Recasting care models for mental illness and homelessness

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Socio-normative representations of homeless persons living with a mental illness (HPMI) have ubiquitously ascribed them to the role of refuge seekers. This has resulted in rescue missions that are singularly focused on transferring them, volitionally or coercively, to mental hospitals, shelter homes, beggars’ homes and even prisons. The primary assumption that HPMIs must be displaced from the streets because of the many risks that it poses, while valid, is also contestable.

As a mental health professional and bureaucrat, respectively, our perspective was similarly limiting over two decades ago, when we prioritised shelter and treatment over agency, choice and place-making. Social order, while it is of relevance and valuable in many contexts, can sometimes constrain the imagination and restrict responses that fall within the safer, more dominant narratives, albeit well-intentioned. That there is a social world not necessarily aligned to the mores of the day and that culture, freedoms and notions of safety can be experienced in non-typical ways take some getting used to.

Challenging notions, efforts at integration

Engagement with lived experience experts can often support this journey and challenge notions of what care and responsiveness constitute. Often, homeless persons form affiliations with local support circles that include fellow homeless persons, local eateries and pets, that offer them a self-curated sense of belongingness. Equally, and perhaps more significantly among the multitude of truths, is the narrative of oppression, scarcity, abuse, exposure to inclement weather conditions, and an exacerbation of symptoms associated with psychoses. Consequently, we would be loath to locate the problem in sacred and rigid binaries. It requires more than the paltry effort that is accorded now, to complicate the narrative and texture the phenomenon with the complexity that it deserves.

Noteworthy among a few efforts in India that have supported several HPMI reenter communities is the collaboration between the National Health Mission, the Tamil Nadu Department of Health, the Institute of Mental Health, The Banyan, the Azim Premji Foundation and local civil society organisations. This has resulted in access to emergency care and recovery centres (ECRCs) within district hospitals. This integration serves two purposes.

First it ruptures the hegemonic domination of large asylum-styled treatment spaces that perpetuate the stereotypical identity of a diseased mind. More importantly, it services an increased number of people with greater immediacy, ensuring last-mile proximal care and crises responses across scattered geographies. Overcrowding, limited human service professionals, the use of restraint, and poor personal attention have impacted care ecologies globally, just as they have in India.

A transformation that allows for design and social architecture adaptations in this context locates care in smaller units, are reasonably staffed, and mandate personal attention and better medical care to address comorbidities commonly found among those exposed to enduring adversities.

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While recent policy shifts represent progress, they also demand deeper engagement and longer term commitment. We must also critically examine when and why rights are stripped away, examine the attitude and practice of society and care professionals and develop leadership and governance systems that are adaptive, dynamic, reflective and address intricate dilemmas and contested issues.

In this context, especially among those who opt to sleep rough despite there being an availability of care options, the symbolism of appearance — matted hair or shaven heads — deserves careful consideration. As Obeyesekere notes, a shaven head can signify renunciation, when seen in contexts, from Vrindavan’s widows to residents of mental hospitals, and must not be immediately conflated with mental illness. Our approach, therefore, must be to be in continuous engagement, drawing frameworks for admission that respect individual agency. While the gains of intervention can be significant and the hardships of street life are real, coercive care often yields poor outcomes.

Problems with institutional spaces

Meanwhile, about 37% of people living in State psychiatric facilities and other care homes experience long-term needs, with a median duration of stay of six years. Most of them have histories of homelessness and have been typically brought 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, mandated that State governments undertake rehabilitative measures. In this context, the Department of Empowerment of Persons with Disabilities, under the Ministry of Social Justice and Empowerment, had filed guidelines for rehabilitation homes. Unfortunately, the imagination of community re-entry pathways for those living long term in psychiatric facilities remains cloistered: in semi-institutional or trans-institutional options that transfer their custodial existence from one place to another. Further, these considerations are limited in their conceptualisation of who is “cured” and therefore “ready for discharge”, imposing deterministic expectations of eligibility to live in the community. Besides perpetuating continued distancing from social resources and participation on equal terms, these institutional spaces risk defaulting to similar experiences of a lowered quality of life and violations of rights violations.

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Globally and in India, large-scale housing initiatives such as Housing First and Tarasha offer comprehensive social and clinical care and demonstrate the feasibility of such groundbreaking options for those with a range of disabilities and clinical needs. Similarly, over 700 people have accessed housing support and social care through the ‘Home Again’ collaborative across nine States in India, piloted first in 2018 as a research trial with support from Grand Challenges, Canada, and scaled up in partnership with the Rural India Supporting Trust. This has also been adopted by the Government of Tamil Nadu and other stakeholders nationally. For those transitioning from hospitals, with mild to moderate disabilities, hostel-like co-living facilities that symbolise enhanced social capital and security, rather than rehabilitation homes, may be considered.

Reframe support measures

Social protection and support measures for homeless people with mental illness require a radical shift and a reframing from paternalistic interventions to liberatory-focused strategies. A monthly priority disability allowance or out of work allowance of ₹1,500, while modest, could serve as a critical lifeline for those pushed to the margins of social hierarchy. By addressing the bureaucratic hurdles of securing Aadhar and facilitating banking access for HPMI, we pave the way for financial inclusion and economic empowerment.

These documentation and financial scaffolds, however, must be complemented by more imaginative and holistic approaches. In parallel, structural issues such as discrimination and violence, segregation and deprivation, need to be emphatically addressed. Towards this end, social care and post-discharge support must be strengthened and integrated within the District Mental Health Programme. As a result of initiatives led by state and non-state actors, service engagement among 800 mental health service users who exited the ECRCs over a three-year period is at 75% post discharge, which is higher than the global experience.

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Advancing economic justice demands confronting systemic barriers, elevating insights from marginalised groups, and creating transformative models that accelerate inclusion. Workforce participation, when thoughtfully facilitated, becomes a powerful tool for reappropriating economic space. Traditional employment models and vocational training initiatives are often not only disconnected from contemporary economic realities but they fail to account for individual agency, strengths and aspirations. Instead, they default to narrow notions of productivity and consistency. In this background, social cooperatives, where groups of individuals drive the exchange of their labour, offer a promising avenue for meaningful engagement, which fosters a sense of community and purpose. Our efforts must extend to cultivating social capital and implementing affirmative action policies that spur substantive socio-economic, cultural and political inclusion of HPMI. Tamil Nadu will be the first State that will soon release a policy that will integrate many of these pragmatic and studied approaches.

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It is our hope that this multifaceted approach will challenge the reductionist view of HPMI as mere recipients of charity to be extricated from their circumstances. Instead, it advocates for a framework that honours their agency, respects their choices, and supports their right to claim a place in society on their own terms.

Vandana Gopikumar is with The Banyan, The Banyan Academy of Leadership in Mental Health and Aaladamara and has worked with homeless persons living with a mental illness (HPMI) for three decades. Supriya Sahu is Additional Chief Secretary to the Government of Tamil Nadu, Health and Family Welfare. With contributions from Lakshmi Narasimhan, Director, The Banyan