Table of Exchanges of the SMES-B Network, 2010
Organised as part of the European Year for Combating Poverty and Social Exc...
Many thanks to Marie, Bernadette, Pascale, Laurent and Serge for their support and careful readings
Contact
S. Alexandre –...
Table d’échanges du Réseau-B en 2010
Organisée dans le cadre de l’Année Européenne de Lutte contre la Pauvreté et l’Exclus...
2 « SMES-B, making contact with the homeless… »
C.H.U. Saint-Pierre
CAW Archipel vzw – Puerto
Centre Ariane
Centre de Guid...
3« SMES-B, making contact with the homeless… »
Table of contents
Prologue
The European Year for Combating Poverty and Soci...
4 « SMES-B, making contact with the homeless… »
Prologue
5« SMES-B, making contact with the homeless… »
Prologue: The European Year
for Combating Poverty
and Social Exclusion
2010...
6 « SMES-B, making contact with the homeless… »
mendations by the independent jury chaired by
Frank Vandenbroucke, Ministe...
7« SMES-B, making contact with the homeless… »
the question of how mental health profession-
als can contribute to the suc...
8 « SMES-B, making contact with the homeless… »
Presentation of SMES-B
9« SMES-B, making contact with the homeless… »
The problem
In our cities and elsewhere, people are facing
situations of ma...
10 « SMES-B, making contact with the homeless… »
The clinical approach built on contact with men-
tally ill persons living...
11« SMES-B, making contact with the homeless… »
The mechanism
The SMES-B (Santé Mentale & Exclusion Sociale -
Belgique) ne...
12 « SMES-B, making contact with the homeless… »
they know that this period will probably be frag-
mented by the history o...
13« SMES-B, making contact with the homeless… »
reflection on innovative clinical practices, the Ta-
bles of Exchanges pro...
14 « SMES-B, making contact with the homeless… »
A network that breaks down barriers and evolves
in the shifting borders b...
15« SMES-B, making contact with the homeless… »
To summarise, for fifteen to twenty years, SMES-B
has focused on a populat...
16 « SMES-B, making contact with the homeless… »
17« SMES-B, making contact with the homeless… »
Beyond the frontiers of mental health and social
exclusion, in the complex...
18 « SMES-B, making contact with the homeless… »
The ethical strand has been examined by pos-
ing the following question: ...
19« SMES-B, making contact with the homeless… »
We have had the opportunity to debate these is-
sues with the following sp...
20 « SMES-B, making contact with the homeless… »
cerned. This is not a question of explicit or tacit
consent; it is more t...
21« SMES-B, making contact with the homeless… »
Third event
of the Table of Exchanges
L’axe « systémique » a The “systemic...
22 « SMES-B, making contact with the homeless… »
 Dr Jacques DEBIÈVE, of the association Diogène
Lille, a medical-social n...
23« SMES-B, making contact with the homeless… »
question and the potential difficulty for an indi-
vidual to shoulder libe...
24 « SMES-B, making contact with the homeless… »
Section 2
Social, mental
and other vulnerabilities:
complex issues
25« SMES-B, making contact with the homeless… »
The tip of the iceberg
Great vulnerability is clearly linked to situations...
26 « SMES-B, making contact with the homeless… »
a public health priority in the Brussels-Capital
Region because it is the...
27« SMES-B, making contact with the homeless… »
Below the surface
So what are the consequences for the so-called
“socially...
28 « SMES-B, making contact with the homeless… »
FEANTSA is supported financially by the European Commission. The views ex...
29« SMES-B, making contact with the homeless… »
Complex responses by definition
The profile of a homeless person has more ...
30 « SMES-B, making contact with the homeless… »
ing corresponds to a long period of life on the
street and support.
Becau...
31« SMES-B, making contact with the homeless… »
Mental disorders:
a health problem affecting
the homeless
The homeless fre...
32 « SMES-B, making contact with the homeless… »
accompanied by extreme personal and domestic
neglect, denial of the probl...
33« SMES-B, making contact with the homeless… »
34 « SMES-B, making contact with the homeless… »
35« SMES-B, making contact with the homeless… »
Section 3
An ethical rethink
of freedom and empowerment
(First event of th...
36 « SMES-B, making contact with the homeless… »
miles from such concerns. Field workers often
remind us that access to so...
37« SMES-B, making contact with the homeless… »
ing society. In one sense, the incurable nature
of the disease could be us...
38 « SMES-B, making contact with the homeless… »
39« SMES-B, making contact with the homeless… »
Section 4
Care, cure, compulsory care
and other aspects of the link
with t...
40 « SMES-B, making contact with the homeless… »
ance, monitoring and support on a person, but
not shutting them away in a...
41« SMES-B, making contact with the homeless… »
rious threat to the lives and integrity of others,
and failing any other a...
42 « SMES-B, making contact with the homeless… »
Section 5
The varying pace
of mental health reform
(Third event of the Ta...
43« SMES-B, making contact with the homeless… »
The vestiges of a Western trend
To better understand the issues associated...
44 « SMES-B, making contact with the homeless… »
The need for outpatient care
in the modern era
We know that the number of...
45« SMES-B, making contact with the homeless… »
The sectors in France
In France, mental health reforms have pursued
a sect...
46 « SMES-B, making contact with the homeless… »
practitioner. A team of nurses and psychiatrists
makes contact with the p...
47« SMES-B, making contact with the homeless… »
Belgium also committed to mental health care
de-institutionalisation with ...
48 « SMES-B, making contact with the homeless… »
The “Psy 107 Health-Vulnerability”
project by SMES-B and its partners
The...
49« SMES-B, making contact with the homeless… »
certed and cross-cutting intervention by many
actors from neighbouring sec...
50 « SMES-B, making contact with the homeless… »
51« SMES-B, making contact with the homeless… »
Section 6
The painful path to insertion
(Fourth event of the Table of Exch...
52 « SMES-B, making contact with the homeless… »
Forcing integration, beating the drum without nec-
essarilytakingintoacco...
53« SMES-B, making contact with the homeless… »
54 « SMES-B, making contact with the homeless… »
55« SMES-B, making contact with the homeless… »
Section 7
SMES-B responses 
For more than 20 years, SMES-B has been imple-...
56 « SMES-B, making contact with the homeless… »
Conclusions
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  1. 1. Table of Exchanges of the SMES-B Network, 2010 Organised as part of the European Year for Combating Poverty and Social Exclusion and the Belgian Presidency of the European Council Making contact with the homeless: the complexity and intricacy of social and mental vulnerability
  2. 2. Many thanks to Marie, Bernadette, Pascale, Laurent and Serge for their support and careful readings Contact S. Alexandre – 322, rue Haute, 1000 Bruxelles – 0474/96 30 40 – coordinationreseau@smes.be Publisher Serge ZOMBEK Editor Sébastien ALEXANDRE Editorial Board SMES-B Photos Arnaud GHYS except pages 4 and 56 Gaëtan CHEKAIBAN photos pages 4 and 56 graphic design Marmelade Printed by Paperland Bruxelles With the support of SPP Intégration Sociale and the Loterie Nationale
  3. 3. Table d’échanges du Réseau-B en 2010 Organisée dans le cadre de l’Année Européenne de Lutte contre la Pauvreté et l’Exclusion Sociale et de la Présidence Belge du Conseil de l’Union Européenne à la rencontre de la personne sans-abri : Complexité et intrication des précarités sociales et mentales
  4. 4. 2 « SMES-B, making contact with the homeless… » C.H.U. Saint-Pierre CAW Archipel vzw – Puerto Centre Ariane Centre de Guidance d’Ixelles Chez Nous / Bij Ons Consigne Article 23 (Télé-Services) Diogènes F.C.S.S. Fami-Home Foyer Saint-Gillois Home Baudouin L.B.F.S.M. Maison d’Accueil des Petits Riens P.F.C.S.M. Pierre d’Angle Projet Lama Rivage – den Zaet S.A.S.L.S. SMES-Europe Source Transit Ulysse Rue Haute, 322, B-1000 Brussels Varkensmarkt, 23, B-1000 Brussels Avenue du Pont de Luttre, 132, B-1190 Brussels Rue de Naples, 35, B-1050 Brussels Rue des Chartreux, 68, B-1000 Brussels Boulevard de l’Abattoir, 28, B-1000 Brussels Place de Ninove, 10, B-1000 Brussels Rue Gheude, 49, B-1070 Brussels Quai du Hainaut, 29, B-1080 Brussels Rue de la Source, 18, B-1060 Brussels Rue de la Violette, 24, B-1000 Brussels Rue du Président, 53, B-1050 Brussels Rue du Prévôt, 30 – 32, B-1050 Brussels Quai du Commerce, 7, B-1000 Brussels Rue Terre-Neuve, 153, B-1000 Brussels Rue Américaine, 151 – 153, B-1050 Brussels Quai du Commerce, 7, B-1000 Brussels Rue de la Borne, 14, B-1080 Brussels Place Leemans, 3 Bte 9, B-1050 Brussels Rue de la Senne, 78, B-1000 Brussels Rue Stéphenson, 36, B-1000 Brussels Rue de l’Ermitage, 52, B-1060 Brussels SMES-B partner institutions
  5. 5. 3« SMES-B, making contact with the homeless… » Table of contents Prologue The European Year for Combating Poverty and Social Exclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Presentation of SMES-B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 The problem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 The mechanism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Prospects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Relevant, innovative but precarious . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Section 1: Making contact with the homeless . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 First event of the Table of Exchanges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Second event of the Table of Exchanges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Third event of the Table of Exchanges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Fourth event of the Table of Exchanges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Section 2: Social, mental and other vulnerabilities: complex issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 The tip of the iceberg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Below the surface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Complex responses by definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Mental disorders: a health problem affecting the homeless. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Section 3: An ethical rethink of freedom and responsibility (First event of the Table of Exchanges). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Section 4: Care, cure, compulsory care and other aspects of links with the homeless (Second event of the Table of Exchanges). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Section 5: The varying pace of mental health reform (Third event of the Table of Exchanges). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 The vestiges of a Western trend …. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 The need for outpatient care in the modern era. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 The sectors in France. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Reform 107 in Belgium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 The “Psy 107 Health-Vulnerability” project by SMES-B and its partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Section 6: The painful path to insertion (Fourth event of the Table of Exchanges). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Section 7: SMES-B responses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Bibliography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
  6. 6. 4 « SMES-B, making contact with the homeless… » Prologue
  7. 7. 5« SMES-B, making contact with the homeless… » Prologue: The European Year for Combating Poverty and Social Exclusion 2010 was an unusual year in the fight against poverty and particularly the fight against home- lessness. The outcome of the Table of Exchanges which you are about to read is the result of work made possible by an exceptional context: the context of the programme of the European Year for Com- bating Poverty and Social Exclusion, at the same time as the Belgian Presidency of the Council of the European Union, as well as the valuable sup- port of the National Lottery. What can we learn from this exceptional pro- gramme framework? For a long time, homelessness has attracted the attention of public authorities as an extreme and most acute form of living in poverty. The calls, recommendations and declarations by the rotating presidencies of the European Union, the European Parliament, the European Com- mission and the Social Protection Committee to put the fight against homelessness on the politi- cal agenda of the Member States and the Euro- pean institutions were tangible signs of this po- litical climate. However, a strong political act was still required. Therefore, the Belgian Presidency took a key step in that determination to make homeless- ness a priority issue of social policy. In fact, it in- corporated the fight against homelessness into its social agenda, alongside issues related to active inclusion and the fight against child pov- erty. The culmination of this priority treatment of the issue of homelessness was the organiza- tion of the European Consensus Conference on Homelessness. This type of conference is based on a specific methodology. It can be described as a public in- quiry, with a key element being a jury charged with evaluating a controversial topic from the social viewpoint. Experts put forward some an- swerstoquestionsfromthejury,whichevaluates the evidence presented in camera, and presents its findings in the form of recommendations. The aim is to stimulate debate on an issue with ex- perts and stakeholder organizations to facilitate political progress on the topic discussed. This major political event, the first of its kind applied to a social issue, ascribed a vital role to participation via a European survey conducted on homeless people and led to policy recom-
  8. 8. 6 « SMES-B, making contact with the homeless… » mendations by the independent jury chaired by Frank Vandenbroucke, Minister of State, former federal and regional minister and university pro- fessor (KUL, UA). As a turning point, the beginnings of a paradigm shift, the new guidelines recommended a course resolutely oriented towards evidence-based policies. The emphasis will in future be placed, among other things, on the consensual use of the ETHOS typology as a framework definition for homelessness, and on the switch from the traditional model known as the continuum of care to one based on rapid, priority rehousing, supported by the relevant floating services. In its own words, the jury called in its recommen- dations, for a shift from the use of shelters and transit hostels as the main solution to homeless- ness to approaches based on housing. This in- volves increasing access to permanent housing and increasing the capacity of both prevention and the provision of floating support services to people in their homes, in relation to their needs and with an overriding concern for the quality of service. Three years later, the European Commission published a flagship document on the Europe 2020 Strategy (Towards Social Investment for Growth and Cohesion - including implementing the European Social Fund 2014-2020) on social investment. This strategy encourages Member States to focus on growth and social cohesion, with a specific annex on tackling homelessness in Europe. This Social Investment Package (SIP) sets out a promising framework for policy reforms in the field of homelessness, advocating urgent and concerted action and calling on Member States to implement housing-oriented approaches. It stresses the necessity of establishment of integrated national, regional and local strate- gies; the definition of specific objectives for the prevention and reduction of homelessness; im- plementation of innovative approaches of the Housing first type, and reinforcement of coop- eration between the health care and social sys- tems, ensuring the effectiveness of social safety nets, with particular emphasis on people in the process of de-institutionalisation and ensuring the quality and training of personnel. In Belgium, the authorities have certainly not been inactive, pushing forward various initia- tives and putting homelessness in the heart of policies, as suggested by the recommendations of the Jury of the European Consensus Confer- ence on Homelessness. The federal plan to com- bat poverty has a strategic objective of fighting against homelessness and bad housing, and is a demonstration of this commitment, strengthen- ing the efforts already made by the regional and community political authorities. Then there is the National Reform Programme, which for two consecutive years has adopted homelessness as one of its priority social issues. After this brief overview of the development of the policy against homelessness, one thing is clear: the prevalence of mental health problems and living in poverty are interactive phenom- ena. They are a social and health challenge that raises questions about how to grasp the needs of users of health and social services and raises
  9. 9. 7« SMES-B, making contact with the homeless… » the question of how mental health profession- als can contribute to the success of the imple- mentation of innovative measures in terms of quality services to (formerly) homeless people. A great challenge, one that must be taken up. Julien Van Geertsom President of the PPS - Social Integration
  10. 10. 8 « SMES-B, making contact with the homeless… » Presentation of SMES-B
  11. 11. 9« SMES-B, making contact with the homeless… » The problem In our cities and elsewhere, people are facing situations of major social exclusion, such as the homeless and those with medical/psychological disorders. Social services and shelters are report- ing deteriorating mental health in their target groups. The emergency psychiatric services, men- tal health centres and even the hospitals are find- ing it hard to come up with the right response to help these people – not only because of the struc- ture of their institutions, but also because of the specific nature of these clinical presentations. We pigeon-hole these women and men, stigma- tised with “mental illness”, in one of the DSM-IV categories listing classical mental disorders. This includes those diagnosed with schizophre- nia, paranoia, depression or even disorders as- sociated with substance abuse (illegal and legal drugs, such as alcohol), which are used virtually systematically in response to the pressure of a hostile environment. Many of them have suffered from psychiatric or physical trauma and often show signs of chronic depressive and anxiety disorders. But we need to look beyond the diagnosis and DSM-IV category, because these sufferers seem to display an alarming habit of resisting, with all their might, being “transferred” to mental health professionals. It seems as if, as they travel around the city with bags containing all their belongings, they find it very difficult to give up what they have for a nebulous alternative: the social safety net for psychological help. In these cases, the transition from one sector to another is always chosen by professionals – rare- ly by them – and it is this very situation that all too often results in psychosocial ping-pong. Certain actors in these two sectors started to conjure with regular consultative professional meetings in order to explore these outer mar- gins, to take in hand those that they habitually classify as “difficult cases”, at the intersection of this all too inhabited No Man’s Land. This space – bringing together players with a shared determination not to abandon to the streets those that refuse to fit neatly into cat- egories of syndromes, except for the infamous blacklist of so-called untreatables. In doing so they accept that they may have to change their conception of “mental illness”, and certainly their procedures for contacting and helping this almost feral population who ask for little or no help. When they do consent to trust someone, they usually make ambiguous requests for help to people clearly in no position to provide it! Worse still, they show very little tolerance for referral to a so-called “specialist”: they shy away from being dissected, to avoid being shattered, in every sense, at the least hint of painful intrusion.
  12. 12. 10 « SMES-B, making contact with the homeless… » The clinical approach built on contact with men- tally ill persons living within the confines of the city is like no other. Better still, sharing experienc- es between the mental health and social support services will create common spaces for new prac- tices, habits of “thinking and acting together”, col- lusion for the benefit of clients, marginally less re- jected on either side of the “psychosocial” frontier. The intense and cathartic meeting of the mental health and social support sectors is so ground- breaking that they will continue to cultivate this “crossroads”, because the grass is always greener at the intersection.
  13. 13. 11« SMES-B, making contact with the homeless… » The mechanism The SMES-B (Santé Mentale & Exclusion Sociale - Belgique) network is an open mechanism, oper- ating in two directions that are not antithetical but synthetic: towards mental health and social assistance. A network, because it provides a platform for exchanges: information, communication and forwarding, with news published on the web site www.smes.be. A network also because it is a fo- rum for discussion: meetings, working groups, debates and arguments. And finally a network because it provides a space for horizontal, asym- metrical and fluctuating partnerships: social housing, mental health services, shelters, street workers, etc. SMES-Bisthereforeamesh,butitfocusesonthree “relays”, start and end points of multiple links that cross and uncross, sometimes holding firm, that we would like to make ever more robust. First, a clinical relay, through the medical-psy- cho-social mobile support unit. The problem is that the users that we are targeting ask their questions, talk about their difficulties, in the place where they are, and not where the city or the professionals would like them to be. And, although certain mechanisms have been devel- oped to enable professionals to go out and make contact, forming links and working arrange- ments, the evidence suggests to SMES-B that access to care for the most alienated requires a certain mobility on the part of those involved, backed by links between them. The Unit is neither an antenna, nor a health sec- tor “ambulance” that will intervene when called by the social sector to help users in distress. On the contrary, the Unit is a mechanism that complements current local care provision, based around and in contact with the user: the social- mental health here and now specific to each user, to each period of his or her life and to each intervention. The Unit constructs, with all the professionals involved (and this time with the user), a credible support and care scenario for all parties. It helps to create and maintain links over time between all the stakeholders involved. It helps to create a custom network, going beyond the crisis period and thereby giving everyone a secure, long-term perspective. This Support Unit is available to the users of ser- vices via professionals. The professionals linked in this way and backing up this mobile unit are experimenting with practices that they had previ- ously only outlined (too remote or too little time); they are no longer alone with their questions and fears and no longer working without a safety net; they can now envisage working with this situa- tion over the long term, together, even though
  14. 14. 12 « SMES-B, making contact with the homeless… » they know that this period will probably be frag- mented by the history of the user concerned. Finally, the Unit promotes continuingtrainingbe- cause it is composed of professionals from SMES partner institutions on detachment for a few hours, so that in return, their experience, week after week, percolates right down into the prac- tices of the institutions. In brief, the Support Unit clinical relay is de- signed to: > create a new intersectoral clinical approach within which the psychiatric dimension of stake- holders becomes mobile: they go to work and ap- ply their model in the territory of others > adapt practices to the target group and not the other way round > avoid fragmenting this marginalised group among as many social players > encourage collaboration without substituting for it > update concerted responses that question, or even overturn, practices > always take an overall and coherent approach > facilitate access, reception and treatment, de- spite the resulting extreme social dislocation and discontinuity. Although this first (clinical) relay is the start and end point of the links in the mesh, the connections aremadelargelywitharelayusedtogaindistance from the clinical aspects: peer supervision. Although peer supervision is traditionally a so- cial support and mental health practice, it is used to a lesser extent on the fringes of the social/ mental health sectors. Each month, a few dozen professionals from both sectors gather in peer supervision groups where they are invited to reflect on their prac- tices relating to these itinerant users. Not only does peer supervision ensure that those who in- tervene are no longer alone and able to handle a case that seems to exceed their competencies, it also offers a sufficiently broad foundation for their practices to allow them to innovate. At the same time as sharing skills, links are be- ing formed that will support an intervention, an approach, a veritable meeting, when the time comes. The same questions are posed on both sides: how to intervene without destroying the few labori- ously constructed links? How to give recalcitrant users partner status in a health project? How to provide care in the place of reception and/or reception in the place of care? Peer supervision groups, a permanent workspace for debate, ad- vocacy and common values relating to shared problems, impose the need for continuous cross- fertilisation of practices. This need applies in particular to the third SMES relay: the reflective, awareness-raising and mobi- lising relay for stakeholders based around major problemtrends.ThesearetheTablesofExchanges. If the support unit is the place for intersectoral intervention and peer supervision is the place for
  15. 15. 13« SMES-B, making contact with the homeless… » reflection on innovative clinical practices, the Ta- bles of Exchanges provide a place for discussion of phenomena that go way beyond the clinical aspects, but have little or no influence on them, depending on the person, the period of life and the timing of the intervention. These Tables of Exchanges are occasions for in- depth debates, looking beyond the clinical dimen- sion,onwhichthestakeholdersconcernedshould be able to forge an opinion. The subject is many faceted and every year we study its relevance, the constraints of outpatient care and the dilemmas posed by unapproved residential facilities. We dealt with unapproved residential facilities in 2009 because, especially in Brussels, places in properly approved residential facilities fall well short of needs, so other unapproved residential emerge to accommodate the same highly vulner- able target group with psychiatric disorders. The sector is not indifferent, but caught in a dilemma: if, on the one hand, these facilities do not pro- vide an intervention within a solid institutional and ethical framework, and some of them are attracting fierce criticism by flouting the rules of hygiene and their contractual relationships with tenants, they are at least satisfying, for bet- ter or worse, a primary need for the target group in question, namely for housing. A working group to draft proposals for legislation on the subject has emerged from this Table of Exchanges. The 2010 Table of Exchanges thought hard about how to make contact with the homeless, which resulted in this publication. In 2012, SMES-B start- ed to reflect on the intersectoral dimension and how to make it happen. These phenomena, these problem trends, pose major questions, and these questions lead to major debates, to which all social support and mental health stakeholders are invited. A Table of Exchanges is therefore based largely on what transpires from the practices of SMES mobile unit interventions and from the SMES peer su- pervision groups, but seen from a broader per- spective. A Table of Exchanges is therefore the ultimate re- lay in our network, the remotest from clinical prac- tice, but nevertheless far from disconnected.
  16. 16. 14 « SMES-B, making contact with the homeless… » A network that breaks down barriers and evolves in the shifting borders between social support and mental health must be constantly looking forward. From a methodological standpoint, we need to sustain and extend innovative prac- tices; from a territorial standpoint, we have to investigate zones other than those inhabited by the homeless; and from a public standpoint, spe- cific interventions are required for certain target groups, at least at the margins. The Outreach methodology has already been put into daily practice by the Unit. It consists of approaching people, while preserving whatever links they already have with the institutions. At the present time we are seeking to sustain this method through projects specifically dedicated to this type of upstream, preventive intervention before a personal crisis occurs or frustrated pro- fessionals becomes inextricably entangled. We want to make this approach structural, backed by long-term funding, allowing the Unit to es- cape from the precarious position it has been in for more than ten years. From a territorial standpoint, SMES-B is open to the reality of social housing, in a promising part- nership with SASLS (Service d’Accompagnement Social des Locataires Sociaux – Social tenant so- cial support service). Because we think of social exclusion not as a state, but as a dynamic pro- cess, we have to accept that vulnerable and pre- carious people living in social housing can find themselves driven into a state of exclusion by the least incident. We need to recognise that mental health problems can make such incidents in life more brutal and damaging. This partnership with SASLS largely takes the form of putting a person from this service on de- tachment within the Unit; once again, the aim is percolation and learning from each other, in this case between SMES-B and social housing. SMES-B is seeking to sustain the work already begun with a target group of new arrivals, who are also potentially affected by mental health problems and social exclusion. Although the Unit already has dealings with this group, it stresses the different results that interventions with this target group can produce, differences that once againrequireinnovationintermsofinterventions. Alas, these attempts at recognition have failed. Whatever the case, and despite its precarious position, the dynamic of SMES-B remains intact: currently it is fully committed to the implemen- tation of a Housing First project in Brussels, pro- viding alternative, direct methods for taking peo- ple off the street and into private housing. Prospects
  17. 17. 15« SMES-B, making contact with the homeless… » To summarise, for fifteen to twenty years, SMES-B has focused on a population that caricatures the difficulties of institutions in producing global and coherent responses to complex problems with multiple factors and determinants. SMES-B is experimenting with new patterns of social/health actions: outreach, low barriers to access, damage reduction, peer supervision in a multidisciplinary network and Housing First. We believe that SMES-B is helping to break down barriers between these approaches and promot- ing health, which is also a right for everyone. However, this does not seem to come easily. The SMES-B Unit has already been in operation for ten years, exploring and assessing, during which time it has given support to social and mental health operators facing an impasse in dealing with these intricate problems. Peer su- pervision has led to the formation of dozens of French- and Dutch-speaking groups and a study morning, and Tables of Exchanges have taken place frequently over recent years. Above all, SMES-B good practice has been recog- nised by the Prix Fédéral 2010 de Lutte contre la Pauvreté(Federalprize2010forcombatingpoverty). Nevertheless, the fact remains that SMES-B is still in a precarious financial situation and has never benefited from structural financing for its basic missions and associated projects, with the Sup- port Unit initiative being extended since it was formed some ten years ago. This is not for want of trying, but in the compart- mentalised context of social and health services, it is difficult to hold resolutely to a position on the border between two sectors with both wary of acceptance. It is also difficult to promote posi- tive discrimination projects to help the most vul- nerable groups. In early 2013, SMES-B realised how vulnerable its position had become, with its very survival un- der threat. Ironically, an organisation dedicated specifically to the most vulnerable populations is going through a period of major institutional vulnerability. We hope that this report will help to raise aware- ness concerning the innovative nature and rele- vance of SMES-B. This is just one of many aspects of SMES experience, providing a mechanism that merits more solid foundations.  Relevant, innovative but precarious
  18. 18. 16 « SMES-B, making contact with the homeless… »
  19. 19. 17« SMES-B, making contact with the homeless… » Beyond the frontiers of mental health and social exclusion, in the complex contemporary world, social problems accumulate and intertwine. So- cial action now very often requires both a men- tal and a somatic response – and the opposite is also true. SMES-B (Santé Mentale & Exclusion So- ciale - Belgique) has therefore put on the agenda of the Belgian Presidency of the European Union for the European Year for Combating Poverty, the ethical, practical, methodological and societal aspects of contacting the homeless, which may stray across the frontiers between mental health and social exclusion. This agenda includes the organisation of four dif- ferent events, each of them broaching one of the above-mentioned issues.  Section 1 Making contact with the homeless
  20. 20. 18 « SMES-B, making contact with the homeless… » The ethical strand has been examined by pos- ing the following question: “Promoting user freedom and empowerment, but to what extent when they find it difficult to handle?”. SMES-B has noticed that an increasing number of social interventions of all types are based on the definition of projects and achieving objectives. The most obvious example is no doubt activa- tion of the unemployed for job seeking. This type of social intervention can be beneficial in certain cases; empowering people can result in greater self-esteem, when the pre-defined objectives are achieved. On the other hand, when the objec- tives are not achieved, and cannot be achieved because of the social exclusion experienced by the person concerned, this type of intervention can have the opposite effect and reinforce the exclusion mechanism. Field workers in contact with socially excluded populations are finding, day after day, that for broken people empowerment is just one more burden to bear. A worker operating in the streets of Brussels recently described accompanying a street per- son to the social services office (Centre Public d’Action Sociale). Although the ultimate objec- tive was to put administrative aspects in order, this all seemed too remote, vague and complex to be taken on board by the homeless person, even with the help of the social worker. Physi- cally accompanying this person to the Centre Public d’Action Sociale therefore became the entire purpose of the intervention: although this represented only the first step in a long and com- plex process, it was also a remarkable victory for a person so socially excluded that they did not know even how to approach an administrative procedure with a public service, and this igno- rance was so great that it generated anxiety and apprehension. The objective was no longer to set the administrative house in order, postponed un- til a later date (but as soon as possible), but the fact of going to the social services office. The advantage of the project is therefore that it can be modulated and finessed in many ways; the drawback is that it makes a high degree of personalisation necessary for the social inter- vention, and that some people will never be able to meet these requirements. Although user empowerment may provide leverage for certain persons, it should certainly not be perceived as a prerequisite for any social intervention. On the contrary, its effects and consequences must be assessed on a case by case basis before any at- tempt at empowerment. First event of the Table of Exchanges
  21. 21. 19« SMES-B, making contact with the homeless… » We have had the opportunity to debate these is- sues with the following speakers: > Dr Alain MERCUEL, of SMES-Paris; > Mr Emmanuel NICOLAS, of the shelter Nuit Dourlet in Charleroi; Mr Christian MARCHAL, of the L’Autre Lieu initia- tive in Brussels.   The practical strand was examined by posing the following question: “Passing from “cure” to “care”, but how far can this go where compulsory care proves necessary?”. For those who are socially excluded and also have serious psychiatric problems, “cure” often gives way to “care”. A cure or reinsertion into work are no longer sought and are replaced by help and care. Utopian goals make way for real- istic and pragmatic objectives. Although people who achieve reinsertion deserve our admiration, especially as their path turns out to be atypical, this is not the rule: the rule is more a reduction in the effects of exclusion – in other words, a reduc- tion in the risks associated with psychosis and life on the streets. This requires support for such people in the various aspects of their existence, to facilitate their life. The crux of the problem is knowing how to act where compulsory care proves necessary, be- cause support and risk reduction are only possi- ble up to a limit: the consent of the person con- Second event of the Table of Exchanges
  22. 22. 20 « SMES-B, making contact with the homeless… » cerned. This is not a question of explicit or tacit consent; it is more the fact that support of this type is only relevant if the person feels the ben- efit. However, it is rare to find homeless people with serious psychiatric problems who under- stand the benefits that they can gain from such interventions. In 2010, a particular situation mobilised many partners in Brussels at the North Station (Gare du Nord). A person was living there in extreme dep- rivation. Homeless, with no income, no voice, no hygiene. The partners wondered how such a per- son could find enough to eat. In short, the most flagrant form of exclusion, for which a “cure” was certainly unrealistic, even if the person in question had had a brilliant career before tak- ing to the street. “Care” was certainly required: the first thing to do was to help the person to obtain food, get clean and sleep, and eventually to provide care or stabilise some of the most bla- tant health problems, which in this case required hospitalisation, so that the person could benefit from more extensive care in line with his needs. This is a difficult question for social workers: the transition from care to compulsory care is cer- tainly not an easy decision. While care is based largely on the benefit felt by the person, com- pulsory care imposes a quite different rationale, often more difficult to apply by the same profes- sionals carrying out risk reduction. The question is therefore: how to implement compulsory care? How far should it go? At what point should it be applied? How much freedom should we give to people to live as they choose? Where do we draw the line between the freedom of an individual and not assisting a person in danger? To deal with these difficult issues, we invited the following speakers: Dr Jenny KRABBE, member of the SMES-B Sup- port Unit; Dr Caroline DEPUYDT, of the Clinique Fond-Roy; Mr Laurent DEMOULIN, director of the Associa- tion de travailleurs de rue Diogènes; Mr Pablo NICAISE, sociologist at the public health faculty of the Catholic University of Lou- vain-la-Neuve.
  23. 23. 21« SMES-B, making contact with the homeless… » Third event of the Table of Exchanges L’axe « systémique » a The “systemic” strand was examined by posing the following question: “De- institutionalising care, but to what extent when the person requires a structuring framework?”. This third question studied contact with the homeless from a more systemic standpoint, as- sociated with de-institutionalisation. The year 2010 was marked by major developments in what is known as the “Reform of article 107”, a mental health reform allowing the expansion of outpa- tient care and freezing funding for hospital beds. Clearly the de-institutionalisation movement is nothing new, dating back to the nineteen sev- enties in some countries. In Belgium we have lagged behind pioneering countries such as Italy and France. It therefore comes as no surprise that we convened a panel of international speak- ers for this theme. De-institutionalisation necessarily raises funda- mental questions. Its legitimacy is certainly not disputed by SMES-B, which supports care provid- ed by and with the outpatient sector, for a popu- lation suffering from mental disorders in addi- tion to severe social problems. The fact remains that, inexorably, people affected by both social exclusion and psychiatric disorders must at cer- tain moments of their life be institutionalised, simply because outpatient care is inadequate. Any study of de-institutionalisation must there- fore take into account its limitations: just how far can we go with de-institutionalisation? This question takes on greater significance where certain regions already have institutional short- comings: this is the case in Brussels, which lacks psychiatric beds, psychiatric care homes, and sheltered housing initiatives. In practice, profes- sionals in contact with the socially and mentally vulnerable are often faced with this lack of facili- ties, even though only institutionalisation can meet these needs. Although de-institutionalisa- tion of help and care should be promoted and ex- tended, it absolutely must take into account the needs of the most socially and mentally vulner- able. Above all, and we shall return to this issue, it must not repeat the mistakes that the outpatient sector has made since its creation, but base itself on factors that have already been perceived as relevant and as superfluous, to best meet the ob- jectives of mental health system reorganisation. To broach this subject, we called on the expertise of psychiatrists involved in the historic or cur- rent de-institutionalisation projects of the Table of Exchanges: Dr Alessandro RICCI, of the Universita di Padova, who has been involved in the de-institutionali- sation movement which began in Italy;
  24. 24. 22 « SMES-B, making contact with the homeless… » Dr Jacques DEBIÈVE, of the association Diogène Lille, a medical-social network aimed at per- sons suffering from both social exclusion and psychiatric disorders, and of the public mental health service of the city of Lille; Dr Serge ZOMBEK, co-president of SMES-B and promoter of the “Psy 107 Health-Vulnerability” project. Fourth event of the Table of Exchanges Finally, the societal strand enabled us to pose the following question: “Integration, but to what extent where the obligation of integration be- comes the determinant of exclusion?”. To terminate our process of reflection, we want- ed to examine a societal question, while study- ing integration, a concept that often meets with consensus among “integrated” persons, but does not necessarily make sense to others. Integration therefore often appears as an objec- tive in itself, taking the form of access to hous- ing, to income and to the satisfaction of “basic” needs. Some people lead such alternative lives that it is integration, and not exclusion, that po- tentially becomes the disorder and the problem. Beyond providing help and care, beyond institu- tionalisation, integration itself needs to be ques- tioned for each homeless person. We know that by wanting to help someone, taking the place of the person, we do not provide help – on the con- trary, we may even put them in difficulty. Our discussion therefore comes full circle, be- cause in some respects we return to the ethical
  25. 25. 23« SMES-B, making contact with the homeless… » question and the potential difficulty for an indi- vidual to shoulder liberty and responsibility. In a society such as ours, integration very rapidly becomes empowerment: those who cannot sup- port this burden find it difficult to integrate. We had an opportunity to close the loop with French and Danish speakers: Dr Sylvie ZUCCA, private psychiatrist, formerly at the SMES of the Hôpital Sainte-Anne and SAMU Social in Paris, author of the book “Je Vous Salis Ma Rue”; Mr Pedro MECA, founder of the Parisian associa- tion La Moquette; Mr Preben, founder of Udenfor in Denmark. The purpose of this report is not simply to sum- marise the exchanges that took place during these four public debates, but also to retrace the links of a rich and relevant practice such as that of SMES-B. At a time when a sword of Damocles is hanging over many social and healthcare projects, we be- lieve that it is crucial to reflect on how to provide access to help and care on a sustainable basis, by giving priority to effective mechanisms that al- ready exist, rather than creating new ones. Creating new mechanisms generally responds to a specific need, but also all too frequently they are created to prevent other shortcom- ings emerging alongside the new mechanisms. SMES-B is therefore seeking to base its actions on existing mechanisms, within which it helps professionals to enhance interaction between institutions and between sectors. The relevance of this philosophy was reaffirmed during this Table of Exchanges.
  26. 26. 24 « SMES-B, making contact with the homeless… » Section 2 Social, mental and other vulnerabilities: complex issues
  27. 27. 25« SMES-B, making contact with the homeless… » The tip of the iceberg Great vulnerability is clearly linked to situations of extreme social distress. Even though the qual- ity of life in our western cities is quite high, we are seeing not only flagrant and increasingly outrageous inequalities, but also real situations of severe poverty. The poverty threshold is a relative indicator as it is equivalent to 60% of the median income of the country, although certain situations liter- ally transcend these statistical values. We refer to those “without”: without a home, without housing, without papers, without income. Newer more contemporary terms have been added to the older ones, born of the end of the Glorious Thirties, migration issues and the current crisis. The 2012 report of the Observatoire Bruxellois de la Santé et du Social notes that in 2010 (based on 2009 incomes), the poverty threshold stood at €973 a month for a single person (€1557 for a sin- gle parent with two children, €2044 for a couple with two children). Note that in Belgium, no minimum social bene- fit, with the exception of pensions, is equivalent to the poverty threshold. Even with no health problems and a properly managed budget, low- income families cannot achieve the physical con- ditions for good health and independence. The number of persons below the poverty line is highest in the Brussels-Capital Region, compared with the Region of Wallonia, the Flemish Region and, of course, Belgium as a whole. In figures, be- tween 21.3 and 35.3% of the population of Brus- sels is living below this threshold: between one person in five and one person in three! More than 5% of Brussels inhabitants between the age of 18 and 64 depend on income from so- cial security (CPAS), three times the Belgian aver- age. Subjectively speaking, no less than 37.7% of the population of Brussels lives in a household where the reference person finds it difficult “to make ends meet”. The situation is even more dramatic because the cost of housing is higher than elsewhere, result- ing in a wider gap between the minimum allow- ances and the standard budget, i.e. the budget needed to buy a basket of goods and services required to live with dignity. What is the impact of access to help and care? There is a clear link with income inequality: we know for sure that social inequalities correlate with health inequalities. In the specific case of mental health problems and psychiatric disor- ders, their prevalence increases as we descend the social ladder, with the highest rates for over- 15s with only a primary education certificate: 14.2% have anxiety problems, 24.5% suffer from depression and 35.1% have sleep disorders. The scale of mental disorders makes mental health
  28. 28. 26 « SMES-B, making contact with the homeless… » a public health priority in the Brussels-Capital Region because it is the leading cause of invalid- ity in Brussels1 . Although there are major health consequences, this is also true for access to healthcare, at a time when more than a quarter of households in Brussels and almost 40% of low- income households state that they have had to postpone or forgo care for financial reasons2 . 1 ObservatoiredelaSantéetduSocialBruxelles,BaromètreSo- cial, 2010, p 67 2 ObservatoiredelaSantéetduSocialBruxelles,BaromètreSo- cial, 2010, p 85
  29. 29. 27« SMES-B, making contact with the homeless… » Below the surface So what are the consequences for the so-called “socially excluded” population? Indeed, what is social exclusion? During the Glori- ous Thirties it could be defined by unemployment: inaperiodofalmostfullemployment,socialexclu- sion referred mainly to those without work. Since the 1970s crisis, mass unemployment and a period ofunemploymentbecameanormalpartofawork- ing life. The unemployed were not necessarily so- cially excluded, even where living conditions were proving difficult and precarious. The long-term un- employed, on the other hand, represent the con- temporary form of the socially excluded, as well as those without papers and the homeless. The difficulty lies is finding a definition of social exclusion that is truly workable. This is proving to be complex, because such a definition will de- pend largely on the societal context and what is deemed to be normal and deviant. The FEANTSA (European Federation of National Associations working with the Homeless) should be congratulated on constructing the ETHOS typology (following page). This typology takes into account not only the homeless living on the streets, but also those living in residential facili- ties, in vulnerable or inadequate housing. Severe exclusion is not only apparent when it produces its effects, but also when it threatens to produce them. Although housing is a major factor in the defini- tion of serious exclusion, it has many facets. Al- though the Observatoire de la Santé et du Social de Brussels-Capitale dedicated one of its reports to poverty in “Vivre Sans Chez Soi à Bruxelles” (Liv- ing without a home in Brussels), it is because the housingproblemgoesbeyondthesimplefactofa roof over one’s head. In addition to shelter, hous- ing should allow people to take charge of their living space to fashion their identity and their mental and symbolic welfare. A home provides a platform for personal, family and collective development; homelessness is a driver of vulner- ability and physical and mental social exclusion. Street people often suffer from severe mental and existential destructuring. During the SMES-B Table of Exchanges, Emmanuel Nicolas, from the “Dourlet” night shelter in Charleroi, spoke about the profound breakdown experienced by such people.
  30. 30. 28 « SMES-B, making contact with the homeless… » FEANTSA is supported financially by the European Commission. The views expressed herein are those of the author(s) and the Commission is not responsible for any use that may be made of the information contained herein. ETHOS - European Typology of Homelessness and housing exclusion Homelessness is one of the main societal problems dealt with under the EU Social Protection and Inclusion Strategy. The prevention of homelessness or the re-housing of homeless people requires an understanding of the path- ways and processes that lead there and hence a broad perception of the meaning of homelessness. FEANTSA (European Federation of organisations working with the people who are homeless) has developed a typology of homelessness and housing exclu- sion called ETHOS. The ETHOS typology begins with the conceptual understanding that there are three domains which constitute a “home”, the absence of which can be taken to delineate homelessness. Having a home can be understood as: having an adequate dwelling (or space) over which a person and his/her family can exer- cise exclusive possession (physical domain); being able to maintain privacy and enjoy relations (socialdomain) and having a legal title to occupation (legal domain). This leads to the 4 main concepts of Rooflessness, Houselessness, Insecure Housing and Inadequate Housing all of which can be taken to indi- cate the absence of a home. ETHOS therefore classifies people who are home- less according to their living or “home” situation. These conceptual categories are divided into 13 operational categories that can be used for different policy purposes such as mapping of the problem of homelessness, developing, monitoring and evaluating policies. Operational Category Living Situation Generic Definition ConceptualCategory ROOFLESS 1 People Living Rough 1.1 Public space or external space Living in the streets or public spaces, without a shelter that can be defined as living quarters 2 People in emergency accommodation 2.1 Night shelter People with no usual place of residence who make use of overnight shelter, low threshold shelter HOUSELESS 3 People in accommodation for the homeless 3.1 Homeless hostel 3.2 Temporary Accommodation Where the period of stay is intended to be short term 3.3 Transitional supported accommodation 4 People in Women’s Shelter 4.1 Women’s shelter accommodation Women accommodated due to experience of domestic violence and where the period of stay is intended to be short term 5 People in accommodation for immigrants 5.1 Temporary accommodation / reception centres Immigrants in reception or short term accommodation due to their immigrant status 5.2 Migrant workers accommodation 6 People due to be released from institutions 6.1 Penal institutions No housing available prior to release 6.2 Medical institutions (*) Stay longer than needed due to lack of housing 6.3 Children’s institutions / homes No housing identified (e.g by 18th birthday) 7 People receiving longer-term support (due to homelessness) 7.1 Residential care for older homeless people Long stay accommodation with care for formerly homeless people (normally more than one year) 7.2 Supported accommodation for formerly homeless people INSECURE 8 People living in insecure accom- modation 8.1 Temporarily with family/friends Living in conventional housing but not the usual or place of residence due to lack of housing 8.2 No legal (sub)tenancy Occupation of dwelling with no legal tenancy illegal occupation of a dwelling 8.3 Illegal occupation of land Occupation of land with no legal rights 9 People living under threat of eviction 9.1 Legal orders enforced (rented) Where orders for eviction are operative 9.2 Re-possession orders (owned) Where mortagee has legal order to re-possess 10 People living under threat of violence 10.1 Police recorded incidents Where police action is taken to ensure place of safety for victims of domestic violence INADEQUATE 11 People living in temporary / non-conventional structures 11.1 Mobile homes Not intended as place of usual residence 11.2 Non-conventional building Makeshift shelter, shack or shanty 11.3 Temporary structure Semi-permanent structure hut or cabin 12 People living in unfit housing 12.1 Occupied dwellings unfit for habitation Defined as unfit for habitation by national legislation or building regulations 13 People living in extreme over- crowding 13.1 Highest national norm of overcrowding Defined as exceeding national density standard for floor-space or useable rooms Note: Short stay is defined as normally less than one year; Long stay is defined as more than one year. This definition is compatible with Census definitions as recommended by the UNECE/EUROSTAT report (2006) (*) Includes drug rehabilitation institutions, psychiatric hospitals etc.
  31. 31. 29« SMES-B, making contact with the homeless… » Complex responses by definition The profile of a homeless person has more than one facet: serious housing vulnerability masks multiple, intricate problems, often resulting in spiralling vulnerability. Responses are therefore not easy. It is simply not enough to make beds available to street people, or to place them in emergency housing, where they do not feel at home. It is not enough to take action for people already on the street. All too often, the response is emotional, mediatised and takes the form a few extra beds. All too often it is restricted to emergencies and cures, as if the loss of a house was neither predictable nor avoidable. All too of- ten, it is over-specialised or not really suitable. All too often, it is left to the initiative of the social services, which come up against the partitions separating the levels of power from the prob- lems in hand3 . The homeless have been caught up in a vicious circle. The only point in common that affects all homeless people is a growing number of prob- lems that accumulate slowly. Each difficulty en- countered, if it is not overcome, brings in its wake new problems that are increasingly difficult to handle. Individuals, blunted by these obstacles, use up the resources available. Fragility leads to 3 L’Observatoire, 2010, p 15, cited in Observatoire de la Santé et du Social Bruxelles, Vivre sans chez soi à Bruxelles, Rapport sur l’état de la pauvreté 2010, p 9 fracture, fracture leads to a break, as Emmanuel Nicolas so movingly explained during his address. This is why it is so difficult to get off the street4 . A long time spent on the street leads to ever long- er street life. Homelessness is a fine example of a chronic problem; it becomes more difficult to overcome as years on the street go by. Dr Sylvie Quesemand Zucca spoke of the “asphaltisation” syndrome, the ultimate phase of alienation: the person becomes one with the street and the con- cept of time and space disappears. Dr Mercuel, spoke of “waste” rather than subjects: yester- day’s “poor” have given way to today’s “undesira- bles” living on the street, where providing care is crucial but at the same time very singular. Unearthing street people, detaching them and deterring them require a sustained effort. Per- severance and patience are the order of the day. Acceptance also, of stagnation or relapse. It is a long and difficult process because making con- tact with street people generally takes time, in repeated, tiny steps. If there are strategies, such as Housing First, offering street people direct ac- cess to housing, the relationship inevitably takes time, because the immediacy of access to hous- 4 B. Horenbeek, http://webzinemaker.com/diogenes/ cited in Observatoire de la Santé et du Social Bruxelles, Vivre sans chez soi à Bruxelles, Rapport sur l’état de la pauvreté 2010, p 9
  32. 32. 30 « SMES-B, making contact with the homeless… » ing corresponds to a long period of life on the street and support. Because of the complexity and intricacy of the problems, homelessness is more than a lack of housing, and providing someone with a home is still a long way from completely resolving the problem. Not having a house means also not hav- ing an address and difficulties accessing social security and social insurance. Although there are solutions, such as a reference addresses, these are often just a lesser evil, banking arrange- ments which the homeless and their helpers have to deal with every day. Not having a home also means difficulty constructing a social world; with no home and no intimacy, relationships for street people can be as precarious as their exist- ence. Not having a home also means greater im- muno-deficiency resulting in all sorts of health problems, due to a lack of cleanliness, comfort, rest, balanced diet, etc. These deficiencies in- evitably lead to physical problems and the life expectancy of street people is tens of years less than that of the general population.
  33. 33. 31« SMES-B, making contact with the homeless… » Mental disorders: a health problem affecting the homeless The homeless frequently suffer from a combina- tion of social difficulties and mental disorders, ac- companied by the consumption of psychotropic substances or somatic complications. Healthcare workers are reporting an increasing prevalence of psychiatric disorders within the homeless population: these psychiatric problems may or may not be a reaction to severe poverty and pro- longed exclusion5 . This is a fact of life for the help and care instruments aimed at this target group. This is also the rule in other more general mecha- nisms, and just as inadequate to deal with situa- tions of social and mental vulnerability. Patrick Declerck, author of the book “Les nau- fragés - Avec les clochards de Paris” (The ship- wrecked – With the tramps of Paris), without doubt provides one of the best anthropological descriptions of the homeless population. He encounters such suffering among these people that it is almost intra-uterine, completely innate. In response to intolerable anguish, people break down and self-destruct: in the street, in alcohol, in anti-anxiety and other drugs. 5 Observatoire de la Santé et du Social Bruxelles, Vivre sans chez soi à Bruxelles, Rapport sur l’état de la pauvreté 2010, p 31 This type of breakdown was widely reported among the homeless at our first Table of Ex- changes. Breakdowns make it more difficult to provide help and care because they are frequent- ly accompanied by physical or psychiatric prob- lems, not just because the homeless are striving to satisfy their primary needs, but also because of the conditions specific to psychotic disorders. Mental healthcare workers are therefore avoid- ed and rejected. This obviously has social consequences, in par- ticular in terms of housing: access to and main- tenance of both private housing and social hous- ing are not always easy if the psychiatric disorder results in problems with cleanliness or disputes with the neighbours. The Diogenes syndrome, which has become an important aspect of debates and interventions in the sector in recent years, is an excellent ex- ample. It takes the form of hoarding miscella- neous objects in the home, sometimes in such quantities that living there becomes difficult. It is by no means rare to find a social worker deter- mined to help such a person to sort out the ac- cumulated hoard. This syndrome is sometimes
  34. 34. 32 « SMES-B, making contact with the homeless… » accompanied by extreme personal and domestic neglect, denial of the problem, a complete lack of shame, social isolation, rejection of help and a pre-morbid personality - suspicious, crafty, dis- tant and tending to distort reality. More often than not, hallucinations result in disputes with the neighbours: hearing voices or noises can lead rapidly to the persons concerned accusing the neighbours of being too noisy or plotting against them. Radical means are often used to resolve such situations, such as eviction from their home. This can prove dramatic where the person con- cerned is on the edge of poverty, which is often the case in social housing. Although social hous- ing real estate companies, as well as some social housing agencies, have human resources for lo- cal follow-up of their tenants, they can find them- selves quickly out of their depth when dealing withpsychiatricdisorders.Withlittleunderstand- ing of a neighbourhood dispute too complex and too old for mediation, eviction is the ultimate so- lution, even if delayed as long as possible. If the person is in a precarious situation and constantly on the edge, eviction can trigger a descent into much more difficult living conditions. Although there are solutions, such as interven- tion upstream of crises and evictions, this il- lustrates the gravity of such problems and how quickly they can become intricately entangled in the administrative situation, access to help and care, social housing and more. This augurs real difficulties for social workers, powerless to stop the degradation of people living on the streets. How to handle such situa- tions cannot be taught in schools, however up- to-date and professional the teachers. This type of information is only transmissible between people that have lived with and confronted such problems. Once again it is a task that cannot be taught in the classroom – only on the job, in di- rect contact with those excluded from society. Nevertheless, we need to be ambitious in seek- ing a response to these problems, in this case by revisiting the link between professionals and the homeless. In his recent book “Quel soin psy- chiatrique pour les sans-abri? Vivre ou survivre” (What psychiatric care for the homeless? To live or to survive), Dr Mercuel attempts to give a voice to those without one and to rethink the link be- tween mental illness and social exclusion. The difficulty lies in the links: the existing (or non- existent) links on the street, as well as those that previously existed in the family at an early age. Although the street is a precarious and stressful environment, it is also a place of contacts, so the idea is to contemplate rehousing without cut- ting people off from their life in the street.
  35. 35. 33« SMES-B, making contact with the homeless… »
  36. 36. 34 « SMES-B, making contact with the homeless… »
  37. 37. 35« SMES-B, making contact with the homeless… » Section 3 An ethical rethink of freedom and empowerment (First event of the Table of Exchanges) The first event of our Table of Exchanges asked the following question: “Promoting user free- dom and empowerment, but to what extent when they find it difficult to handle?” Freedom and empowerment are central tenets of our liberal society. But we need to take the time to recontextualise social and healthcare interventions in the overall societal context. It should be bitterly regretted that those who in- tervene do not position their actions sufficiently in the broader context of a changing society. When the first maisons médicales (medical cen- tres) were created, they were designed to make healthcare accessible to the greatest number, in line with the aspirations of the 1968 upheavals in France. Their medical staff acted within society, not just noting the growing inequalities result- ing from the crisis, but also taking action. Since then the crisis has never stopped. Although it has proven more severe in the past few years, it has existed in reality for almost forty years. Mass un- employment is the most striking example. Faced with this dramatic situation, social work- ers have been trying to manage the risks associ- ated with social exclusion: their goal is no longer reinsertion and reintegration, but consists large- ly of putting the administrative situation “in or- der”, hospitalising psychotics for a few weeks, finding them housing and monitoring them for several months to avoid the risk of relapse. The same applies to many mental health servic- es: although of course resilience and cure remain the rule for many patients, others are only in- volved in managing their problems. This applies mainly to groups living, or having lived, in an ex- tremely vulnerable situation. The goals of reinsertion and reintegration often turn out to be pious hopes, or even contradic- tory, given the social and clinical situation of the persons concerned. Workers, who retain the goal of empowerment of their target group, are confronted, day after day, with the impossible task of responding to the needs imposed by such empowerment. Getting the unemployed back to work provides an excellent example: forcing the unemployed to re-enter the world of work, sub- mitting job applications and perhaps perform- ing charitable work proves to be totally illusory where mind of the person concerned is a million
  38. 38. 36 « SMES-B, making contact with the homeless… » miles from such concerns. Field workers often remind us that access to social services for such persons can, in itself, be a huge victory, a big step forward in their situation, a stepping stone of such importance that involved accompanying them for weeks or months, helping them to over- come their fears and anxieties, before approach- ing the social service in question. What more can we expect from broken and frag- mented people? Symbolic violence is therefore potentially at its peak in the relationship between the “assisted” and the “assistant”, the former often having to proffer credentials in terms of motivation for reinsertion, resocialisation, and (dare we say it) re-normalisation. They then have to abandon all deviant practices to comply with the require- ments of certain care-givers. This is all the more necessary where the care-givers themselves are increasingly governed by a result-driven ration- ale: the targets are translated into measurable and recurrent indicators, where the goal is rein- sertion. Where problems are intrinsically incura- ble, care-givers must aim for a cure. They are then caught between the realities and possibilities of the homeless and the ideal of a society without mental illness, without the homeless, without people with no income. Patrick Declerck chal- lenges the ideal of a full and prosperous society, contradicted by socio-economic forecasts and, above all, rejected by those with a different view of normality. At best, care-givers can cope by not quantifying the results, but the means and the actions im- plemented. The question is then no longer the human dimension of contact with the homeless, but its frequency and regularity, with any inci- dents along the way deemed irregularities and the steps taken noted. Care-givers say that they have done everything they can, which is general- ly true. But such self-justification takes the focus further away from the homeless. Because the po- litical, social and economic options that partially determine the roads leading to social exclusion are no longer the focus of studies, care-givers become the first responders and take front-line responsibility. The rule is therefore more often than not: three steps forward, three steps back. Relapse and de- compensation have become the new norm. Pat- rick Declerck advocates rethinking the concepts of failure and success for interventions with the homeless by first accepting the chronic nature of the problem. Cure makes way for risk reduc- tion, easing suffering, decreasing intolerance of homelessness. The severity of the problems of social and mental vulnerability therefore contra- dicts the ideal of an increasingly liberal and em- powering society. A liberal and empowering society is in reality closely linked to help and care in the commu- nity: individuals, even if suffering exclusion and mental disorder, must be able to gain in terms of independence, and not be such a burden on so- ciety, living at home with access to local, human care. This may not give full autonomy, rather semi-autonomy, but at least it gives a measure of independence, a certain freedom, a degree of re- sponsibility. This challenge to the asylum-based approach and the return to the community are in part the fruits of this liberal and empower-
  39. 39. 37« SMES-B, making contact with the homeless… » ing society. In one sense, the incurable nature of the disease could be used as an argument for providing help and care in the community: it has become inconceivable, in financial and human terms, to keep people shut away for years, dec- ades, or even for their entire lives. The difficulty is that freedom and care in the community calls for responsibility, and that such responsibility requires a project such as this. This becomes the rule. As an instrument of independ- ence, it has proven to be a useful tool for getting people to (re)learn to “live their lives” in relative independence. The project, as an instrument of independence, can however also be used as a tool for exclusion, especially where it is backed by a contract: a project that mobilises and liber- ates can very quickly give way to a contract that controls and punishes. Social workers will never be in a position to re- duce inequalities in society; the best they can do, at the cost of sometimes long, painful and disheartening interventions, is to manage the consequences of such inequalities. Within the context of their accompaniment role, they can use the ideals of independence, empowerment and freedom to design projects, maybe not on a large scale, maybe even somewhat out of step with societal norms, but in any case relevant to the persons concerned.
  40. 40. 38 « SMES-B, making contact with the homeless… »
  41. 41. 39« SMES-B, making contact with the homeless… » Section 4 Care, cure, compulsory care and other aspects of the link with the homeless (Second event of the Table of Exchanges) We now revisit the link between professionals and the homeless, and the need to tackle the questions of “cure” and “care”, and to link them with the issue of compulsory care. The second ses- sion of the Table of Exchanges raised the follow- ing question: “Passing from “cure” to “care”, but to what extent when compulsory care is necessary?”. In the previous section, we already broached the subject of the shortcomings of cure-based objec- tives, where the problem is so complex and en- tangled with others that cure and reinsertion are at best hypothetical, and at worst illusory. “Care” therefore seems to be the first form of help to give to the homeless. It involves taking care of them without imposing curative goals on them or ourselves. User participation is often mentioned in relation to social and health problems. Participation of this type has the notable advantage of recognis- ing users of help and care as full citizens, able to react, speak out and be listened to by the au- thorities and professionals, which may in time improve policies, mechanisms and practices. Par- ticipation means that the desires and opinions of users can be taken into account. Nevertheless, participation can fall short in terms of help and care. This aspect of the link between professionals and the homeless and/or mentally ill brings with it the dilemma of intervention when the person concerned feels no need, does not know it is necessary or how to make a re- quest. Although the homeless can express certain demands, social workers are often confronted with situations of profound social distress where no request has been made for help. This situation is well-known, but still just as com- plex. Socially and mentally vulnerable people are often in denial and make vague requests, make completely unrelated demands, or ask for noth- ing at all. Faced with this situation, society has to choose between a position of security and one of freedom. Adopting a position of security imposes help and assistance. According to this rationale, even the provision of care is rejected. Imposing attend-
  42. 42. 40 « SMES-B, making contact with the homeless… » ance, monitoring and support on a person, but not shutting them away in an institution such as an asylum, or making them harmless through biochemical means, is an option defended by some, including politicians, but generally not by the specialised sector. Another option is to allow complete freedom. Thisisbasedonthepremisethat“itistheirchoice to live on the streets”, so professionals only feel they can intervene when the person expresses a clear request. The problem is that this posture is based on an error of omission – the fact that the person probably did not choose to be homeless. Under the law, assistance to anyone in danger is as sacrosanct as respect for their independence. Total freedom is therefore no more desirable than total security. The mainstream in the sector sometimes oscil- lates between these two positions, because it is not easy to navigate the troubled waters of freedom, on the one hand, and helping a person in danger on the other. Although the freedom of patients must remain sacrosanct, it cannot over- ride ethical concerns where the doctor identifies a threat. The framework used is the Universal Declaration of Human Rights. Wehavetoapproachthehomelesstogetthemto come forward and benefit from their entitlement to care. What matters is not the permanence of care, but the permanence of the link to access to care, which involves helping people to arrive at a situation where they can make a choice. Forging links with the homeless first enables us to take care of them, and to be ready to respond whenever they express a need, explicitly or oth- erwise. But beyond this, such a link can form the foundation of co-empowerment between professionals and the homeless, linking both parties. The goal of co-empowerment should be examined to avoid returning to an exaggerated form of full empowerment for the homeless. Both assisted and assistant can use their rela- tionship to define the elements through which a degree of empowerment, a certain participation will be possible, without becoming too onerous for the homeless person. “bemoeizorg”6 , an at- tentive attitude for and alongside the homeless, can create this co-empowering, co-constructing and co-involving link. We have to take into account the capacities of individuals and street interventions to establish contact with them, without providing ready- made solutions. Compulsory care may still sometimes be neces- sary. The fundamental ethical criterion must be assistance for persons in danger. In Belgium, placement of people has been replaced by ob- servation, generally in an approved psychiatric facility. This is decided by a Justice of the Peace, within ten days of submitting a request and for a period of 40 days. This can be extended by a new judgement, for a potentially renewable maxi- mum of two years. This law is based on certain indicators, namely the fact that it should apply only to persons suffering from mental disorders that seriously endanger their health and safety or present a se- 6 A relatively new Dutch term indicating a socio-psychiatric form of care and support for vulnerable people
  43. 43. 41« SMES-B, making contact with the homeless… » rious threat to the lives and integrity of others, and failing any other appropriate treatment. In an emergency, if all three conditions are satis- fied, any person can contact directly the Courts of the place where the mentally disturbed person is and request observation; the Court then handles the procedure if this should prove necessary. If there is no emergency, any interested person can submit a request to a Justice of the Peace with a detailed medical report dating back at least 15 days. In all cases, a lawyer is appointed to assist the person for whom observation is requested. The real difficulty occurs where compulsory care is not possible, for example because there is no diagnosis of a mental condition. To understand this, you have to bear in mind that such diagno- ses are generally performed in the surgery of a psychiatric doctor, within a circumscribed pro- fessional framework. The problem is that the social sector is awash with stories of homeless persons, clearly suffering from mental disorders undiagnosed by social workers, behaving com- pletely normally in front of the psychiatrist, so the doctor could not diagnose any psychiatric disorder, putting the person back on the street with the complex support provided by outpa- tient services. These outpatient services are then often forced to bend the rules, taking a more ac- tive role, and even becoming actively involved in the daily life of the homeless person. This is what we mean by “bemoiezorg” (see foot- note on page 7), a Dutch concept that is difficult to translate. This relatively new form of “care” provides socio-psychiatric support, focusing mainly on the factors that are a barrier to help- ing the person. It is aimed particularly at vulner- able people who cannot access care or do not wish (no longer wish) to access care. The main feature is therefore putting more power in the hands of the field operator, even if it means a de- gree of meddling in the affairs of the person.
  44. 44. 42 « SMES-B, making contact with the homeless… » Section 5 The varying pace of mental health reform (Third event of the Table of Exchanges)
  45. 45. 43« SMES-B, making contact with the homeless… » The vestiges of a Western trend To better understand the issues associated with “care” and compulsory care, it is a good idea to re-examine the history and compare the differ- ent pace of mental health reform in Italy, France and Belgium. In order to do this, we put the fol- lowing question on the agenda of our third Table of Exchanges: “Deinstitutionalisation of care, but to what extent when the person needs a struc- turing framework?”. The so-called antipsychiatry movement was born in the 1960s in both Italy and Great Britain. Based on recent mental health reforms, the first Italian developments were promoted in particular by Franco Basaglia. As a fervent supporter of closing asylums in favour of outpatient care, he revolu- tionised patient care in the psychiatric hospital in Gorizia, banning containment and developing the institutional therapy that he had observed in the therapeutic community of Maxwell Jones. The foundation of care in the community had now been laid and was to be applied in the forth- coming mental health reforms in the West.
  46. 46. 44 « SMES-B, making contact with the homeless… » The need for outpatient care in the modern era We know that the number of mental health psy- chiatrists and nurses is comparatively much higher in Europe than in other regions of the world, including North America. The figure is even more impressive in the case of France and Belgium, where the number of psychiatrists and hospital beds is one of the highest in Europe. The percentage of the health budget devoted specifi- cally to mental health is also one of the highest, even though both France and Belgium are facing quite serious financial difficulties. Recognising the citizenship of the mentally ill is just one of the arguments, albeit fundamental, for closing asylums; cost is another. During the Helsinki Conference in 2005, The World Health Organization issued the following recommendations for care in Europe: 1. Develop community-based services to treat and care for persons with mental health problems. 2. Set up specialised teams to treat sensitive groups in their own environment. These services should be available 24 hours a day, 7 days a week, and they should be dispensed by a multidiscipli- nary mobile team. 3. Provide residential services. 4. Provide emergency services with mobile emergency teams or teams attached to hospitals. 5. Promote, prevent and inform about mental health problems and the care on offer. The 20th -century hospital-centric model, onto which outpatient services are grafted, is giving way to a much more complex and fragmented, multi-nodal model, in which the mental health community plays a dominant role in terms of care coordination. This community finds itself at the intersection of care provision, including home-based care, acute hospitalisation, social reinsertion, housing provision and self-help.
  47. 47. 45« SMES-B, making contact with the homeless… » The sectors in France In France, mental health reforms have pursued a sectoral policy where each sector provides a wide range and diversity of integrated care in the community. The key objective is to separate patients as little as possible from their families and their normal environment, treating them at an early stage and providing post-cure services to avoid multiple hospitalisations. Hospitalisation therefore represents only the time required to take the patient in hand and then handing over to non-hospital structures, but with the same team providing care both in- side and outside the hospital. In practice, this means working together and or- ganising services, with family doctors, families and friends, as well as with users. More broadly, this requires a huge effort by all psychiatric ser- vices to integrate into the community, as well as by the patient, who should be recognised as a full citizen. Raising awareness among local poli- ticians, inhabitants and healthcare professionals is a fundamental element of sector-based care. A perfect illustration of this French policy is pro- vided by the Lille-Est sector. In 1970, Lille had a large flagship psychiatric hospital. There was no such thing as outpatient care and all patients were hospitalised for an average period of 180 months. At present, although more patients are receiving care than during this period, compul- sory care now results in around 20% hospitalisa- tion. In the sector as a whole, the number of beds fell from 290 in 1971 to only 12 now. The Lille-Est sector is focusing on facilitating ac- cess to care, reducing the number of serious dis- orders requiring hospitalisation, promoting opti- mum, continuing and local care by adapting to user needs, preventing relapses, “occupying” the city and coordinating with other healthcare op- erators, emergency services and attending physi- cians, and finally supporting insertion. Replacing hospitals in a diversified range of healthcare services is achieved by offering con- sultations that allow people to be seen at any time of the day or night by a nurse, at the request of a general practitioner. Consultations provide an opportunity to assess the urgency and organ- ise pathways, based on a multidisciplinary opin- ion, including that of the doctor. An integrated intensive care unit has also been set up in the city, which can provide care for 10 persons in their homes, in contact with resource persons and care-givers, including the general
  48. 48. 46 « SMES-B, making contact with the homeless… » practitioner. A team of nurses and psychiatrists makes contact with the person at least once a day. Therapeutic foster homes take charge of people, who thereby benefit from full-time care, and mutual help groups are managed by and for users. Finally, hospitalisation rounds off the range of services on offer, within an open service, whatever the type of hospitalisation. At the very heart of this mechanism, a mobile team is on call 24h/24h, with nurses and psy- chiatrists in daily contact with the emergency services, responding to all medical requests and coordinating with all units via conference calls, meetings, agendas and computer forums. In addition to optimising the range of support and care services, ongoing political action is re- quired because the mechanism fully involves the local political authorities and the population, mainly via an information and awareness-raising programme. An inter-municipal health, mental health and citizenship council has been set up consisting of a consultation platform bringing together the mayors of six communes, citizens (users or otherwise), families, artists, cultural ser- vices, affordable housing offices, guardians, so- cial and health services and psychiatric services. No decision concerning the creation of services or the organisation of care is taken without con- sulting it. In addition to exchanging information and raising awareness, it can identify specific needs, facilitate mobilisation and coordination, broaden the range of interventions, improve ac- cess to public health services and social services, encourage the active participation of the popula- tion and propose the creation of local networks for new local policies. In terms of citizenship, the council helps with access to housing, jobs, cul- ture and leisure activities, as well as prevention and combating stigmatisation. To summarise, organising suitable local care, integrated into the community, intersectoral and linked to local information and prevention initiatives, has a direct effect on the risk factors associated with stigmatisation. It helps with ac- cess to and continuity of care and reduces the exposure of users to victimisation, exclusion and withdrawal.
  49. 49. 47« SMES-B, making contact with the homeless… » Belgium also committed to mental health care de-institutionalisation with the reform known as “article 107”. This reform takes place in a context where recourse to compulsory hospitalisation is deemed too frequent. In any case, it has to be acknowledged that the number of psychiatric hospitalisations per inhabitant is higher than in most western countries. It would therefore be reasonable to think that this reform still makes complete sense, despite its late arrival. In practice, it involves freezing the number of hospital beds for chronic patients: the money no longer allocated to these beds is then reinvested in mobile teams, working in the community to develop outpatient care. In Brussels, however, it should be noted that there is a structural short- age of beds, which requires changes to the fund- ing mechanism. Following a call for projects in 2010, ten appli- cants were selected to implement the reform in the different regions of Belgium. Each “Psy 107” project has to satisfy the following five functions: Mental healthcare prevention, promotion, early detection, screening and diagnosis; Outpatient intensive treatment teams for both acute and chronic mental problems; Rehabilitation teams working on reinsertion and social inclusion; Residential intensive treatment units for both acute and chronic mental problems, where hos- pitalisation proves indispensable; Special residential formulas to provide care where home-based care or care in alternative housing proves impossible. The “Psy 107” reform aims to provide mental health care as close to those suffering from mental disorders as possible by giving prior- ity to support where such people live, in a given area. Depending on the actors available, this in- volves diversifying and adapting the services to the needs of the population by networking re- sources, optimising their adaptation, intensify- ing certain procedures and setting up innovative mechanisms. Reform 107 in Belgium
  50. 50. 48 « SMES-B, making contact with the homeless… » The “Psy 107 Health-Vulnerability” project by SMES-B and its partners The partners involved in the “Psy 107 Health-Vul- nerability” network project seized on this reform as a real opportunity to respond to the difficulties they had been encountering for a long time in implementing the “collaborative care pathways” thattheyhadbeentryingtointroducedespitethe scant means at their disposal. Most of them knew each other and the quality of their work, as well as their limitations. This reform gave them the op- portunity to enhance the quality of the care and support they provide to a target group for which they had been struggling to find a response. SMES-B and its partners decided to focus their at- tention on an extremely vulnerable group, where networking is essential in the areas where they live and where they can benefit from help. It should be remembered, as we stated in the early pages, that the economic and social life of Brussels presents a flagrant contrast between wealth and poverty. Its population is one of the youngest, but also one of the poorest (25% liv- ing below the poverty line); unemployment is endemic and health perhaps the worst in the country, despite its unrivalled density of social and health services. As for mental health, hospitals in Brussels fall below the usual standards of patient scheduling and hospitalisation, especially for emergencies, which is an uphill battle, even for psychiatric emergency services. Waiting lists are the rule for admissions to psychiatric beds and sometimes even for a first mental health appointment. Finally, where they are facing a combination of problems of social exclusion and chronic somat- ic pathologies, in increasingly vicious circles, ex- perience shows that getting patients to adhere to a programme of regular consultations is very difficult over time, both for mental health and for general and specialised medical care. Places in sheltered housing or psychiatric care homes generally involve a wait of more than a year. It therefore comes as no surprise that today many of these patients in Brussels are clearly liv- ing in places inappropriate for their condition: hospitalisation for social reasons, shelters (ap- proved or otherwise), rest and nursing homes, and even on the street. Without access to spe- cialised care, they develop scenarios that front- line professionals and general practitioners cannot handle, hence the recurrent recourse to emergency services. These double or triple psycho-medical-social diagnoses are self-sustaining and are difficult obstacles to overcome without proactive, con-
  51. 51. 49« SMES-B, making contact with the homeless… » certed and cross-cutting intervention by many actors from neighbouring sectors: mental health, drug abuse, general and specialised medicine, social, hospital and outpatient services. These are the players involved in the “Psy 107 Health-Vulnerability”, network project, held together by the maxim that “access to mental health care (outpatient, emergency, long-term and hospitalisation) has become highly problem- atic for patients suffering from social vulnerabil- ity and/or chronic somatic disorders”. These difficulties are associated as much with their complex and chronic pathologies as with their living conditions, social exclusion, lack of insurance coverage or institutional barriers. The “Psy 107 Health-Vulnerability” network was the product of brainstorming by the actors usually involved with these complex patients, as well as rigorously rethinking the dysfunctional as- pects of the help and care system and trying to come up with innovative responses to palliate its shortcomings and gridlock. Unfortunately, the authorities were not con- vinced by the “Psy 107 Health-Vulnerability” pro- ject, mainly because it focused on socially and mentally vulnerable people, diverting reform 107 from its objective of addressing the general population. Although these partners were given a chance to review their plans, they preferred to maintain their position, namely that any general provision mainly profits wealthier populations and the middle classes, to the detriment of the most vulnerable. In practice, it is vital that mental health care should be largely dehospitalised, so it is also necessary to consider the most vulnera- ble groups. For each level of the mechanism, they are the ones that remain at the threshold, with- drawn and therefore always in need. In terms of access to social assistance and healthcare, posi- tive discrimination is a prerequisite for everyone to have equal access. Unfortunately, SMES-B and its partners failed to make this sufficiently clear to those who promoted mental health reform in Belgium.
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  53. 53. 51« SMES-B, making contact with the homeless… » Section 6 The painful path to insertion (Fourth event of the Table of Exchanges) Our Table of Exchanges concludes by closing the loop, returning to the original ethical question concerning freedom and empowerment, which is sometimes difficult to apply to the homeless. The question “Integration, but to what extent where the obligation of integration becomes the determinant of exclusion?” seems very similar to what was discussed during the first event of the Table of Exchanges. Its societal nature gave rise to other exchanges, focusing more on the politi- cisation of social actions and actors. Such politicisation is not always easy, especially because of the language required: hard terms, re- lating crude realities, can scare off citizens and politicians. Conversely, blander language can obscure intrinsically serious, even deadly, events and processes, further aggravating them. This is the case for both homelessness and psy- chiatric disorders. Nevertheless, around one in three of the homeless are affected by psychiatric disorders. Homeless people are not just without a home: they often suf- fer from radical mental alienation, in addition to socialexclusion.Thisisthegroupusingemergency housing and shelters. In Brussels today, there are not enough places in these residential facilities. If such facilities cannot handle all needs in terms of housing,whatcanbesaidfortheintrinsicallycom- plex problems affecting these people? The truth is that homeless people with psychi- atric problems are being housed, doing what we can with the means available, in facilities completely unsuitable for their situation. These words have to be said. Political action is neces- sary. We are calling for an urgent review of the entire sector, which is bending, but not yet bro- ken, under the complexity and aggravation of the problems associated with exclusion. As long as the debate is not clarified, as long as the words used are not strong enough, as long as people are only half aware, integration of the homeless will face multiple failures. Some peo- ple do manage to get off the streets, and this is good. But how many more chronic homeless are there, because the existing mechanisms are not best suited to respond to situations of exclu- sion? Because at present, these are not places of transit, temporary and episodic, in a rather cha- otic life. In truth such places are static. The com- ings and goings are all based around the street, rarely impinging on the other stages of a highly theoretical and schematic reinsertion.
  54. 54. 52 « SMES-B, making contact with the homeless… » Forcing integration, beating the drum without nec- essarilytakingintoaccounttherealityofthehome- less, often makes it the determinant of exclusion. This is all the more true where the world on of- fer becomes increasingly hard. Where begging becomes commonplace. Where assistance be- comes mundane. Where such hardening be- comes run-of-the-mill. Speaking about integration means speaking about our societal context. Here and now. And about the future, because tomorrow it will be the elderly, in vast numbers, who become the new homeless. Innovation is necessary because our countries currently lack funds. But this cannot happen without refocusing the debate and our society. Above all, it cannot be reduced to techniques and normalisation, because it is these very tech- niques and such normalisation that sometimes prove to be the determinants of exclusion. The failure of language must give way to a return to discussion. The aggravation of problems must give way to new models and new practices. Technical aspects should give way to relationships, links, real contact with the homeless, over the long termandthroughnetworks,respectingtheirchoic- es, as well as our responsibilities as social actors. There is another difficulty encountered by social and mental health workers, which is aggravated where professionals and/or their projects, or even their institutions, find themselves in a vul- nerable situation. Operators, caught up in a daily battle to find funding for their projects, have fewer opportunities for rethinking their practic- es, their style of intervention and the goals they set themselves. The situation is becoming dramatic and it is time to take it in hand.
  55. 55. 53« SMES-B, making contact with the homeless… »
  56. 56. 54 « SMES-B, making contact with the homeless… »
  57. 57. 55« SMES-B, making contact with the homeless… » Section 7 SMES-B responses  For more than 20 years, SMES-B has been imple- menting inter-institutional and intersectoral practices, for the benefit of socially and mentally vulnerable people living on the edge. At the out- set it was an initiative by a few professionals, campaigning for decompartmentalisation, large- ly based on peer supervision. With the dawning of 2000, this unit supported social and mental health workers. In 2007, its approval as a health network allowed it to add Tables of Exchanges to accommodate intra- and inter-sector debates. Partnerships with the social housing sector came into effect in 2009. Although the “Psy 107 Health- Vulnerability” project was not accepted, SMES-B and its partners at least had the opportunity to raiseawarenessofthepsychosocialsupportfunc- tion through “RAPS” (Réseau d’Accompagnateurs Psycho-Sociaux – Psychosocial support network) research. In early 2013, SMES-B was actively in- volved in designing a Housing First project in Brussels, in collaboration with the cities of Ant- werp, Charleroi, Ghent and Liège. SMES-B proposes innovative and relevant re- sponses for the benefit of the most vulnerable. It has been recognised several times for its good practices, including the award of the Prix Fédé- ral de Lutte contre la Pauvreté in 2010, and men- tioned in various national plans. The problem is that it still has to sail through the troubled waters of vulnerability. Operating on the borderline between the social and health sectors, it encounters difficulties because of a lack of approval and structural financing. With the first broadside, it could sink without trace. In early 2013, it carried out an intensive aware- ness-raising campaign to bring home to politi- cians its extreme vulnerability. Its hopes depend on those who supported it over the years putting it on a solid foundation, benefiting from struc- tural funding in line with its ambitions. This has now become the number one priority of SMES-B.
  58. 58. 56 « SMES-B, making contact with the homeless… » Conclusions

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