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O U T R E A C H:
attitude - method - practice
1.
INTRODUCTION
Institutions and associations have, for centuries,
offered basic help – food, shelter, clothing - to people
living on the streets.
But, in the past, such poverty was seen as an
unavoidable condition of life.
Homeless people were seen as unfortunate examples of
extreme but individual poverty, not as the consequence
of specific deficits in health or social provision.
Today, poverty is increasing everywhere in Europe. More
than 22.5% of the European population is at risk of
poverty or social exclusion (Eurostat
2018),
and more than 4 million European citizens are homeless
(FEANTSA
estimation).
Homelessness has become a political priority, even if
only at the level of rhetoric rather than concrete
actions which require the allocation of specific
resources.
Studies in England, Germany and other EU countries have
demonstrated the excessive prevalence of mental
disorders in homeless people.
Apart from the increasing numbers of people affected by
homelessness and mental illness, there are major
problems for such people in accessing appropriate
services. These can be administrative, a result of
mental illness, or arise from personal experiences of
helping services.
Outreach
initiatives in the past were focused on providing for
basic needs, distributing food and blankets to those
living on the streets. Such volunteers had often had no
specific training in the social or health sector, just a
desire to make themselves useful. However, faced with
the particular challenges faced in doing this sort of
work, during the 1980s many of these organisations
reorganised and offered
a range of increasingly professional and skilled
services – sometimes within NGOs but also existing
health, housing and social services.
Originally it was thought that such services could
significantly impact the number of homeless
people on
the street (1) – and for a while, they did. The
principles of outreach have also been found to be
effective with people who have a home to live in but are
« cut off » from other people, for whatever reason.
However, the era of austerity has fostered the recent
increases in homelessness. So, instead of becoming less
necessary, such services have become more essential than
ever.
Hence the importance of this Erasmus project – to
enhance the skills and experiences of people engaged in
providing service to homeless people.
The following proposals are grounded in practical
experience and intended to clarify the skills and
practices needed to meet homeless people, to hear their
voices, and to understand their situation – so that they
can, as much as possible, gain access to their
fundamental rights - to social and health services, to
a home, and to the support to live there.
OUTREACH - description
-
The idea of Outreach is used to describe programmes
and schemes that locate people who need help
or
advice, rather than waiting for those people to come and ask for help.
(Dictionary Collins)
-
Bringing medical or other services to people at home
or to where they spend time (Dict. Cambridge)
-
It is to provide
services
to any group of people
who might not otherwise have access to those
services.
Such services go to meet those in need of their
services where they are, rather than expecting them
to
come to an office or clinic. (Wikipedia
encyclopaedia)
Outreach is more than a specific pillar
in our scheme
– it is the common element that links the other
service pillars and creates a pathway from exclusion on
the streets to social inclusion and connection with
health and social services.
Different definitions of outreach share some ideas:
-
To find, to meet, and engage with people
who need help
-
To identify and provide assistance
for basic needs.
-
To build bridges
with social & health services to facilitate both
access to services and continuing contact with
them.
It’s not easy to find an exact literal translation of
the word ‘outreach’ in other languages. For
example, in French, we find ‘aller vers’… (to
tend towards) and ‘aller à la rencontre’ (to go
meeting).
In the past, outreach initiatives were focused on
providing for basic needs, such as the distribution of
food and blankets. The new element in outreach is the
involvement of those with professional skills and
specialist knowledge – doctors, nurse, psychologists,
social workers – going out beyond their usual
professional setting to meet people where they are.
2.
MAIN
IDEAS
a.
Outreach is an attitude:
More
than a method, and it requires that the practitioner
is:
·
Open
·
Attentive
·
Accessible
to people who do not have access to health and social
services.
b.
A good outreach service is:
- Offered
where the person lives or spends their
time - streets, shelters, squats, the home
- whether or not the location is familiar to,
or comfortable for, the worker.
- Offered
if accessibility is a problem.
- Open
to the client, without any request necessary
from the client.
- Open
to the client, without needing a referral
from any other service.
- Informal,
offered within the context of a personal
relationship.
- The
worker’s position is more alongside the
client, rather than looking at the client — a
non-hierarchical and relationship-based
approach.
- Partnership
based, where the client and service work
together.
- Normal
- outreach work is seen as an integral part of
work rather than as an exception.
- Accessible
- this is seen as more important than
specialisation.
- The
first priority is to establish a
person-to-person helping relationship –
and where time and resources are allocated for
this.
-
Offered
purely for the benefit of the patient, to
facilitate their progress towards social
inclusion - not to satisfy political or
bureaucratic aims.
- Respectful
of the client's dignity, their right to
be different, their right to be heard, of their
space and their time.
- Able
to consider all possibilities, both in
terms of the individual, but also in terms of
other significant actors and service
providers.
- Offered
purely for the benefit of the patient, to
facilitate their progress towards social
inclusion - not to satisfy political or
bureaucratic aims.
- Respectful
of the client's dignity, their right to
be different, their right to be heard, of their
space and their time.
- Able
to consider all possibilities, both in
terms of the individual, but also in terms of
other significant actors and service providers.
c.
Changing practice to an outreach model
We, as service providers, are used to predictable,
organised (perhaps comfortable) environments that, in
some sense, we feel we “own”. However, effective
outreach work takes place in less-planned, more
spontaneous ways in other people’s space.
Greater emphasis is placed on establishing a helpful
relationship with a client than on making a diagnosis or
gathering information.
Outreach work requires that a worker can listen to a
person’s concerns, be attentive to their body language,
be flexible enough to accommodate their feelings and
desires and can respect their voice before acting.
This is characteristic of good mental health practice
anywhere but can make extra demands in less
conventional, less private and (possibly) more hazardous
surroundings such as the street.
Homeless people tend to have needs in multiple domains
at a single point of time, which reinforce each other –
so no one service can act effectively. This applies to
all homeless people who live on the street. So,
collaboration and coordination are absolutely essential
for an outreach model to work effectively.
In order to avoid competition between services, or
clients “falling between” services, this needs to be
mandated at managerial level by service providers.
Social and health Outreach
A. Phases
of outreach work:
- Identification
of a person in need:
You, or a member of your outreach team, may see
someone on the street who seems to need assistance.
But you may equally be told about such a person by a
family member, the police, private persons, or a
shopkeeper in the neighbourhood.
-
Establishing contact:
Introduce yourself – as yourself, saying who you are
and why you are there and asking permission to talk
to the person. You can then sit down with them and
start to work out how much they are willing to talk
– if at all.
It may be that you don’t need to talk much at first
but can just spend time with the person, perhaps
over a coffee or a cigarette, allowing both of you
to become comfortable with the other. If he or she
tells you that they don’t want to talk, or moves
away, just try another day again,
don’t take it personally. It can take some time, and
it can be lonely to work on your own with clients.
Working in pairs has some advantages, but can be
perceived as threatening by a homeless person.
You may want to
establish informal contacts with other people
involved with the client, perhaps even their family.
Clarification:
Getting to know the person
Meeting someone several times, even if only for a
short time, can create the basis for establishing
trust and mutual understanding.
These meetings can be as short as your client wants,
on a bench, in a park, in a café. You can sit
together and chat or smoke a cigarette and drink a
cup of coffee. After some time, you can clarify what
kind of help the person needs.
This can elicit conflicting thoughts and feelings in
the worker. Any homeless person with severe mental
illness will want to live as good a life as
possible, even given their difficult circumstances.
It may seem, sometimes, that this way of life has
been freely chosen, and so one does not want to
interfere. But, at the same time, we know that a
person can be trapped in their homelessness by
symptoms of mental disorder.
- Interventions:
Establishing the right form of help
This can start with an offer of the simplest form of
help that will be accepted. This will often be
practical, such as supplying clothing, food, or a
sleeping bag. Or it could be a physical health
problem, where a worker can offer simple treatment
for skin sores.
Gradually, more substantial issues can be addressed,
such as obtaining welfare payments, a health
insurance card obtained, or housing applied for.
If mental health problems are evident, these can now
be discussed. You can ask for
permission to contact the welfare office,
psychiatric hospital, family, or other help
organisations. A comprehensive plan can be made,
preferably involving both the individual concerned
and the responsible institutions and organisations.
- Support:
maintaining support and contact
As the person comes off the street and moves into
more settled and appropriate accommodation, their
support needs will change.
The conditions of deficit or conflict that first
contributed to social exclusion can easily happen
again – and need to be addressed, if possible. It’s
important to maintain contact to ensure early
intervention if problems should arise.
-
Conclusion:
The art of ending the helping relationship at the
right time. This needs to take account of the fact
that the relationship with the client may be the
only substantial relationship they have had in many
years. So, the ending of contact with the client
needs to be planned well-ahead, giving the client
time to get used to the idea, to grieve (perhaps)
and to adjust to their new situation.
A good ending can help to ensure that what has been
gained from this contact and work will not be lost.
Contact may, for some, need to continue at a lower
level of intensity for many years. For example, in
the form of visits a couple of times a year or the
possibility to contact the team by telephone.
The team should try to slowly phase out support and
interventions while others take over.
B.
Roles of healthcare workers in street work:
-
All those working with people
on the street must be aware of the principles of
outreach work and engagement, and be familiar with
the practical ways of developing a positive, helping
relationship with a client.
- Nurses:
o
Can work directly with a person’s hygiene, care,
motivation, evaluation of any medical problems,
assessment of capacity and vulnerability.
o
Can work as intermediaries between the person
and medical staff (hospital, GP- medical
doctor), particularly to clarify/translate
medical language” for the patient.
o
Can support follow-up treatments and medical
appointments, by both accompanying and by
helping to negotiate bureaucratic processes.
o
Will meet with the person regularly.
- Mental health nurses:
o
Will meet the person regularly
o
In addition to the role of generalist nurses, MH
nurses work in a specialist role with people
experiencing and/or affected by mental disorder,
in whatever setting they may be (street,
shelter, etc.)
o
Bridge-building for health care services through
the mutual trust relationship established with
the person
o
The guidelines are to follow the person’s
demands, desires and needs (with no preconceived
objectives and no time limit), using a proactive
approach and trying to deliver holistic
attention and sense of dignity.
- Medical
doctor
(GP): Will meet the person on the
street, to:
o
Enhance the person’s engagement with the whole
service
o
To break down any barriers of mistrust that
exist due to previous bad experiences with
medical services.
o
Give clinical advice in non-urgent cases.
-
Psychiatrist:
Will meet the person on the street to:
o
Enhance the person’s engagement with the whole
service.
o
Establish a psychiatric diagnosis and
formulation.
o
Provide non-urgent and urgent (compulsory)
interventions,
where possible.
o
Facilitate access to psychiatric resources,
whether in hospital or not.
-
Psychologist:
Will meet the person on the street to:
o
Help to establish a working relationship with
the patient.
o
To establish a psychological diagnosis and
formulation
o
Support and advise the team in the psychological
aspects of their daily work with the patient.
-
Social workers:
Like nurses, will often function as case
coordinators
and will see the person regularly to:
o
Provide social work interventions
o
Facilitate access to healthcare and social
services.
-
Issues to address in re-housing
o
To be proactive in
maintaining contact with clients.
o
To be aware of the
paradoxical dangers of moving into fixed
accommodation – e.g., lower levels of activity
can make thrombosis more likely.
-
Increased risk of overdoses
(alcohol or other drugs) because of:
o
The ability to stock drugs or alcohol.
o
Increased privacy (desirable in most senses) making
overdoses less visible, and so reducing the
possibility
of intervention.
-
Loneliness at home.
- To
create, inform and support a network of health
professionals from the “normal system” that are able
to follow these patients and provide both continuing
and urgent help when needed.
3.
difficulties:
In relation to homeless people:
a. Fire-fighting:
It is common for services to focus on immediate and
urgent need, without tackling underlying issues. The
danger is that the homeless person merely becomes
dependent on the service, without any
change in their underlying situation.
b. Repeated
social or health emergencies without any resolution
of the underlying causes for the individual.
c. Refusal
of service
by people sleeping in the street - even a refusal to
meet or to speak.
d. “Urban
hygiene”:
Interventions, usually by police or cleaning
services, to remove homeless people from certain
areas without improving their predicament.
e. Widespread
fear and distrust
(of homeless people) towards those in any kind of
authority.
In relation to workers
:
f.
Discouragement:
In spite of great efforts, the homeless person
disappears or dies.
g. Institutional
barriers to access:
- clinic opening hours, physical accessibility etc.
h. Competition
and individualism of NGOs and statutory services:
tendering culture discourages collaboration
and encourages organisational self-aggrandisement
i.
Lack of reciprocity
in giving and receiving.
j. Time,
urgency and lack of resources
limit options for more permanent solutions.
k. The
stigmatisation of homeless people on the street:
they can be seen as unhelpable – or as not deserving of
help.
Co-working and Coordination:
Networking and cooperation are essential, both at an
organisational level and in each individual case.
Unfortunately, funding is organised in such a way that
agencies that should be working together are, instead,
competing with each other.
Competition
Collaboration Coordination
§
COMPETITION:
This is the “natural” state of organisations, competing
for funding and customers/clients. It can lead to
improvements in standards, particularly where
professional standards are involved.
However, most of the issues surrounding homelessness are
not susceptible to effective intervention by one
organisation or team, and so competition has the
potential to limit the effectiveness of help given by
excluding other, potentially helpful, sources of
assistance.
§
COLLABORATION
Collaboration is the most rational response to complex
problems, such as those generated by homelessness and
mental illness. Ideally, a collaboration between two or
more entities (people, departments, associations,
institutions) both public and private, will produce
joint working which can achieve results that individual
agencies would be unable to accomplish on their own.
Good collaboration produces better quality, facilitates
project execution, improves team efficiency, creates
better work environments, and makes organisations grow.
By collaborating, people share skills, knowledge,
talent, information and resources to achieve a common
goal.
Given that collaboration will go against normal
organisational instincts, it cannot be assumed to be
happening. It needs to be formally acknowledged and
valued at the highest level in any organisation.
Collaboration needs to be planned, well-structured and
monitored – and focused on results.
§
COORDINATION:
Coordinating the actions of different agencies can
focus attention, avoid needless duplication of effort,
and achieve complementarity. It allows the deployment of
diverse approaches to a common problem.
4.
Good
practices
Specific
outreach practices
Phases of outreach
1.
Preparation
(prior to meeting with someone on the street)
·
The
collection of as much information as possible
before planning any intervention or first
contact.
· The
use of a multidisciplinary team composed of (at
least) a coordinator, health and social workers,
with both salaried & volunteer workers.
· To
plan a “program” of interventions.
· To
assign
the ' case ' to a member of the team who
will take continuing responsibility for the
person concerned. It can be helpful to have two
people allocated in this way, to allow for
sickness, leave etc.
2.
Planning the
first meeting on the street:
· A
meeting should be held to assess risks,
opportunities and the objective of the proposed
meeting with a potential client.
3.
Continuing
recovery:
Regular meetings to monitor and plan the progress of
social and/or health reintegration.
Good practices in outreach
work
-
Time:
One may need to manage time differently from that
used when working within more structured systems. In
more formal systems you may be able to plan to get
a job done within a specific time,
to make and keep appointments, and "use" time
optimally (or, in the eyes of the organisation,
“efficiently”. In outreach work on the street, time
is far less under your control – most often, the
needs of the person will determine how long a
particular task or intervention will take.
-
Patience:
It can take weeks and months to get close to another
person - quick results can be achieved, but usually
take a while. Again, it is important to make any
timetable contingent on your client’s needs and, as
far as possible, let the other person decide the
tempo. A rejection does not need to be a rejection –
if you can wait and allow the person to establish
trust with you over time.
-
Recognise
and respect the client’s needs and desires.
-
Trust/credibility:
must be earned. It is not enough to work on the
streets with good intentions alone. People
living in the streets
have met many well-meaning people in their lives –
in institutions, from social work departments, NGOs,
etc. – and yet, they are still on the street.
-
For
someone who has suffered a great loss the process of
developing trust in others can take a much longer
time than in mainstream health or social work.
You need to demonstrate that you are punctual,
reliable, honest, can act effectively and that you
are a safe person to be with.
-
Timing:
The right time to make contact is when the homeless
person wishes it; the right time to apply for a
pension is when the person wants it. One must have
provisional plans, but these need to be adjusted
according to the ability of the client to tolerate
them – one often needs to wait until the client is
ready.
-
Resilience:
You may have to do uncomfortable things – such as
approaching, several times, a person who rejects
your attempts to establish contact with them.
-
Reject hierarchy:
To lay aside any professional status and to relate
to the client, first and foremost, as a person, to
create as equal a relationship as is possible.
-
Curiosity:
Be curious, genuinely want to understand another
person’s world.
-
Team working:
Roles and functions are clear, but workers are
flexible enough to share assignments and to work
beyond their roles where necessary.
-
Supervision:
Street work is demanding. It can be lonely, and it
can easily leave the worker without the collegial
support that is usually part of working together.
Therefore, no street-level project carrying out work
with homeless mentally ill people living on the
street should be without a well-organised structure
for regular supervision.
5. CASE PROFILE
Context:
This happened during a winter period of municipal
emergency cold alert (November- March). This increases
the number of night beds available for homeless people,
and the number of mobile units for street outreach.
Report:
The urban police reported to the municipality's social
service the presence of a woman of a certain age and
under ' pitiful ' conditions, who rejected any form of
contact and dialogue
Mobile Unit
: The Coop Soc X mobile unit, composed of a volunteer
(driver), social worker and educator, was sent to
evaluate the situation,
First meeting:
The social assistant discreetly tried to establish a
contact, a few words. The woman was in a visible state
of self-neglect, with an infected leg wound. She refused
to talk, did not acknowledge their greeting and gave no
reply to any questions. She did not respond to the offer
of a hot drink, so it was just left next to her. The
team said good night and that they would come again
tomorrow.
Evaluation and brief report
Observations from this first contact suggested that her
predicament needed to be dealt with urgently. She was
without money or appropriate clothing or accommodation,
she was in poor health and not receiving proper
treatment (leg infection), she had not been able to keep
herself clean and was not equipped to be sleeping out on
a cold night. This information was shared with other
night services that operated mainly in the central
station, an area frequented by the homeless.
Team meeting
at the shelter, with the participation of a physician.
The case was classified as urgent and was allocated to
the social worker. The immediate objective was agreed to
be to create enough of a relationship with this lady to
try to convince her to come off the street and accept
treatment for her leg.
Plan:
A frequency for subsequent meetings was proposed, to
enable the social worker to gain the trust of the lady,
and hopefully to help her to accept dressings for her
leg from the hostel infirmary, to avoid gangrene and
possible amputation.
Results & Synthesis:
After the next meeting she accepted
dressings from the hostel infirmary – and then stayed to
sleep in a chair. She then moved to a four-bedded
room – and, ironically, complained that the other guests
weren't clean enough.
So, in spite of her original indifference to the
outreach team at their first meeting with her, the lady
was subsequently able to accept medical treatment for
her leg and accommodation in the hostel after roughly
ten weekly visits.
Conclusion
The primary process of outreach and engagement –
meeting, listening, taking care, providing basic help
(the hot drink) – enabled an alienated woman to
re-engage with helping services.
Questions:
- What
strengths and risk factors do you identify in the
intervention described?
- What could
be the critical moments in the process?
- Starting
from your experience can you imagine a different
intervention? If
yes can you describe it?
6.
GLOSSARY
:
o
Client:
a person who makes use of supportive services,
whether professional or voluntary. Other phrases
used to describe clients are, in different settings,
patients or service users.
o
Home:
a place where a person feels they belong and that
they have a right to be there. A place of affections
and emotions, protection and security, where a
person feels welcomed, recognised and supported,
o
Housing:
a place where people can live in quietly.
o
Homeless and mentally ill people:
people who are homeless who also have a mental
disorder which may have precipitated the
homelessness, but almost certainly serves to
perpetuate homelessness and social exclusion.
o
Institutionalisation:
The process by which an individual becomes dependent
on an institution, to the detriment of their
independence and ability to make decisions for
themselves.
o
Psychiatric deinstitutionalisation:
A cultural and scientific process that recognised
that mental illness and psychological suffering is
not best helped prolonged isolation in psychiatric
closed institutions. The alternative is
community-based treatment, which involves a
substantial investment in personnel and services.
o
De-hospitalization The closure of hospital
beds. Although carried out under the guise of
“constructive” deinstitutionalisation, it is often
carried out for financial reasons rather than
therapeutic ones.
o
Compulsory health treatment:
If a person's mental disorder means that they
become a risk to themselves or others, or just
cannot look after themselves adequately, they may be
detained in hospital against their will (or, at
least, without their expressed permission), using
the laws applicable in that particular country.
o
Undocumented migrant: A foreign-born person
who does not have a legal right to be
or remain in one specific country, but who has – as
a human person – the basic entitlements recognised
by the Declaration of fundamental human rights.
OutREACH :
go outside
to meet people
InREACH
:
 welcome
inside
to access services
References:
-
https://www.eaof.org/
-
https://www.mungos.org/our-services/outreach-teams/
-
https://files.eric.ed.gov/fulltext/ED364617.pdf
-
http://homelesshub.ca/resource/value-outreach
-
http://www.nhchc.org/wp-content/uploads/2012/02/OutreachCurriculum2005.pdf
-
http://homelesshub.ca/resource/homeless-outreach-practises-bc-communities-volume-1
-
https://dmh.mo.gov/docs/mentalillness/litreview.pdf
-
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3441802/
-
http://www.mhwilliams.com/community-outreach-important/
-
https://www.ncbi.nlm.nih.gov/pubmed/20482410
-
https://www.drugsandalcohol.ie/11925/1/outraech_work_among_marginalised.pdf
-
https://missioncommunityservices.com/homeless-outreach
-
http://homelesshub.ca/solutions/emergency-response/outreach
-
https://www.linkedin.com/pulse/20140706223307-50642561-nonprofits-benefits-of-community-outreach/
-
https://www.theguardian.com/commentisfree/2016/feb/15/secret-life-homeless-outreach-worker-abuse
-
https://www.santeestrie.qc.ca/nouvelle/outreach-aller-a-la-rencontre-des-gens-en-contexte-ditinerance/
APPENDIX 1.
(if useful) about two outreach practices :
Project UDENFOR
does outreach
work on the local and regional plan in Copenhagen and
other parts of Denmark in the following fields:
homelessness, drug abuse and mentally ill people
together with other marginalised groups in Denmark. It
is a non-profit organisation registered in the City of
Copenhagen, Denmark in 1999.
Our objects are :
-
an improvement in
the conditions of the socially rejected in our society
by identifying and documenting factors
which
result in social rejection in order to prevent any
further effects. her of (delete)
- to spread knowledge of such
factors and spreading knowledge of preventing people
from being rejected and ways
improving conditions for those already rejected.
-
to develop new
methods for working with severely excluded persons.
-
to try directly,
through practical work to improve the conditions of the
people already socially rejected.
The
activities of Project UDENFOR shall reflect the view
that there have always been many different approaches by
professionals depending on their educational and
professional background.
-------------------------------
Infirmiers de rue
(Street nurses).
-
A medical
non-profit working on outreach to and rehousing of
the most vulnerable homeless people of the streets
of Brussels.
- The
organisation has developed a specific approach based
mainly on hygiene, medical care, and the valuing of
the resources and the talent of people.
-
Teams of two
nurses, go in the street to meet homeless people,
raise awareness of the importance of hygiene for
well-being and inclusion, and help them, step by
step, in the process to recover good health and
self-care.
- At
the same time, they respond to demands around
medical care, treating people on the spot when
needed, but trying as much as possible to bring them
back to « normal » medical structures, and helping
them to get enough confidence to get back by
themselves.
- During
their contacts with the people, a lot of attention
is paid to actively discover their talents,
resources and wishes, in order to promote
self-esteem.
Training is given regularly to professionals, around
the importance to work on health and self-care, how
to speak about it, and how to do it. Basically, the
training aim at having the professionals see health
as a useful tool, in their work, rather than as an
obstacle.
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