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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
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“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:
http://www.socialfirmseurope.org/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5846108/
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Checklist:
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:
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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.
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Questions
-
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?
7. REFERENCES:
• 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).
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