of diffrent tensions and stress.

Personal history of the person

Ernest, a 29- year-old male, brought up in a dysfunctional, alcoholic family. His father, alcoholic, used psychological, material and physical violence, tormenting his wife and children. Ernest has 5 sibilings, he was the second child. He is convinced that he was mostly hated by his dad, and therefore was mostly abused. Ernest remembers a leather belt with lead balls at the end, which his father used to beat him until the belt down. Sometimes his monster father soaked the belt in the water to make it more elastic and cause more pain. He also remembers the father’s counting his kids and picking one at random. “The lucky one” got the beating. Sometimes when his brother happened to be chosen, his father would say- laughing – that it would be Ernest anyway. Ernest remembers the suffering of his mother, who did not complain and did not defend his children.

Ernest was constantly in fear and stress, and his sense of security was deeply shaken. He would often run away from home and come back after a few days. One day, when he was 13, he went to the state orphanage and asked to be admitted. Lived there until he was mature. He studied at an electronic technical school and then moved to a professional school, where he learnt to work as a brick layer.  When he reached maturity (18 years old), he got a place to live in a dormitory of that school. Later he joined the army and volunteered for an Iraqi military mission. He was a member of the Polish Military Sector Syria – Israel from February  2006 till November 2006. In July 2012 he got a status of a war veteran. After the mission, he moved in with his grandmother and then with his uncle. Worked at a gas station. Then rented an apartment, earned some money, became independent. At this point his older sister asked him to help with her child, since she was getting through a divorce. Ernest moved in with her, but after 2 months when he was not needed anymore- he moved out. Then he lived by himself and tried to cope with reality. Lived in a forest, in a shack, moved from town to town, worked part- time and odd  jobs. He started to think about revenge on his father, blaming him for his homelessness and mental problems. One day he decided to buy a can of gasoline and to go to his father’s house. He wanted to make him admit all the crimes committed on the family. In case of refusal he was planning to burn his father’s house. He did as he planned and threatened that he would kill himself if his father does not apologize to him. He had a riffle with him. Somebody called the police and an ambulance. He was tied and taken to the psychiatric hospital, where he was diagnosed with paranoid schizophrenia. (F.20.0).

He spent 9 months in a hospital.

During the last 4 years he was in a relationship a few times. Each time when the relationship was over (when his girlfriend would betray him), he would try to commit suicide. He would swallow pills and was hospitalized. In the hospital he would recover, his mental state would be stabilized via medication, and then the same scenario would happen again. Again he lived in a forest shack, in a tent on the river bank, got involved with strange people, the police would find him and take him back to the hospital.

Since 2006 – till 2015 he was hospitalized 15 times.

In march 2015 after leaving the hospital, he would turn to his father for help, but got rejected. Then he asked for help in the Social Care Center and Veteran Center in Warsaw. There he learned about our shelter.

Physical and mental shape of the patient (diagnosed? assumed?)

During the last stay in the Military Medical Institute (Wojskowy Instytut Medyczny, Centralny Szpital Kliniczny MON, Klinika Psychiatrii, Stresu Bojowego I Psychotraumatologii w Warszawie; 10.06.1015 – 4.10.2015) the diagnose was changed. It went as follows: “ our examination process excludes the earlier diagnosis of schizophrenia. The patient seems to be an individual functioning with mixed personality disorders” (F.61).

Description: patient infantile, manipulative, impulsive, suicide attempts and other auto-aggressive behaviours of the demonstrative character, his aim: to attract attention of other patients. Emotionally unstable, historionic, narcistic, impulsive – typical of  mixed personality disorders.

Prescribed: 11 various psychotropic drugs

Recommended: activity in a therapeutic community, therapeutic group, life- line sessions, psychodrama, relaxation.

Attempts of help (successful? unsuccessful?)

Ernest was placed in a 50 person room, with other males living in the Center. Quickly started to manipulate others, presenting himself as the wronged person that needs continuous attention. This aroused tension and reluctance from other residents. Ernest was moved to a double room. However, isolated from the "audience",  he could not practice behaviours that would satisfy his histrionic disorder, narcissism and demonstration. Probably he was no longer taking medication, which resulted in the activation of the behaviour characteristic of his disorder.

Drugs were administered in a controlled manner – during the week it was done by a social worker (2 times a day) and on weekends – by the residents on duty.

Nobody, however, had time or remembered to check whether Ernest have actually taken his pills. The Center is not prepared for such a far-reaching individual treatment of a resident (not to mention that the Centre workers should have special licence to administer such strong, prescription medications)

In the meantime, Ernest started another relationship with a girl-inhabitant of the Centre, a 30-year-old alcoholic, who came to us straight from the rehab unit.

When Ernest was faced and disciplined about not taking the prescribed drugs, he acted as if he got  offended. He refused to admit, how serious his situation was, and during the conversation referring to the so-called "common sense" had no effect in his case. He took his belongings and walked away from the Centre. When Ernest saw that no one was stopping him,  he began to manipulate residents and led to the situation in which one  resident called an ambulance. Eventually, he was once again transferred to the hospital psychiatric ward. We are currently waiting for his return. We received a call from the hospital that the patient's condition is stabilized now and since he has been taken from us, he should come back here.

The workers involved in this case, organizations and their cooperation

There are consultations between the social workers of the Centre, a psychotherapist and support institutions. There is a proposal to engage in talks with the Social Care Center for Persons with Mental Illness. However, we are afraid that we will encounter serious obstacles. A monthly stay in this kind of facility costs 3-6 thousand zlotys. A major part of the costs is paid by the Municipality (a resident returns 70% of his earning to cover his maintenance costs). The family of such a person, in accordance with the Social Welfare Law, is obliged to pay alimony for his relative. However, the family repeatedly underestimate, or even hide their resources, trying to avoid supporting homeless or mentally ill relative. Sometimes the verifying and enforcing procedures last for many months. During this time a man like Ernest can only wait for the decision, staying at the Centre - Shelter. Here, unfortunately, we cannot offer him such care and interest as he needs (group therapy, therapeutic community, working on problems by the method of psychodrama, controlled medication application). In effect  the sick man does not receive proper care and he does not rework his problems, stops taking drugs, his disease becomes active again and he ends up in a psychiatric hospital. There he is taken care of, stabilized and ... comes back to us ...

Propositions of  a conduct in similar situations

We have experienced a similar situation in case of a women, 60 years old, who after several years of living in our Center and  after passing acceptance procedures to the Nursing Home for the Chronically Ill Persons,  received social housing from municipal resources (ie training). We do not know similar cases when it comes to the homeless and mentally ill patients. (Investing in the necessary facilities for the woman in the apartment - because of her physical disability - ultimately proved to be less costly than paying for her living in the DPS-e. Especially, given that she is a relatively young person and has many more years to live.

The best solution seems to be an institution of the Family Coach, which is a novelty in Poland, but well-known and used, for example, in Germany.

The Department of Family Studies at the University of Cardinal Stefan Wyszynski University in Warsaw, in cooperation with the Faculty of the Academy of Pedagogical Sciences of Cardinal Stefan Wyszynski - the  Academy of  Quick Study, the Association of Antidrug Catholic Movement KARAN, and Katolische Universitat Eichstatt-Ingolstadt – they all cooperate to create the Family Coach. The idea is based on the assumption  that modern society gives us many opportunities, choices and they can create a change, but they can also be a risk. In this context the family background appears to be free in their choices, free to work on their growth and development.

The family becomes a client for a professional consultant – family coach. The family wants to grow and develop, solve crises afflicting it at different stages (such as death of a loved one, empty nest, separation, illness, homelessness, mental illness, job loss and ... 100 others) Family coach is a professional, who combines the competence of a psychologist (without being one), a therapist (without practicing therapy), an ethic, a clergyman, strategist, expert (...) Coach works so that the client (on one hand it is the family, on the other – our  homeless or mentally ill person) could develop a process of self-regulation. There is an idea is that self-regulation prevents and becomes a precautionary measure for various dysfunctions or pathologies in the family. The goal is to turn the self-regulation into auto-coaching.

The coach works on the resources and deficits family, which are not perceived by him as exclusive or mutually eliminating factors. They overlap and each of them can be a protection or a risk factor. The coach aims to strengthen the customer's decision position to enable him to have a better insight into himself. This, in turn, initiates and supports the self-regulatory process, and the client becomes a kind of a coach for himself.

Coaching can be directed to the families with or without children, to couples before deciding on marriage and having children, and to the  families in the post parental period or in crisis (separation, divorce, death, mental illness ...) . Coaching can be an extension of the work  of a therapist, psychologist or it can  operate on the principle of synergy with specialists when he encounters a problem.

Profile of, Italian women, 77 e 74 years old (1986/2015) 

1.      BACKGROUND:

Francesca and Concetta are two elderly sisters living on the streets for over thirty years.

Through verbal reports of people who have known them, the Emergency Social Service of Rome has managed to rebuild a track of their story, marked by mourning and hard losses.

Because of such traumatic events the two women started a way of life marked by distrust of agencies and social avoiding, while living in a state of personal carelessness.

The isolation in which they lived for a long time and that has quickly taken hold of their lives drastically interfered with the beginning of a process of help and protection.

Evidently the tormented life experience has deeply marked their lives to the point that they do not want - or cannot – put their trust in people, not even in those who live on the streets, in isolation from the rest of the homeless people.

They have often been the special attention of citizens and target of bullying. During the recent years they have lived in a traffic divider at risk of being hit by cars.

Their slow walking and their attitude to cross the roads with their hand trucks made necessary to intervene with a plan aimed at avoiding risks to their - and others - safety, in particular to verify their mental and physical health.
 

2.       HEALTH: 

Their physical conditions were clearly deteriorated with the passage of years and because of their age. Their general conditions are shoddy, clearly observable in a change of posture – this physical aspect could be an expression of their social avoiding.

They use to stay bent with their eyes facing down. Only after ASO (Obliged Sanitary Assessment, in Italian legislation) it was found that in addition to a mild glycemic decompensation the two sisters had no disease worthy of relief.

No skin disease was diagnosed despite their long stay on streets.

 

3.       INTERVENTION:

A constant monitoring has been realized over the years and numerous were the attempts to persuade the women to accept recovery and  assistance also through help of volunteers.

The objectives included their transfer in a protected center suitable for their age and needs .

The attitude of total closure and isolation, in addition of a strong adaptation to life on streets, has made impractical any action of risk reduction.

 

4.      WORKERS & NETWORK:  

Various interventions have been implemented over the years, both social and sanitary.

Voluntary associations were involved for observation and to meet the basic needs of the two women.

It was concerted an intervention with the Center for Mental Health under ASO (Obliged Sanitary Assessment) in order to verify the presence of  psychiatric suffering behind the constant refuse of any social help – eventually identified as an effective chronic psychosis.

The main difficulties were found in the development of a shared action participated by all services involved - social work agencies, local health authorities, voluntary work, police, health centers.

 5.      PROPOSALS:

It is necessary to rethink and give concrete form to any possible action that points to the full integration of social and health care.

Only through a shared participation chronic situations could be avoided– this topic is also related to a real reduction of spending in health and social care.

Similar interventions are often difficult to organize because of conflicts with an ethical dimension that sometimes does not include the concept of social protection; this vision may represent the best response in terms of respect for the dignity and wellness of the people, and also a step forward for the rationalization of public spending and for the appropriate use of available resources.

DIVERS: the two sisters are admitted under ASO from 9.6.2015 but they still do not accept sanitary interventions – even basic ones – and they hope to go back on streets and to regain their freedom. They have evident fragilities related to a deterioration in the psychological sphere .

1.     BACKGROUND and environment:

Beginning in Denmark in the 1970’s the large mental hospitals were criticized for isolating and disempowering patients.

The reorganization of the entire psychiatric treatment for what is called ‘community mental health’, took off in the 1980s and 1990s.

The number of beds in psychiatric hospitals was drastically reduced and the mentally ill were instead given treatment at the mental health res, set up in cities across the country.

The hospitals were due to lesser beds and more intensive pharmacological treatment more critical to who was taking in and the duration of inpatient status was shortened. To some mentally ill people that meant that they ended up in homelessness.

1992: Peter, 25 year old, grew up in a middle class home with a father, who was often absent and a dominating and alcohol drinking mother, who was quite often violent towards Peter. The family moved around often.

He has expiring troubled school years, no exams, no education. He started drinking at fourteen, becoming more and more isolated. He was admitted to mental hospital for the first time at eighteen.

Diagnose was schizophrenia. After he partly lived at home with his parents, partly with friends with whom he drank and smoked cannabis.

He often slept in parks. From he was 23, also at shelters for homeless people. He had no trust in grown-ups and no trust at all in social workers or the municipality social service.

Peter is representing one of the new groups of homeless; young and middle-aged men and women with multiple and complex issues, such as severe mental illness, drinking problems, drug addiction, a weak social network, no experience in working and housing marked and poverty, besides homelessness.

In 1992, I completed my thesis on young homeless. I interviewed 127 homeless people. Among them was 25-year-old Peter. My thesis (Young Homeless in Copenhagen, 1992) ends up in an attempt to define homelessness; ”A person is homeless, when he or she does not have a home, which is stable, permanent and meeting the person’s requirements as to housing of a reasonable standard. In addition, the person is having difficulties coping with the relations and institutions of society in a wide sense – such as family - as well as private and public institutions of any kind, the reason for this being obvious or more obscure circumstances of the individual or in the way, society is.”

1993: Peter did not feel welcome neither in the homeless institutions nor in the mental hospitals. He was not wrong. He was not welcome in shelters for homeless people because he was mentally ill and was taking drugs and he was not welcome in psychiatric hospitals because he don’t want to take antipsychotic medicine and because he was addicted to drugs and alcohol. In 1993, he disappeared from Sundholm. Did he really have his life on track?

Since 1990, I have been working as a volunteer doing social psychiatric outreach street-work beside my normal job in a municipality shelter for homeless people.

1994: I saw Peter in the street. He was quite dismissive of my attempt to speak to him. He was now 27. In a deplorable state, dirty, his clothes ill fitting. He was mostly angry, shouting at people.

Similar project as mine I Copenhagen had begun earlier for instance project HELP (USA) meeting the homeless in their environment. In Lisbon, a psychiatrist went out searching up the homeless mentally ill in the streets. In Bruxelles (Diagones). In London, where both social workers and a psychiatrist did street-based work.
More was coming. In the report ’To live in health and dignity’ (SMES; 2000), on basis of an exchange programme visiting 10 capitals in Europe and there in all 57 services to homeless with mental problems. Hereof, 41 initiatives were set up during the period 1990 to 1999, thirteen with outreach street-based work as their main task. We found an increasing interest and a will – probably due to increasing need – to do outreach street-based work.
The conclusions of the report were among others: ”Outreach: a very high perage of the staff feels the need for enhancing outreach (go out and meet) dimension as a method. I should be in mobile and cross-disciplinary teams”

2.     HEALTH: Physical - psychic

2002: I had during the years from 1995 seen Peter on and off in the streets.

Offering him – as harm reduction – different kind of support for surviving such as sleeping bags, food, contact, a little money, established a quite good contact with Peter, who is now 35.

He is a rough sleeper, but sometimes uses hostels a few nights at a time, is in prison or admitted to psychiatric ward. Always so briefly, that no one has the time to care for him. His substance abuse problem is massive; he has hepatitis and has only fifteen teeth left in his mouth.

3.     INTERVENTIONS
 

In 1994, I have with a group of people working with homelessness tried, to create permanent housing for six homeless with mental illness and substance abuse in a co-housing scheme.
We placed the usual demands to the inhabitants and the staff lending support, it were: No substance abuse, receiving pharmacological psychiatric treatment, training in daily skills and participating in daily-shared activities. It did not work.

Three months later, everybody had moved out. We realised that we were thinking in the wrong way and turned all demands in the opposite direction.

That is, you had to have a mental illness and it is okay to receive treatment, but it is not a demand. You had to be an active addict of drugs or/and of alcohol. You can have a story of being violent and still be accepted to live in the house. And if you cannot manage your money, your food, your hygiene you will be very welcomed in the collective house.

The staff take over the responsibility. It worked. Not as a laissez faire solution, but it did give the homeless a possibility of ‘starting from where he is, and not from where I think he is’. More of such residences have appeared since then.

One of them, the Pension Mette Marie, which is run as a non-for-profit organisation where the council pays for services that each resident receives and gives a contribution to the apartment, whereas the residents pay for the rest of the rent and the food.

The sixteen residents have their own separate residence with the right to live, as they want. In addition, there are common areas and a staff of six with different professional backgrounds as well as a social health care assistant.
The staffs are present from 8:00 in the morning to 21:00.

4.     WORKERS & NET

2005: Peter moves in the Pension Mette Marie. He is now 38. Peter has his own apartment, with a lock on the door and the right to use his home, as he wants, also to bring home friends. He is not met with demands of stopping his abuse. In his own apartment he can do as he wants.

The staffs are doing relation work. The purpose is to create possibilities of developing life through empowerment and damage reduction. There are no rules apart from ordinary common sense and no resident can be evoked. The resident may choose to eat together (and thus with the staff) or see to their own meals. They can choose to get help with managing their finances or do it by themselves. Besides the sixteen apartments, there is a common area and in the basement room for the staff.

2015: Peter still lives in the house ‘Mette Marie’. He is now 48 years old. He plays in the house-band, he goes on outings and holidays and he is the residents’ observer on the Board. Occasionally, he visits the national union of homeless people (SAND – member of the European umbrella organisation HOPE) He is an accepted part of the local area and often has good talks with neighbours and local business owners in the neighbourhood. He has accepted to take pharmacological treatment and meet a psychiatrist who is coming in the house every second months. He has only been-inpatient a few times and for only shortly.
PBr  

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