Recasting care models for mental illness and homelessness

Socio-normative portrayals of homeless people living with mental illness (HPMI) ubiquitously assign them to the role of refugees, leading to rescue efforts focused solely on transferring them, voluntarily or forcibly, to psychiatric hospitals, asylums, begging houses, or even prisons. The basic premise that they must be removed from the streets due to the many risks that street life brings is valid, but contestable.

As mental health professionals and bureaucrats, our perspectives were similarly restrictive more than 20 years ago, prioritizing shelter and treatment over agency, choice, and placemaking. While social order is relevant and valuable in many situations, it can sometimes limit imagination and restrict responses, even if well-intentioned, within the bounds of safer, dominant narratives. It takes time to become accustomed to the idea that there are social worlds that do not necessarily conform to modern conventions, and that concepts of culture, freedom, and safety can be experienced in atypical ways.

Challenging concepts, efforts at integration

Engagement with experts with lived experience can support this journey and challenge notions of what care and response are. Homeless people often partner with local support groups that include fellow homeless people, local eateries, pets, and other self-chosen sources of belonging. Similarly, and perhaps more importantly, among the many truths, are stories of oppression, deprivation, abuse, exposure to the elements, and exacerbation of symptoms related to mental illness. We may therefore be reluctant to situate the issue in sacred, rigid dichotomies. Complicating the story and giving it the complexity the phenomenon deserves will require more than the small effort currently given.

Among the few initiatives in India that have helped HPMI reintegrate into their communities is a collaboration between the National Health Mission, the Tamil Nadu Department of Health, the Institute of Mental Health, The Banyan, Azim Premji Foundation, and local civic organizations to provide access to Emergency Care and Recovery Centers (ECRCs) in district hospitals. This integration serves two purposes.

First, it breaks the hegemonic hold of treatment spaces like large psychiatric hospitals that perpetuate the stereotypical identity of the mentally ill patient. More importantly, it serves more people faster and ensures last-mile proximate care and crisis response across scattered communities. Overcrowding, limited human service professionals, use of restraints, and lack of personal attention impact the ecology of care across the world, as well as in India.

The transformation that allows for the adaptation of design and social structures in these circumstances allows care to be located in smaller units, adequately staffed, and mandates personal attention and better medical care to address the common complications in people exposed to prolonged adversity.

Recent policy shifts represent progress, but they also call for deeper engagement and a longer-term approach. We must also critically consider when and why rights are disenfranchised, examine the attitudes and practices of society and care professionals, and develop systems of leadership and governance that are adaptive, dynamic and reflective and address complex dilemmas and contentious issues.

In these circumstances, the symbolism of appearances such as shaggy hair and a shaved head deserves careful consideration, especially for those who choose to live on the streets despite the availability of care options. As Obeyesekere points out, a shaved head, when seen in contexts ranging from the widows of Vrindavan to the inpatients of psychiatric hospitals, can signify abandonment and should not be immediately confused with mental illness. Our approach is therefore one of ongoing engagement, delineating a framework for hospitalization that respects individual agency. While the benefits of intervention are great and the difficulties of street life are real, coercive care often leads to poor outcomes.

Problems of Institutional Space

Meanwhile, around 37% of people living in state psychiatric institutions and other care homes have long-term needs, with an average length of stay of six years. Most of them have a history of homelessness and are typically integrated into the system as a result of police and judicial intervention. In 2017, the Supreme Court of India, in response to a public interest litigation, ordered state governments to take rehabilitation measures. In this context, the Department of Empowerment of Persons with Disabilities, Ministry of Social Justice and Empowerment, submitted guidelines for rehabilitation homes. Unfortunately, the conception of a return pathway to the community for people living long-term in psychiatric institutions remains trapped within semi-institutional or inter-institutional options that transfer their confinement from one place to another. Moreover, these considerations are limited in their conceptualization of who is “cured” and therefore “ready for discharge”, imposing deterministic expectations on their eligibility to live in the community. In addition to continuing to distance themselves from social resources and equal participation, these institutional spaces risk similar experiences of poor quality of life and rights violations.

Also read |Tennessee health secretary brings emergency care model for mentally ill to rural areas

Globally and in India, large-scale housing initiatives such as Housing First and Tarasha provide comprehensive social and clinical care, demonstrating the feasibility of innovative options for people with a range of disabilities and clinical needs. Similarly, over 700 people have accessed housing support and social care through the ‘Home Again’ collective across nine states in India. This was first piloted as a research trial in 2018 with support from Canada’s Grand Challenges and has been expanded in partnership with Rural India Supporting Trust. It has also been adopted by the Tamil Nadu government and other stakeholders nationally. For people with mild to moderate disabilities and transitioning out of hospital, hostel-like communal living facilities, which represent enhanced social capital and safety, could be considered rather than rehabilitation homes.

Review of support measures

Social protection and support policies for homeless people with mental illnesses require a fundamental shift and restructuring from paternalistic interventions to strategies focused on liberation. A priority disability allowance or unemployment benefit of Rs 1,500 per month, though modest, could be a critical lifeline for those relegated to the margins of the social hierarchy. Addressing the bureaucratic hurdles of securing Aadhar and facilitating banking access for HPMIs would pave the way for financial inclusion and economic empowerment.

But this documentation and funding must be complemented with a more imaginative and holistic approach, with a focus on structural issues such as discrimination, violence, segregation and poverty. To this end, social services and post-discharge support need to be strengthened and integrated into district mental health programmes. As a result of government and non-government led efforts, 800 mental health service users discharged from ECRCs over a three-year period achieved a 75% post-discharge service uptake rate, higher than the global average.

Promoting economic justice requires confronting institutional barriers, elevating the perspectives of marginalized groups, and creating models of change that accelerate inclusion. Workforce participation, if thoughtfully promoted, is a powerful tool to reclaim economic space. Traditional employment models and vocational training efforts are not only disconnected from contemporary economic realities, but also often fail to take into account individual agency, strengths, and aspirations. Instead, they fall prey to narrow notions of productivity and coherence. Against this backdrop, social cooperatives, where groups of individuals drive the exchange of labor, are a promising avenue for meaningful engagement and foster a sense of community and purpose. Our efforts must extend to implementing affirmative action policies that cultivate social capital and foster substantive socio-economic, cultural, and political inclusion of HPMIs. Tamil Nadu will soon be the first state to unveil a policy that integrates many of these practical and well-thought-out approaches.

With this multifaceted approach, we hope to challenge reductionist views of HPMI as merely beneficiaries of charity who need to be liberated from their circumstances, and instead advocate for a framework that respects their agency, honors their choices, and supports their right to claim a place in society on their own terms.

Vandana Gopikmal is associated with The Banyan, The Banyan Academy of Leadership in Mental Health and Aradhamala and has been working with homeless people living with mental illness (HPMI) for 30 years. Supriya Sahu is Additional Secretary, Health and Family Welfare, Government of Tamil Nadu. This article was written in collaboration with Lakshmi Narasimhan, Director, The Banyan.