PAINTING PAPERS Brizuela Dominguez R.*, Brihuega Hernandez C.*, Linares Briones M.**, Ávila Sanchez MJ.**, Muñoz Gomez JH.**, Medina Téllez de Meneses E.* * Equipo de Atención Psiquiatrica a Enfermos Mentales Sin Hogar. Madrid.**Residentes de Psiquiatria del H. Universitario de La Paz. Madrid.

UNIT OF PSYCHIATRIC ATTENTION IN HOMELESS PEOPLE WITH MENTAL ILLNESS We attend homeless people with mental disease with/without toxic consumes. City of Madrid,Homeless,Up 18 years Severe and chronic mental disease. tries to be a bridge between the street and mental health services and community. We exclude: - People who receive attention in any other resource of System of Mental Health.

General Aims Improve sanitary attention in homeless. oEvaluation and diagnosis. oPsychiatric Treatment and follow up of people who are not been attended in other resources oHelp in the link to normalized resources. Coordinate sanitary and social resources. Trainning the staff in needs that appears in daily work (multicultural issues, legal issues, participation)

Área 5Área 7PRISEMI* Enfermeros22 Educadores Sociales 5 Trabajadore s Sociales 111 Psicóloga1 Psiquiatras11 Second level of attention NO DETECTION Is not an emergency attention Walking or by trains Two teams: Engagement and rehabilitation Resources we have 17 places on a Residency 30 on Day Center 6 places on pensión “ virtuales” Work in network Coordination Movement, Flexible, work in the street or in any other resource Flexible timetable (de 10 a 17h)

Rehabilitación Relation of trust/ rehabilitation alianze PSICOLOGY / EDUCATORS/SOCIAL WORKER Skills Housing Transition Leisure MEDIATORS/ SUPERVISION Engagement Relation of trust/ Link NURSE/ EDUCATORS/ SOCIAL WORKERS Self cares, health, housing and papers Pharmacological treatment/supervision Accompaniment Negociate CRISIS

How we coordinate –Referal Monthly meeting with social services (SAMUR SOCIAL and other resources) Phone calls from income units of Psychiatry Periodic meeting with: –Resources of the homeless network –Social services »Weekly/ monthly »When it´s required, “informal” meetings »Phone / e mail!! –Discharge from the program Integration meeting Mental Health Bimensual –Take care of the “perverse” coodination/ Confidenciality

How we care ourselves Prevention on burnout: –Supervision with extern staff –Meeting teams, informal meetings, yoga –Trasnparence, confidence in comunication –Taking care each other. –Share reponsability, share opinions…TAC and outreach. Stabilized staff

This case represents the phases of the work done by the team of psychiatric care for homeless people with mental illness in Madrid (Spain),

- 38 year old male, Nigerian, Catholic. - He Lives in the street, in irregular situation (no papers).He has criminal records (one stay in prison) - He speaks the local language and English, difficulties in spanish. - Heavy drinking, he lives in the street with a bottle, dosen´t let anyone get close to him and speaks to himself. PRE-ENGAGEMENT (information before contacting the patient) Get all the information about the culture of the patient, the language, everything that could helpto emphatize. Information about his rutine, habits…

After 2 years since we met him, intervention was suspended because of 2 disappearance, and suddenly (it was his time) he was found again and within in a month we could: - Communicate through pictures and music. - We knew part of his social networks (neighbor-friend, she was a motivator and support in reducing alcohol consumption, a great source of information). - Uncertain diagnosis: PTSD or T. Psychotic: relates to have suffered physical and sexual abuse for political reasons in his country, so it came to Spain 5 years ago, leaving in Nigeria a wife and daughter (with whom he maintains contact). - He has a psych income in the Netherlands and another in Nigeria: suicide attempts and hospital escaped, vagrancy and aggression against objects. - 6 months in jail for as long disappeared. RISK AGREEMENT SPECIFIC OBJECTIVES ENGAGEMENT (linking process and creation of the therapeutic relationship. Nurse+educator+psychiatrist)

REHABILITATION (process of recovery through potentialities towards greater autonomy and quality of life. Nurse+educator+ psychologist+psychiatrist) SUPERVISED PENSION Facilitates: Agreement in medication administration, creation of habits (hygiene, nutrition, reduce consumes) Required: care of friend and mediation with landlords pension mutual adaptation SOCIAL SUPPORT NETWORK AND OCCUPATIONAL (Day Center) COMMUNITY INTEGRATION (library, sapanish classes, paintings exhibition) accompanies and facilitates the link Being in prision supposed a fracture life (first contact with his reality, he asked: "What is schizophrenia?") Expectatives imprisoment REESTABLISHMENT Process stopped 6- months: crime being in psychotic crisis. After 3 months in jail, exchange for stay In our Residence

DIFFICULTIES For migrant status: - "European dream" : setting expectations and control impulse - cultural issues (reproductive effort, difficulty breaking romantic relationship family: responsible for maintenance) - Bureaucracy: Asylum expected makes response slows recovery process Chronic Mental Illness (negative symptoms) Prison Alcohol consumes Flexibility of resources

KEYS OF INTERVENTION High time for engagement (2 years waiting and we needed 1 month for engagement, his time-we need to respect times ) We followed wherever he was Mediation Respect, listening Working from his scheme of life trying to adjust to his reality Agreements tailored to his abilities

BIBLIOGRAPHY Ramirez Goicoechea, E Inmigrantes enEspaña: vidas y experiencias. Madrid: Centro de Investiogacion sociologica. Larry Davidson et al “Simply to be let in”: Inclussion as a basis for recovery..Psychiatric rehabilitation Journal