Case Famiglia

Housing homeless people
An experience

F. Pezzoni°, P. Badano°, S. Battistin°, C. Bonzani °°, M. Degli Abbati°°, R. Rodo°°, L. Segaerba°°, C. Ferrobraio°°°, C. Ratto°°°

The Mental Health Centre via Peschiera in Genoa is a psychiatric community service and belongs to the National Health Service. Care is free, users either ask personally for help or are referred to by general practitioners, hospitals, other health and social services and no-profit organizations. The opening time is from 8 to 20 every day and from 8 to 13 on Saturday. The staff includes psychiatrists, psychologists, social workers and nurses. The users suffer from psychosis, mood disorders, anxiety disorders and personality disorders. They are about 1400.
The Mental Heath Centre is located near the harbour. Its catchment area includes five districts, including the inner city, where live 140.000 inhabitants. Among the users there are 115 homeless people. They live in shelters, warehouses, hotels and other facilities. None of them has been released from the Psychiatric Hospital, which has been closed in 1980. They often come from broken families, with alcohol and psychiatric troubles, or lost their job even after twenty or thirty years of regular employment. Their more common diagnoses are psychosis, personality disorder and alcoholism. They are referred to the Centre by social services, charitable institutions and volunteers. The Centre has been collaborating with all these agencies for twenty years, in order to build a social network to help these users and all psychiatric patients.
During 2006 20 homeless patients were allocated public housing units by Genoa town council. The Mental Health Centre has worked to help them to take possession of their apartments, to find the furniture, to do the paperwork and above all to get used to their new status of tenant, after many years of life in the street. This change requires a difficult psychological work in order to adapt to a new personal situation.
The users are 6 women and 14 men, from 30 to 70 years of age. 13 are psychotic, 1 has a bipolar disorder, 2 have a personality disorder and 4 are alcoholic. Their psychiatric disorders are impaired by long years of stress and hardship. They show a psychological distress that can hardly be assigned to a specific diagnosis.
We noticed that there was no simple connection between psychiatric diagnosis and difficulties in managing the new accomodation. Severely ill patients were able to keep their house in order and to pay punctually their rents, while less disturbed people prove themselves less able to cope with problems.
First of all, the Mental Health Centre helped the users to apply through the proper channels for the allocation of the lodgings. They have been waiting for one or two years. During this period, the staff had to keep in touch with the users. If they lost touch, they could not know the answer from the local authorities and submit other papers when requested. Homeless people are known for their distrust of public services and we succeeded in keeping in touch working together with the other social agencies.
When applying for a new house the users must come out of their passive attitude and invest in a long-term project, exposing themselves to uncertainty and disappointment. While waiting for an answer from local authorities, they were regularly met by psychiatrists and social workers, who treated their psychiatric disorders, tried to know their life stories, to improve their abilities and to activate social resources in the community.
During the second phase, when the users entered their lodgings, they had to face new problems. The house, seen as a material good, didn't automatically change their attitudes and lifestyle. Once satisfied their basic needs, the users' psychiatric disorders became more evident. Worries and complaints often covered deeper conflicts, regrets and traumas, which came up again when patients took possession of their houses. In their interviews with the staff, they reminded previous losses and family break-ups and sometimes tended to act in aggressive or harmful ways. When faced with even small difficulties in everyday life, they said that they wanted to give up, to return to homeless life and even expressed suicidal thoughts. Besides, the bureaucratic processes needed to sign the lease and to connect gas and electric supply were long and discouraging.
The users often had too high expectations, sometimes they lived their new house as an impossible compensation for their sufferings, as an opportunity for a personal revival and a neglect of their past life, exposing themselves to further disappointments. Some women hoped to restore their relationship with their children, who had been living in foster houses, were at present grown-ups and often refused to keep in touch with their mothers. Unfortunately reality often proved to be worse than expected and homeless people often became defeatist again and tended to give up hopes in future improvements in their lives.
Sometimes the house appeared empty and bare and gave a sort of picture of a life lacking of human relations, after years spent in the street. The homeless people realized to be alone, to lack any social role and saw the new lodging as cold and hostile, without a sense of belonging. This feeling was a risk factor for relapsing into homelessness.
The flats allocated by local authorities were spread in all town areas, in districts with a working-class population; the users had to adapt to new neighbourhood and to rules and nearness, after long periods of isolation. People living in jointly-owned buildings can often have little disagreements, but the patients thought they were unable to solve these problems and sometimes felt persecuted.
After one year, all patients are still living in their houses, but one of them saw the allocation of a flat as a release from a transitional shelter, where he had to follow some rules, and relapsed into drinking, with an impairment of his conditions (at least from our point of view).
After been allocated a lodging, some homeless people refused and decided to go on living in other facilities run by no-profit organizations. It is difficult to understand if their decision is a further form of resignation, a realistic choice or a no more modifiable adaptation to institutional care.
Clinical work during this phase is particularly complex and sophisticated; the staff must have more frequent interviews with the users, listen to their stories, go and see them at home, be flexible and available for extra-calls. Above all, the staff must intensify the collaboration with other health and social services and with no-profit agencies working in the community, in order to strengthen the social network around the patients and to support them in this difficult period. If they move to another area, they are referred to the Mental Health Centre working in the district, but the passage takes place by degrees avoiding a sudden discharge.
While working with homeless people the staff learned from experience and noticed some factors that can reduce adjustment problems:
1) a social network already working before the allocation, including formal and informal relationships with relatives, friends, colleagues, parishes, public and private services, general practitioners, volunteers. When this network exists, the user is helped to go through bureaucratic processes and, first of all, to sustain psychological stress.
2) a social role whatsoever acquired o maintained by the user, who by this mean doesn't feel devoid of commitment and value. He/she can give meaning to his/her lodging and carry out his/her social role, "filling" in this way the new life. We don't speak only of a social identity as worker or parent, but also of less valued roles, that nevertheless sustain self-esteem and self-image.
3) The appointment of a "amministratore di sostegno", a lawyer who looks after the user's interests and responds to the judge with responsibility for guardianship cases. The users are not deprived of civil rights and remain free in all their decisions, but are supported by the lawyers, who act side by side with them. This form of management has been introduced by an Italian law in 2004 and helps to protect the patients and also to strengthen the network and to pursue the housing project.
During 2008 other 20 public housing units will be allocated and the Mental Health Centre is now putting into practice its previous experience with other homeless people.
We present Mr. Giuseppe T.'s case in order to illustrate our work. He is a chronic psychotic patient, who has been in charge of our Service for more than ten years. After his parents' death he lost his job and his house and was sent to an hotel at the expense of the local government. He applied for a public housing unit and had to wait for a long time because of the great number of applications. Meanwhile Giuseppe lived in a lonely way, refused medical treatment and had rare meetings with psychiatrists, nurses and social workers. He kept on painting pictures with a good technique which he had learned on his own without going to school, but refused to expose his works in the rooms of the ex Psychiatric Hospital and to participate to rehabilitation activities at the Mental Health Centre. However he gave some paintings to the social workers as a gift and kept the other canvas with him in the hotel room.
When he was allocated a house, the psychiatrists and the other members of the staff were afraid he could not be able to manage his new accomodation, because of his illness and of the habit of living in a hotel. His new district had been built in the first years of the twentieth century and was inhabited by families well integrated in the social network. The buildings were not too high, there was a square, a church, small gardens, shops.
After a while Mr. T. began to paint a "mural" (wall painting) on a wall of the district, where he represented a small Ligurian village, with boats, dogs, people, fountains, clouds, seagulls. The inhabitants of the district observed, appreciated the good level of the painting and collected money to buy colours and have the fresco done. In the end Giuseppe wrote the date on the painting and signed "Giuseppe T., painter".
We can present some hypothesis on this case. Mr. T. always defended his "normal" identity as painter and always refused to be a psychiatric patient involved in rehabilitation activities; this attitude can paradoxically have helped him to maintain a good self-image and a good self-esteem during the long wait for a lodging, when he lived in a hotel and was at risk to loose his normal skills. He could in this way introduce himself to the new district with a positive and worthy identity, expressed by his signature on the fresco, and his neighbours to some extent recognized his ability.

°Psichiatra, U.O. Salute Mentale Distretto 11, ASL3 Genovese, Genova
°° Assistente Sociale, U.O. Salute Mentale Distretto 11, ASL3 Genovese, Genova
°°° Infermiere, U.O. Salute Mentale Distretto 11, ASL3 Genovese, Genova