1.      Introduction


People in a situation of long-term homelessness often went through a long process of social exclusion and compound trauma (Cockersell, 2018).

Research consistently shows that in infancy and adolescence homeless people frequently present indicators of dysfunctional homes, such as histories of physical and/or sexual abuse in infancy, parent substance abuse or mental illness, running away from home, foster care and institutionalisation. In adulthood, homeless people frequently are affected by the loss of jobs, economic crises, poor physical and mental health, substance abuse, exposure to physical or sexual violence and lack of social networks to support or protect them. (Munoz, Vásquez e Panadero in Levinson e Ross, 2007).

This means that working with the homeless is not just a matter of providing answers to the lack of housing, treatment or jobs. It is also a matter of addressing the process of social exclusion and helping to recover a sense of a stable self, a sense of home- a place where one feels welcomed and belonging to- a sense of connectedness to stable relationships and social networks and a sense of personal value, where one feels to have something valuable to share with others and feels recognized by that.

This dimension is so essential that it becomes elusive and challenging to capture in one word. “Participation”, “Recapacitation”, “Reconnecting”, “Empowerment”, “Rehabilitation”, “Recovery”, “Employment” are some of the words that may come up when one tries to think about it.

“Recovery” has the advantage to connect with current literature on the subject but at the same time, it is not entirely suitable.  On the one hand, it evokes “illness”- one recovers from an illness, for example.  But at the same time, it requires a shift from a medical model to a social model of understanding that focuses on wellbeing, strengths and opportunities rather than deficits and weaknesses.

 On the other hand, it evokes the idea of “return”- returning to the state that preceded whatever the person is recovering from. But it is also important to be aware that one may not have lived in a previous state of so-called “normal” social and economic conditions, which means that it is not often a matter of returning to but of trying to build from” scratch” what was not there before.

According to Repper & Perkins (2006), recovery is a personalised process, which is connected with the growth of future hope, the discovery of a new meaning in life, empowerment, development of personal skills and strategies, a safe economic and social base, supportive relationships and social integration.                                                    

So recovery is not something that professionals do but rather a personal journey that has to be understood from the user’s point of view. The role of professionals may be best understood to be a role of support, of trying to provide the environment and opportunities that the person can use on his recovery journey rather than hinder that journey with the imposition of solutions and plans designed by professionals that supposed to know better. That requires the abilities to listen, respect the right to choose and to work collaboratively with users.


2.      Main ideas

·         Recovery is not treatment: Recovery and Treatment are two different things. Recovery is about gaining self-management. According to this approach, a person takes risks.  For example, he chooses to return to work; at the same time, he has strong support from his family (when there is one) and professionals (Chamberlin, 2005). The users themselves must manage their own recovery – it is RECOVERY BY THEMSELVES with support.


·         Recovery is a process, not a state: It is a process of change, through which individuals improve their wellness, their quality of living and lead themselves to more degrees of autonomy, preferably being able to support themselves and not being dependent on other people. This means being treated as a person rather than as a patient.


·         It is a personal journey, and everybody recovers at his own pace. Thus, it should be supported by -but not managed by- a professional. The first reason for that is related to the fact that a person's needs and a professional’s opinion for the same individual can vary greatly (Lasalvia al., 2005; Thornicroft & Slade, 2002). In addition, the needs that have been assessed by the service users themselves are much better indicators for the assessment of the quality of life compared with those reported by professionals (Slade, Leese, Cahill, Thornicroft, & Knipers, 2005). The second reason is related to the individual's right to make his/her own decisions, even if it is proved in the way that it was the wrong choice or that his/her decisions were harmful and risky. The right to take personal risks and regain the control of one’s own life, through free will, fits into the broader context of the concept of recovery and should be assigned, even if there is substantial disagreement or concern for the results of this choice (Slade, 2009).


Additionally, we should be aware that:

·     Engagement and trying to establish a trustful and meaningful relationship between people in a homeless situation and the professionals are central to support the recovery process. Through that relationship choices and options can be given to the persons regarding their needs and will. This is of critical importance in outreach work (see outreach chapter).  

·    The road to recovery is never straight, and there’s no predetermined destination.

Professionals should be aware of not trying to force their clients into some sort of ideal (ex: get a house, get a job, get a family) regardless of the will and possibilities of the clients. We should also have in mind that normality is a statistical concept, but each one of us has a subjective approach to it, and therefore this has to be taken into account when working with people that have been exposed to severe life events and have created a certain “personal way” to interact with the environment.

·     The role of professionals working from a recovery perspective is to instil hope and build a positive and realistic view, to support, connect and discover opportunities as well as to respect needs and choices, focusing on strengths, self-determination and somebody’s resources, instead of focusing on symptoms and deficits. It is a holistic approach, facing users as individuals with roles rather than as patients. 

·     For someone to gain or regain self-respect, self-confidence and meaning in life, it is important to feel “included”, to feel that he/she belongs in a community and he/she is somebody not only accepted but valued as someone worthy as well. All the above can be gained partly through increased connection with others, being able to participate as a citizen actively and having access to jobs.  

·     Access to jobs may be very important in the process of recovery, as it can lead to self-support, independence and recognition. Besides that, earned money/salary can also be linked to dignity, as it is one kind of exchange. Moreover, through a job homeless people can gain a structure in their life and a purpose. Thus, for some people job can definitely be a step towards recovery 

·     On the other hand, it is crucial to be underlined that having a job is not everything. There are people for whom having a job is not their priority (i.e. older people or more severely ill), so we should accept diversity and recognise the right to live with dignity without a job.  If we consider a job to be prerequisite for a fulfilled life, we may end up blaming and diminishing those who might not be able to work anymore, but who can live with dignity with a pension or other social benefits, and find purpose in life through a hobby and other social and meaningful community activities 


3.      Difficulties

·     Time-scale: Services often fear the dependence of users and tend to put pressure on professionals in order to produce fast results and have their clients become autonomous as soon as possible. This contributes to an emphasis on short-term solutions and rigid plans where users are compelled to do things under the threat of losing support if they don’t.  This defensive mode can turn services into a system that readily blames, punishes and excludes people, instead of one that cares, supports and helps people on their needs.  

·     Professionals often have big caseloads, making it difficult a person-centred and a person-tailored approach. However, dealing with people who suffer from a long process of social exclusion, requires a central focus on the relationship, fostering the development of a close, regular and trustful relationship between professionals and users.  

·     The fear of addressing the long-term needs creates the paradox of increasing the risk of institutionalisation, where being a service user becomes a “full-time job”, and people live permanently in supposedly temporary accommodations, like shelters, hostels and other big institutions. 

·     Professionals may not consider the possibilities of entering into the labour market and tend to use a step-wise model where people are asked first to attend occupational activities or professional training courses before trying the job market. This might contribute to trapping people in vicious circles of preparatory training without any access to the job market. This can be prevented by a “first job approach” where people are helped to find a “real” job and are supported and trained while they are at their jobs.

·     More and more, due to the socioeconomic crisis, some European countries face a situation of lack of jobs combined with the exhaustion of family provisions, as well as reduced investment in social welfare, leaving more vulnerable those in need. At the same time, we face a more competitive free labour market where there is only place for the “fittest”, leaving out many who could work, even if they are not the fastest or the youngest. (Social cooperative style businesses can be an alternative).  

·     However, the issue of labour may be controversial, in the sense that labour can be different from a “job”. Very often labour is seen as an inclusive action in the community and not as work, on its own right. As labour/ work is a strong symbolic identity feature, the idea of how labour affects somebody’s identity has to be looked at very carefully. If that identity construction is achieved through a specially “developed job”, targeted for people with mental illness and homelessness, to what extent do we identify them with their illness and to what extent do they see themselves with that condition and not as citizens with rights and responsibilities?  

·     The staff in institutions and services can get frustrated with the process of recovery if they are not well trained and supported. Stereotypes and misconceptions can lead to constant marginalisation and discrimination, especially for those with mental health problems and/or addictions. Thus, the staff needs to be given the tools to clearly understand that treatment does not equal recovery. Teams should be given time for reflection, team approach, mentality and culture of networking, communication within and out of the team.  This is essential to understand that the recovery process takes time and during this process, we have to deal with frustrations, steps back and forward and at the same time respect people's resources.  A team has to be continuously supported to be flexible (see also next chapter about staff care-staff training).


4.      Good practices

·     Since we are often facing persons who have been through a long process of social exclusion, it is of the utmost importance to try to build an environment that people feel safe, stable and containing key figures that can be trusted enough to turn to when help is needed.

·     The intervention has to have a central focus on relationship, and try to foster continuity, trust, interactivity, an attitude of positive regard, respect, responsiveness, non-retaliation, with a special attention to power dynamics, avoiding the activation of feelings of shame, humiliation and anger by offering alternatives that the person can choose and not imposed solutions with an attitude of ”take it or leave it”.

·     It is essential to have access to stable case managers and not see a different professional each time they go to services. It is also important that case managers have caseloads that enable them to see their clients regularly and do things together.

·     A person-centred approach should be the foundational approach style, as it is vital to meet people where they are, listen to and acknowledge their point of views, needs and hopes. At the same time, workers should try to support their aspirations proving information, access to opportunities and mentoring them through a tailor-made plan according to the person’s choices, potentials and impairments.  

·     Provision of appropriate levels of care according to the individual's needs, avoiding an oversupply of care and treatment, which poses the risk of long-term dependency, gradual loss of autonomy and empowerment — at the same time, being alert for availability and flexibility in crises and relapses. 

·     Networking is also of vital importance, specifically person-centred networking, which means collaboration among the different services based on the special needs of each person every time. The complexity of the problems that homeless people are facing demands progressive assistance and support from various professionals in social services, health services, etc. So, it is important to facilitate with formal and informal associations and community resources, something that requires a high level of expertise among the professionals as well as flexibility and “thinking out of the box”.(see the chapter on networking). 

·     Continuity of care: is the process by which the person and the professional are cooperatively involved in ongoing care management toward the shared goal of high quality, cost-effective care. It also facilitates the services by making early recognition of problems possible. Continuity of care is rooted in a long-term partnership in which the professional (or the team) knows the person’s history from experience and can integrate new information and decisions from a whole-person perspective efficiently without extensive investigation or record review. In that way, it reduces fragmentation of care and improves a person’s safety and quality of care. Continuity of care is strongly connected with the ongoing follow up, whereas it presupposes the existence of a network.  

·     Mutual self-help groups, peer support specialists, peer-run programs: groups or programs implemented by persons who have experienced homelessness and sometimes they have also faced addiction problems or mental illness. Through these groups or programs open dialogue, consultation and in some cases even debate is encouraged. Peer support occurs when people provide knowledge, experience, emotional, social or practical help to each other. A peer is in a position to offer support by virtue of relevant experience: he or she has "been there, done that" and can relate to others who are now in a similar situation. It commonly refers to an initiative consisting of trained supporters (although peers can provide it without training).

·     Active citizenship: A wide range of stakeholders should be meaningfully involved in policy development and program implementation, delivery and evaluation. In particular, people who have experienced (or still experiencing) homelessness should be included in decisions that affect them and should be allowed to be active in their communities and be able to use the community resources or other means that reinforce human bonds.


5. Case study

“Red Sin Gravedad”: A community action and participation project that has been developed by the following associations: Radio Nikosia, Saräu, ActivaMent and Cooperativa Aixec.

The project consists of the creation of a network of workshops and/or laboratories of art, culture, well-being, etc. in Community Centers of Barcelona that are open to the community, and that are meant to create a natural atmosphere of opportunities among people with and without mental health problems. The origin of the Network is in the need to generate “light” community settings, without diagnostic categories, with the aim of opening real spaces for interaction and participation.

For further information: https://redsingravedad.org/

Social cooperatives of Limited Liability (SCLL)

The Social Cooperatives of Limited Liability (SCLL) are Private Law Entities, with limited liability of their members. They have a commercial nature and can develop any economic activity supporting it by vocational training programs for their members, as well as sheltered laboratories, and supported employment pertaining to the Social Cooperative Enterprises. Economic migrants, refugees and mentally ill individuals are among those groups that are being provided for. 

The activities of SCLL aim:

·    To ensure the viability of the enterprise and the continuous creation of new employment positions;

·    To be active in the local open market;

·    To maintain a balance between the entrepreneurial strategy and the social aims;

·    To fight and eliminate the social stigma, through – among others - the creation of a work;

·    To provide continuing education and vocational training to its members with psychosocial problems.

For further information:





Ask yourself in every intervention or proposal to a client:

1.   Who is this for? Whose interests am I trying to serve? The client’s, mine, my service, a third party? 

2.   Does this add to their recovery, their development, their learning? 

3.   Is it enabling or is it oppressive? Does it encourage trust and a positive interaction or does it contribute to mistrust and mutual defensiveness? 

4.   What does it say about power? Is it respectful or forceful? Does it allow choices or is a “take it or leave it” proposal?

6.  Case Profile:

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

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

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

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

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

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

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

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

At this point, the D.C.f.H. started cooperating with the association “Society of Social Psychiatry and Mental Health (SSP&MH)” to provide more efficient and integrated services to homeless people with psychosocial problems. Therefore, a psychologist from SSP&MH had a weekly presence in the D.C.f.H.

With this setting, N. started having weekly sessions with the psychologist from SSP&MH (May 2017 until April 2019), aiming at his psychological support, empowerment and guidance. His clinical situation was gradually improved due to a combination of counselling and medication. Therefore, he became less aggressive and paranoid whereas he was more “open” to talk about himself.

Although he didn’t visit the Day Center on a regular basis, he was there on time for the session, and he was looking forward to them. He said that it was the only reference point in his life and made him feel resilient.  Meanwhile, with the support and guidance of both the psychologist and the social worker, N. got his Tax Registration Number, applied for a social allowance and started earning some money as a street painter.

The route/path to recovery was never easy for him, and there were many times he lost his courage. Those times he used to say: “Prison is better than homelessness. There you could sleep and eat…However, prison affects you physically and mentally. You feel that you are under a sheet and this keeps you “down”. You “forget” you have a body”.

Meanwhile, N. participated in a street fiesta that was organised by the D.C.f.H. in 2018 under the umbrella of the municipality of Piraeus and during the fiesta he painted in front of the audience. His painting was impressive and was finally bought by the municipality for a relatively high amount, which made him regain his self-confidence and start seeing himself as an artist instead of a homeless and hopeless person.

At present, after many relapses and steps backwards N. has made considerable steps in his life. His social allowance has been approved, and he has found a job in a Social Cooperative as a cleaner. Moreover, with the intervention of the social worker of the D.C.f.H., he was accepted back to Unesco’s hostel. The last months he has even made a relationship with a young woman, and he is pleased about that. He, therefore, is trying to save money to make his dream come true; To rent his apartment, as according to him: “The most valuable thing in life is to have a key and open the door of your own home… In a different case, you feel “lost”. Everything seems to be in vain”.

N. is considered to be a vivid example for the successful recovery of a person when there is effective collaboration among the professionals, person-centred approach, tailor-made plan and above all the strong will of the person to change his fate.




-          What strengths and risk factors do you identify in this client?

-          What were the critical moments in the recovery process?

-          What professional interventions added, or not, to the recovery process?



     American Academy of Family Physicians (1983) (2015 COD)  

    Appleby, L. (2007). Breaking down barriers: The clinical case for change. London: Department of Health. Retrieved from http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_074579 

    Anthony, W.A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16, 11-23. 

    Cockersell, Peter (2018). Social Exclusion, Compound Trauma and Recovery. Jessica Kingsley Publishers. 

    Deegan, P.E. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4), 11-19. 

    Munoz, Vásquez e Panadero. Stressful Life Events in David Levinson and Marcy Ross (2007). Homeless Handbook. Berkshire Publishing Group.  

    Repper, J. & Perkins, R. (2006). Social inclusion and recovery: A model for mental health practice. Edinburgh: Bailliere Tindall.  

    Recovery and Independent Living Professional Expert Group (R&IL PEG) (2010).   Recovery orientated prescribing and medicines management. Retrieved from http://www.recoverydevon.co.uk/download/prescribing_project_report_FINAL_PEG_Advisory_Paper_8.pdf.


8.   Glossary - keywords:

-    Co-construction: the delivery of public services in an equal and reciprocal relationship between professionals, people using services, their families and their neighbours.  (Boyle and Harris, 2009).

-    Connecting: joined or linked; linking two things

-    Empowerment: to take their lives into their own hands an opportunity to control their own life. There was much discussion on the use of the word empowerment. Empowerment is an external action, but it is also a two-way relationship, it can drive someone to recovery, but recovery can also lead someone to empowerment.

-    Establish relationships: create and maintain a connection of mutual trust, transparency and respect between a professional and a client (in our case a homeless person with mental difficulties). This is the basis for any further planning and cooperation. Confidentiality and honesty from the professional. A caring attitude but also set limits.

-    Institutionalisation: Harmful effects such as apathy and loss of independence arising from spending a long time in an institution.

-    Network: a group or system of interconnected people, services or organisations. They interact with others to exchange information and develop professional or social contacts. It may be formal (see the example of NPISA in Lisbon for homelessness) or informal.

-     Personal Choice: involves decision making. It can include judging the merits of multiple options and selecting one or more of them. One can make a choice between imagined options ("What would I do if...?") or between real options followed by the corresponding action. It is associated with free will. (through Wikipedia).

-     Recapacitation: To facilitate the capacity to recover.

-     Recovery: see the definitions given at the beginning of this chapter.

-     Step by step approach: The method in which does something carefully, gradually and in particular order (Longman Dictionary).

SMES-Europa      -      Secretary   Tel.  +32.475634710       -        E-mail:     smeseu@smes-europa.org