1.
Introduction- why this pillar (why this issue is
important)
Providing accommodation to
homeless people is essential for a new beginning but
it should definitely not be the final goal of our
interventions; if this is not joined with meaningful
activities or a purpose in one’s life then it might
lead to isolation and loneliness. Especially for
homeless people with mental health problems and/or
addictions, lack of socializing and being part of a
community may also lead to institutionalization.
Thus, another approach, recovery,
is necessary in order each person to be able to find
his/her personal meaning of life. But what do we
really mean by this term?
Some of the most common
definitions are the following:
A deeply personal, unique process
of changing one’s attitude, values, feelings, goals,
skills and/or roles. It is a way of living a
satisfying, hopeful life, and contributing to life
even with limitations caused by the illness.
Recovery involves the development of new meaning and
purpose in one’s life as one grows beyond the
catastrophic effects of mental illness. Recovery
from mental illness involves much more than recovery
from the illness itself.
(Anthony, 1993).
P.Deegan
some years earlier (1988)
reported for the first
time recovery:
«As a
journey rather than as a destination»,
pointing out that it is
about the process and not necessarily the result.
She described it as:
“…the
living or present experience of real life in people,
as they accept the
difficulty of their disability and they overcome it”.
Recovery from the users’
point of view is referred
to a personalized 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.
(Repper&Perkins,
2006)
Of course these are not the only
definitions. However, in all of them the central
meaning is "to live a meaningful life in the
community and strive to achieve your potentials".
Thus, recovery is above all a basic human right.
Everybody has the right to have a meaningful and
fulfilling life, although for some recovery might
have to be built from “scratch” rather than
recovered.
Recovery needs also to be placed
into practice in a collaborative way and to be
co-constructed. As it is obvious, this is a
different approach and "paradigm" and we have to
keep in mind the United Nations' Convention on the
Rights of People with Disabilities, which means a
shift from medical to social model of disability.
In practice, this means to
focus on overall health
and wellness, to face service users as individuals
with roles rather than as patients, to help them
strengthen their self-organization and
self-representation and above all to focus on
opportunities rather than on deficits and
weaknesses.
In this perspective, Recovery
should be transversal in all interventions as it is
strongly connected with other basic rights:
·
right
to housing
·
access to health services
·
access to basic goods
·
access to education and training based on
individualized needs
·
the
right to live independently in the community of your
choice
·
the
right to participate in the community life and being
included as an equal member of the society
·
the
right to work and have the
support to find work
At this point it is worth
mentioning that regarding housing, there is a
dispute about the roles of Housing First and
Shelters in recovery.
Some argue that Housing First
supports recovery more than a shelter, as it is
housing without conditions and this provides someone
with time and space to
recover. Through housing first, we alter the focus
point from participation
to citizenship in a broader way in society.
Instead, in
a shelter there are a lot of people for a short
period of time and
for recovery, which is a slow
process, this is not an ideal situation as it is not
feasible so many people to be stimulated and
motivated in order to recover themselves.
Others, still claim that a
shelter can provide a great deal of meaningful
participation, as in many shelters nowadays, service
users are invoiced with participation in cleaning,
catering, kitchen work etc.. From this perspective,
the shelter is a first community where people have
to contribute to stay in; that fact gives meaning,
purpose and structure in their daily life.
2.
Main
ideas we want to highlight
Recovery:
·
Is a process not a state;
It is a process of change,
through which individuals improve their wellness and
life and lead themselves
to autonomy. This means being a person
instead of a patient. It also means that one can
support himself/herself and not being dependent on
other people.
·
Is a personal journey
and everybody recovers in his
own time. Thus, it should
be supported by -but not managed by- a professional.
The first reason for that
is related to the most widely held view that a
person's needs and a professional’s opinion for the
purposes of 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 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 strong disagreement or
concern for the results of this choice (Slade,
2009).
·
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 returns to work, but at the same
time he has strong support from his family and the
professionals (Chamberlin, 2005).
The users themselves must manage the row recovery –
it is RECOVERY BY THEMSELVES with support.
Additionally:
·
The key to recovery
is to establish a trustful and meaningful
relationship between the homeless and the
professionals. Through
that relationship choices and options
can be given to the persons
regarding their needs and will. Especially
in the interventions with
homeless people with mental health problems and/or
addictions the outreach/proximity approach can
provide rapid responses to their needs and give
access and clear pathways. Stabilisation
of one’s situation is the first process, followed by
finding one’s self again and starts to enjoy life.
·
The road to recovery
is never straight and there’s no predetermined
destination. The role of recovery is to install
hope, to give positive perspective (of course not
unrealistic); to support, connect and discover
opportunities as well as to respect needs and
choices focusing on strength, self-determination and
somebody’s own 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 is to feel
incorporated; to feel that he/she belongs in a
community and he/she is somebody not only accepted
but worthy as well. All the above can be gained
partly through connection with others, being active
citizen and having a job. However, regarding the
issue of “job”, there is a dispute. On the one hand,
job is considered to be very important in the
process of recovery, as it can lead to self-support,
independency and recognition. Besides that, earned
money/salary can be also
linked to dignity, as it is one kind of exchange.
Moreover, through 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,
especially if we focus on
real jobs, which means links to jobs or social
cooperatives, reinvention of jobs and
readjustment of occupational
training. On the other
hand, it is important to be underlined that job
may be important but it is not everything. In
some cases, especially in the countries that lack
social welfare and where there’s no access to social
benefits, job is a vital solution. However,
there are people who will not or ever be able to
work (i.e. older people or more severely ill), so we
have to recognise and accept diversity. If we
consider job to be prerequisite for recovery, we may
“trap” people into vicious cycles of training
without any success. Therefore, it is important to
have in mind that it
doesn’t necessarily have to be a job in order
somebody to gain a purpose in life or feel
self-efficient. It can also be a hobby or other
social and meaningful activities. Professionals’
“work” is to empower people to follow their own
pathways.
3.
Difficulties we might expect
·
Recovery is considered also to be “a return to a
normal state of strength, mind and means”.
However, the
perception of 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.
·
Lack of person-centered approach
especially in big institutions (shelters, hostels
etc.). This, combined also with the fact that being
a service user sometimes becomes a “full-time job”,
can lead to institutionalization.
·
The lack of social welfare in combination with lack
of jobs in the free
labor market that appears in more and more European
countries, due to the socioeconomic crisis. Even in
the countries that there are available jobs though,
free labor market seeks for performing workers and
that can be a barrier for people with mental illness
and homelessness. (This is not observed in social
cooperative style businesses, though).
·
There is also a controversy in the issue of labor,
in the way that labor could be different from a
“job”. Very often it could be seen as an inclusive
action in the community and not as work, on its own
right. As labor/ work is a strong symbolic identity
feature, the idea of constructing somebody’s
identity through labor has to be looked at very
carefully. If that construction is achieved in 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 the constant
marginalization and discrimination of homeless
people, especially those with mental health problems
and/or addictions. Thus,
staff needs to be given the tools to clearly
understand that treatment does not equal recovery.
Teams have to be given
time for reflection, team approach, mentality and
culture of networking, communication within and out
of the team. This is essential in order them to
understand that 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 own recourses. A team has to
be constantly supported to be flexible (see also
next chapter about staff care-staff training).
Summarizing, we could say that
some people may be stuck to vicious cycles because
we offer them solutions that do not fit to their
needs or to their present condition. So, we should
first listen to the needs and then offer!
4.
Good
practices to face those difficulties
•
The person -centered approach
seems to be the foundational approach style, as it
is very important to meet people where they are and
listen to each one’s hopes and dreams. In other
words, it should be a co-work between the
homeless people and the professionals. First we
listen (without being judgmental or intrusive) and
then we co-construct the individualized plan for and
with each person according to his/her capability and
will.
•
Different work models
are available which in general could be divided in a
stepwise model and non-step wise model. Most
professionals agree though that since
a person-centered approach is used, a tailor-made
plan is needed and not a step by step. Tailor-made
plan means a plan according to a person’s choices,
potentials and impairments.
·
Provision of appropriate levels of care
according to the individual's needs, avoiding
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 a person-centered
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 different
professionals in social services, health services,
etc. So, it is important to facilitate with formal
and informal associations and community resources,
something that requires high level of expertise
among the professionals as well as flexibility and
“thinking out of the box”.
·
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
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.
·
Harm reduction:
refers to policies, programs and practices that aim
primarily to reduce the adverse health, social and
economic consequences of the use of legal and
illegal psychoactive drugs without necessarily
reducing drug consumption. It is
a targeted approach that focuses on specific risks
and harms and all the interventions are grounded in
the needs of individuals. As such, harm reduction
services are designed to meet people’s needs where
they currently are in their lives. Harm reduction
opposes the deliberate hurts and harms inflicted on
people who use drugs in the name of drug control and
drug prevention and promote responses to drug use
that respect and protect fundamental human rights.
In this case, such interventions, respect people
have will and help them become gradually more and
more responsible for their choices and their lives.
·
Low-threshold approach:
refers to programs
that make minimal demands on the patient, offering
services without attempting to control their intake
of drugs, and providing counselling only if
requested. Low-threshold programs may be contrasted
with "high-threshold" programs, which require the
user to accept a certain level of control and which
demand that the patient accept counselling.
·
Mutual self-help groups, peer support specialists,
peer-run programs:
groups or programs runned 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 it can be
provided by peers without training).
·
Active citizenship: A
wide range of stakeholders should be meaningfully
involved in policy development and programme
implementation, delivery and evaluation. In
particular, people who have experienced (or still
experiencing) homelessness should be involved in
decisions that affect them and should be given the
opportunity to be active in their communities and be
able to use the community resources or other means
that reinforce human bonds.
5.
Practical case to make a reflection exercise to use
in a context of training
From our visits to the countries
of the participants in this Erasmus+ project, we
have seen a few examples considered to be good
practices and that could be noted here:
In
Lisbon:
o
“Solidarity Lockers”, through which people are
integrated into the community whereas others even
succeed in getting casual work. (Needs
further elaboration).
o
Workshops where people do crafts? (needs
further elaboration).
In Greece:
a)
Social cooperatives of
Limited Liability (SCOLL)
The Social Cooperatives of
Limited Liability (SCOLL - KoiSPE in Greek),
which are Private Law Entities, with limited
liability of their members, were instituted by L.
2716/1999 "Development and Modernization of Mental
Health Services and other provisions "(Government
Gazette 96 A / 17.05.1999) of the Ministry of Health
for the" Development and modernization of mental
health services ". The SCOLL 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 by the Law 4430 of 2016.
So, they are a
special form of cooperatives, since they are both
productive/commercial units and also Mental Health
Units.
The activities of SCOLL 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 identity and
the improvement of the financial position of the
Cooperative’s members;
·
To
establish cooperation with the family and the
therapeutic framework and provide counselling
support to the members;
·
To
provide continuous education and vocational training
to its members with psychosocial problems;
·
To
provide continuous education and vocational training
to its staff and collaborators - mental health
professionals, so as to contribute to the employment
of people with special needs, disadvantaged and
psychosocially challenged.
b)
Invisible
Tours, the social tour
It is a
social tours program based in the capital of Greece,
Athens, in which homeless people become tour guides
-and indeed, community leaders- in a very different
kind of a city walk. This is a tour that does not
take people to the archaeological treasures of the
city but leads them through the backstreets of
central Athens. As is the case with other social
tours organized by street papers all over the world
(Hamburg, Basel, London, Munich etc), the tour
introduces visitors to some of the important social
and solidarity institutions of the Greek capital
(soup kitchens, day centers, drug rehabilitation
centers, homeless shelters etc). The guides provide
information on the types of services offered by each
institution as well as how they themselves have
experienced or are still experiencing homelessness.
The goal of these social tours is to energize the
person who is leading the tour and to create new
ways for him/her to support himself/herself,
providing new training and educational opportunities
and supporting them to move a step closer to social
(re)integration.
We have to be careful not to
stick with the label of homeless and "sell" this
idea!
c)
Homeless football team-
uses football to energize people to change their own
lives and raise social awareness
d)
-
“Job first” initiatives?
6.
Glossary - key words:
-
Co-construction:
the delivery of public services in an equal and
reciprocal relationship between professionals,
people using services, their families and their
neighbors. (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.
-
Institutionalization:
-
Network:
a group or
system of interconnected people, services or
organzations. They interact with others to exchange
information and develop professional or social
contacts. It may be official (see the example of
INPISA in Lisbon for homelessness) or unofficial.
-
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 in the beginning of this
chapter.
-
Step by step approach:
The method in which does
something carefully, gradually and in particular
order (Longman Dictionary).
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 1990’s. Psychosocial Rehabilitation
Journal, 16, 11-23.
•
Deegan, P.E. (1988). Recovery: The lived experience
of rehabilitation. Psychosocial Rehabilitation
Journal, 11(4), 11-19.
•
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.
