Exchange for changing




To be homeless, in most cases, means to have multiple needs that require multiple answers to be coordinated and that can hardly be met by a single agency: housing, bureaucratic, working needs, physical or mental health problems.

Furthermore, the way most of the homeless persons ask for help is not usually direct and explicit: very often the necessities emerge because the person “breaks” the fragile balance between the social context and his exigencies.

It is significant that third parties mainly convey the help’s requests: ordinary citizens, volunteers, social operators, and police officers.

Being urgent and not specific are therefore two additional characteristics of such requests, although the need that is detected in immediacy is usually of a health nature or to defend the public peace.

      1.1  Complexity

We may refer to a typical experience to highlight the complexity of the phenomenon: a citizen sees a person with characteristics easily attributable to a homeless (particular neglect, lack of hygiene, rough clothing, presence of backpacks, bags, cartons) in a severe physical difficulty, probably even in a state of chronic alcoholism or in a state of mental alteration, such as to determine disturbing, dangerous or disruptive behaviours.

In such a case, the first institution involved is usually the health care system, which, once resolved the emergency (mostly a state of poisoning or a psychiatric acuity) tends to avoid, for several reasons, a more comprehensive sanitary takeover of the person.

One of the reason may be represented by the lack of a further level of care in case of a hospitalization, consisting of a response to basic needs: clothing, changing of linens, toiletries, as well as company, encouragement and support, is usually supported by relatives, are missing or  absolved in a discontinuous and not exhaustive way by the most various figures (nursing, medical, volunteer).

In addition to the issues strictly related to healthcare, this is often interfered by bureaucratic and administrative irregularities, a phenomenon that is increasingly present as a result of the large migratory flows affecting Europe in recent years: migrants, in fact, compose a significant part of this population.

Going back to the example, suppose that instead of calling for a health emergency to assist the person in trouble, the Social Services were directly involved: in the luckiest case, they will provide a more or less temporary shelter to the person until his recovery, in compliance with the legal requirements and the legal status of the person.

Rarely, however, the matter is exhausted through a solution of the housing order: it is very likely that the same reasons that led to the call, will occur again in the short time and that the situation will be repeated in a vicious circle that makes the failure of interventions an element of deep frustration for the person in need and for those who are in charge

1.2 Actors involved

As seen in the previous paragraph, in a typical situation of an intervention for a homeless person, we may need to refer to the following agencies:

      .     healthcare workers
.     municipal police
.     law enforcement
.     social workers
.     embassies
.     volunteers

 It is interesting to underline that none of these actors is the only and directly responsible for the situation and each of them are therefore in the position to delegate towards other institutions.

For all the above, in some European realities, it has come to the constitutions of networking, that is, of meta-organizations including all the formal and non-formal institutions, which in various ways deal with this phenomenon. 

1.3 Networking as a multi-layered approach

Networking is a “process which fosters the exchanges of information, ideas and practices among

Individuals or groups that share a common interest” (

Networking, in our case, means to optimise resources and competencies and to avoid contradictory or overlapping interventions.

Creating a network may allow to build a better diagnosis of the problem and to design the intervention and share it at the presence of all the involved entities; to organize the intervention in a procedural and organic manner granting the continuity of care; to overcome each institutional limitation and the different timing between organizations; to take part in the difficulties, not feeling to be solely responsible or, even worse, getting out and avoiding any responsibility.

1.4 Structural and operative networking

Talking about a network implies to contemplate two different levels, strictly interrelated: the structural and the operative.

We indicate with structural, the entire range of the organisation participating in a network in an explicit and agreed way. The network may be constituted in this case both by formal and informal institutions, governmental and non – governmental, public and private.

We define operative, the network strictly constituted by the persons, belonging to the different organisation represented by the structural network, directly involved in the specific case management: a front-line level, that designs tailored intervention and follows the process, case by case, on the field.

As said, these two levels should be interrelated, which means that in a certain way, the operative level should be a kind of output of the structural one, the concrete expression of the values and projects shared by the parties.

Reasons for networking:

A.      Reasons related to the patient: 

·     The principal reason is that the person is not in a situation, for various reasons, of being himself in charge of making its network and going to one place to another. The person needs someone else to make the connection between the different actors, that are necessary to help him and respond to his needs, to transmit information, to coordinate, to refer him, to accompany him, as long as the patient is not able to do that himself.

·     Additionally, a very good reason is that the patient needs to have access to different people or institutions, in order to recreate its own, personal network.

B.       Context reasons:

·     Patients have multiple needs that no institution can respond to alone (general medical, specialised medical, social, psychological, practical, housing, educational)

·     From the beginning of the care, patients need support at multiple different times, and will need it for a very long period: you cannot bear that alone

·     The situation of the person is often very hard, difficult, complicated, sometimes critical, so it’s good that several institutions share the burden of those difficulties and persons.

·     The recovery of these patients takes a very long time. Therefore, it’s crucial that several institutions support that process together.

·     The different institutions have to make an effort to be able to work together without doing two times the work (complementarity), without doing contradictory work (coherence) and ensuring that all the needs are covered (sufficiency).



2.   Main ideas

2.1    Networking as an opportunity

       To be part of a network should be an opportunity to:

·     overcome the feelings of solitude and disqualification that too often are part of these disadvantaged situations,

·     become more aware of each other missions, values, languages, skills and difficulties

·     feel in turn recognised and appreciated  

·     leverage over proactive elements even dealing with a complex reality as homelessness

·     prevent the defensive occurrences of delegating operations

·     reduce the burnout phenomena

·     avoid the recurrence and overlapping of interventions (unsuccessful admissions due to lack of planning distribution of essential goods to the same person by several contemporary operators; paperwork being taken and never concluded; impossibility to access to a safety valve for insufficient documentation)


2.2 To build a network

To build a network is not a spontaneous process: it underlies willingness and a specific effort and may take a long time and care.

First of all, it is necessary to “detect” the knots of the net, those sharing with us the same “problem”.

It is important to know the role of each “player”: missions, specific competencies, limitations, inspirational values. To deeply respect the identity and values of each participant, even the “free players”, for instance volunteers whose contribution may become really significant but is rendered on chance, for free and out of any structured organization, is the first step of a process that should lead to share common goals and to design appropriate and coordinated tasks.

In this first phase of contacts, the most common feeling may be of fear and suspiciousness: not to be understood or recognised in our efforts or limits; to be those who will receive most of the duties and responsibilities; to lose our decisional power. It is a very delicate moment, in which the aim should be to create the conditions for mutual trust and to build a “win/win” playground.

A “win/win” approach rests on strategies involving: going back to underlying needs; recognition of individual differences; openness to adapting one’s position in the light of shared information and attitudes; attacking the problem, not the people. Where both people win, both are tied to the solution: they feel committed to the plan because it actually suits them.

A.     Networking inside the institution:

It’s not always evident, but inside the institution, it’s sometimes difficult to network while it is necessary, and generally for the same reasons as outside. For example, in a hospital, you need different competencies, and different exams and further on. In medical practice, you can have various competencies which should work together, but they don’t always do it, or do it in a very fragmentary way.

Several skills contribute to the ability to network and work together in the same institution:

1.    Speaking together:

This implies a place - there must be a place where meetings and discussions can take place; it can not only be in the corridors.  And possibility- there must be a possibility, as a rule, for the people of different competencies, to speak to each other; it must be something normal, not an extraordinary initiative taken by an individual (example: nurses or social assistant should be able to ask a doctor to speak about a patient). Also respect- there should be total respect and confidence between the different competencies that they are a part of the solution and that their view on the patient's situation is legitimate.

2.    Establishing common objectives towards the client:

This means that both parties can agree implicitly or explicitly on objectives. These objectives are both general (« for the patients in our service we expect to reach that or that ») and very specific (« for this patient, we agree that we should aim specifically at that, but renounce at this moment, on that »). 

Sometimes we can hold objectives for the patient if he is unclear about his goals until he reaches a point where he has more clear ideas about agreeing or not with us.

3.    Sharing information:

There is a need to share information, the necessary information, which doesn’t mean all the information. It means the information required for each competency to act accurately towards the patient.

4.    Patience together:

All professionals have to agree on what time they are ready to spend and to wait on the resolution on the case. This also allows to work on a relay-mode: when one competency or person is out of patience another can take over for a while.

5.    Complementarity:

Collaboration works better when it is very clear for all the parties what complementarity there is between them.

6.    Leader or case manager:

There is better collaboration and progress when there is someone who takes responsibility for the advancement of the case


 B.     Networking between institutions:

Networking outside an institution is more evident but probably more difficult and time-consuming. It is an everyday task, takes time and energy, confronts the workers with competition, misunderstanding and prejudice.

Institutions should be aware of the advantage it is to take this task seriously and explicitly inside there day-by-day working. To have a person in the team specifically responsible for networking helps the institution to devote enough time and resources to this task, and will be time-saving at certain points. 

Helping factors in networking and working together with other institutions:

1.  Good information about possibilities: knowing what partners can do what, where they are, when they work and how to contact them. It can take a long time before to know exactly all the possibilities of the network.

2.   Ability to share information: there must be an agreement about what information can be shared or not, or will be shared or not, especially because we speak of dealing with an external organisation. Often there is a meeting needed to clarify that. It should also be remembered to always share only the necessary information.

3.   Clear view of everyone’s job: it must be clear for everyone involved in the partnership what is it’s task and contribution to the care to the patient.

4.   Shared objective: it’s easier to coordinate efforts and actions if the specific objective is shared (e. g. to get the person followed by a doctor).

5.   Win-win operation: it is an ideal situation when both services have a (different) interest in the collaboration. This happens specifically when there is clear complementarity between the services. A “win/win” approach rests on strategies involving: going back to underlying needs; recognition of individual differences; openness to adapting one’s position in the light of shared information and attitudes; attacking the problem, not the people. Where both institutions win, both are tied to the solution: they feel committed to the plan because it actually suits them.



3.1 Networking as a problem

 Several issues can undermine the set-up of the proper functioning of a network.

Different values, cultures and languages between different professionals or roles, may represent a barrier in terms of sharing a goal or in the way this is reached.

To be a public organisation or a private, as well as to be an official or unofficial one, can raise the feeling of a power imbalance between the institutions and threaten the identity of the parties.

In some cases, it may occur that the persons representing the organisation to which they belong to, do not have any decision making power, a condition that could weaken the specific role or function.

The number of participants too can represent a problem: being “too many on the boat”, may affect the decisional and operational processes, creating the condition for a role blurring phenomenon.

A poor communication flow, a fragmentation or a lack of information, the absence of coordination between operators, may seriously affect the continuity even of a good plan, but especially of the long-term ones.

Another issue often disturbing the positive functionality of a network is the tendency to convert the role of the “facilitator” of the meta-organization, into a “coordinator” as the only responsible for the integration of the entire process, the only entitled to take decisions or, even worse, the only responsible for the outcome.

On the other hand, the lack of a “case manager”, that should be not the first and last responsible for the person in charge, but the facilitator of a fluent process may cause the collapse of the project, whenever any difficulty is encountered, due to a discharge of responsibility.

In some cases, the gap between the so said “structural” level and the “operative”, may become an obstacle to the agility of the process and the good results of the outcome. The structural level should be a frame, that grants the awareness to be in the position to overcome limits otherwise insurmountable, thanks to the presence of other institutions. Whenever the structural network prevails through requests of bureaucratic commitments, power struggles, lack of a co-working culture, lack of a common training, this may become a severe threat to the whole functioning of the net, in particular may affect the operative level whose main duty will become to be a function of the structural level, instead of being an efficient enactment.

Last not least in a list that might be longer due to the complexity of the subject, is the handling of all is related to the personal data protection (General Data Protection Regulation, UE 2016/679) a complex matter to manage, being many the agencies involved and the data shared between different professional figures and agencies.

 3.2 Preventing difficulties

 Building a network, as seen, is a process that foresees several steps.

The mutual knowledge of the parties, as a first step, not only is a necessary, but is also a very delicate phase: it is mainly about building relationship and any initiative that has to do with the promotion of social situation, is highly recommended in order to meet and better know each other, even in an informal way.

 Especially for what concerns the so said “operative networks” it will be a must to plan meetings with the attendance of all the parties, to organise the activities and be debriefed on the developments of the different cases. A detailed follow up of the activities is also necessary, in order to check achievements, monitor results, share difficulties and implement recovery plans.

It may happen to have “extra – meeting”, due to the urgencies that arise dealing with human “material”: to be flexible is always a good way to cope with difficulties and complexity.

A good communication, based on shared Information is the basis of the network functioning: not only to provide the updates on every single case that the network is caring for but also to have common access to the information and the resources shared in the net.

Communication and commitment should follow the top - down and bottom – up way, and this is also why it is necessary that the persons in charge for each organisation, should have the decision-making power of the institutions they represent and feel in a peer to peer condition.

 It is a good practice to agree on a Memorandum of Understanding, which should not sound like a strict and mandatory contract, but as document fine-tuning each entity, duty and responsibility.

The more the mutual understanding develops, the more will become a necessity to make experience of joint training, which means for instance to visit the places in which each member of the networks and operates: on the street for nurses, doctors, social workers; in some “war room” for the coordinators of the outreach team; in hospital wards or clinics; inside the houses of our clients; in some soup kitchen or shower service; in some government office, etc. etc.

To experience in real life and real time the way the other partners work and the problems they have to deal with daily increases the mutual understanding and tolerance and improves the esprit de corps.

In the light of the above, once the network is well structured, and that suspicion of subjugation or dominance by any party have been dispelled, and mutual trust is acquired, to provide a common training could strengthen the links and the mentality of the group.

To share a common space, in which contacts and communication may happen in a fast way, and the intervention may follow in an easier way the possibility to be tailored for the person in need, may be a big challenge for many European realities, but a good solution for many reasons.




1.    Feed-back, when the patient gets better, feedback given to the partner can motivate him to continue the collaboration for other cases.

2.    Concessions are often necessary to facilitate collaboration, but still: good collaboration works on equality between partners.

3.    Responsibility: each partner should feel totally in charge and responsible for his part, and also for final success.

4.    Coordination of the care is a service provided to all partners, not a way to control the situation.

5.    Necessary information and only necessary information should be shared

6.    Confidence: a reasonable level of confidence between partners is neccessary.

7.    Win-win situation: maximises the involvement of each partner.

8.    Presentation: it is useful to take time take by the different services to present themselves to the different partners in a particular situation.

Who to involve:

A good collaboration with a few services is probably preferable to a large  number of nearly unknown partners, but:

-          a certain amount of partners are needed, because of the risk of saturating one service with the most difficult cases.

-          diversity is needed because the same solution will not be fitted for all patients.

-          new ways, new services are to be explored continuously



A concrete example: NPISA in Lisbon

The idea of NPISA (Núcleo de Planeamento e Intervenção com Pessoas Sem-Abrigo) was made explicit in the National Strategy for the Homeless published in 2009 by the Social Security Ministry. With this document as a guide, several NPISAS were created in different regions of the country. The NPISA of Lisbon was created in 2015. It took several years of preparation, requiring the will of the Municipality of Lisbon, Santa Casa da Misericórdia de Lisboa and Social Security, together with NGO’s and associations working with the homeless in the city.

 NPISA has a building where all the organizations are represented and where the homeless can be assessed. The work of outreach teams from different associations was organised and planned in an articulated way: attribution of territories, responsibilities, case managers. There is also a sharing of information and resources.

The person who addresses to its social services is welcomed and listened to, by a social worker and a psychologist simultaneously. Starting with this meeting, an agreed and shared plan for caring corresponding to the needs takes shape, whether these needs are of a physical, psychic, housing, or working nature.  The recovery process is supported by all the partners of the network according to the individual’s needs and is facilitated by the partners being able to communicate directly and plan their interventions together.

By doing so the operational times and costs are enormously reduced, as well as the bureaucratic obstacles: it is evident that the opportunity to draw up an assistance through the establishment of a network shall then determine effectiveness or even success to a large extent and makes the eventual failure more tolerable as it becomes less frequent and widely shared.


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

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 on diagnosed a long term course of schizophrenia, with significant deterioration.

The staff working at the psychiatric hospital, that was used to have regular meetings (every 2 weeks)  to discuss difficult situations with particular concern for the homeless with mental health problems, first heard about him through an outreach team belonging to the city council and therefore started to visit, on a regular basis, also this family.

Also, a local church group was very much involved in the case and tried to help Felipe and his family. They called for the city outreach team which 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 to their home. We had the chance to talk to his sister and 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 to 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. Amid his rabid 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 responsibility for the shelter called the head-director of our service, which was also the psychiatrist who had visited Filipe's home. They planned that Filipe would come directly to our service after being discharged from the other hospital. So he did, by taxi!

Filipe stayed as an inpatient in our service for three weeks. During this time he was diagnosed and treated for schizophrenia, 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 specialised 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 this nursing home were a little higher than usual, but the social services managed to obtain special permission to go a little higher than the regular budget because they were conscious that Filipe needed specialised care.

A few weeks later, our team paid him a visit at his nursing home. He was more communicative (in his deficient 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.

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

This case highlights 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 the hospital, enable the psychiatric team to open the doors and admit him as an 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.


Five main ideas from the Profile:

1.    Are there impossible cases?
The case presented had been stuck for years in the streets, and a lot of different actors felt helpless to help. This profile suggests that even the apparently impossible cases can be transformed and it is useful to try to research what makes some cases seem impossible to intervene, and what are the factors that open a possibility to a useful intervention. 

2.   What seems impossible can become possible by cooperation
This case brought together a diversity of actors, both from the private and public sectors, as well from the social and health fields, that started to work together. This intervention was possible because trust and openness to cooperate had been built. Instead of an attitude “it’s your job to do this…”, a different attitude was displayed: “if you’ll help me here, I will be able to do that”. In this case, hospitalisation also enabled social services to find a more adequate solution (nursing home).

3.   It is useful to have regular meetings to discuss difficult cases that bring together professionals from the social and mental health fields.
The regular meetings between an outreach team that belonged to the municipality and a psychiatrist and a psychologist, with experience with outreach for the homeless and working in a psychiatric hospital, proved useful to several difficult situations. From these meetings came out the idea to go and visit Filipe, his sister and brother, and because of this first-hand knowledge, it was much easier later to cooperate for the hospitalisation.

4.   It is critical to evaluate which situations need hospitalisation or mental health consultations, which situations need a good social support that fits the individual needs, or both.
This case highlights the importance of a good evaluation and intervention that takes care of both social and mental health needs.
Hospitalisation opened the possibility to plan and find a better housing solution.

5.   A successful intervention is everyone’s  success
In the end, everyone involved in the case felt like a winner, and no one felt that success was especially his doing.


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

-          What were the critical moments in the networking process?

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


Complexity: characterises the behaviour of a system or model whose components interact in multiple ways and follow local rules, meaning there is no reasonable higher instruction to define the various possible interactions.

Facilitator: someone who helps a person or organisation do something more easily or find the answer to a problem, by discussing things and suggesting ways of doing things.

Meta – organisation: is defined as organisations which are formed of other organisations, rather than by individuals

Networking: A process which fosters the exchanges of information, ideas and practices among  Individuals or groups that share a common interest.

Win-win position: the “win/win position” is about changing the conflict from adversarial attack and defence, to co-operation. It is a powerful shift of attitude that alters the whole course of communication: I want to win, and I want you to win too.



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