SMES-B explores complex issues of homelessness

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

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

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

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

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

Prologue

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-

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

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

Presentation of SMES-B

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.

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.

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

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

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.

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

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

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

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

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

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.

Third event
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;

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
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

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.

Section 2
Social, mental
and other vulnerabilities:
complex issues

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

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

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.

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.

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

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.

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

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.

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

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-

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.

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-

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

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.

Section 5
The varying pace
of mental health reform
(Third event of the Table of Exchanges)

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.

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.

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

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.

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

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-

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.

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.

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.

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.

Conclusions

SMES-B explores complex issues of homelessness

SMES-B explores complex issues of homelessness

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