Socio-normative representations of homeless people with mental illness (HPMI) have ubiquitously assumed the role of shelter seekers. This led to rescue missions that focused exclusively on transferring, voluntarily or forcibly, to mental hospitals, shelters, beggars’ houses and even prisons. The main assumption that HPMI should be moved off the road because of the many risks it poses, although legitimate, is also debatable.
As mental health professionals and bureaucrats, our perspectives were limited more than twenty years ago, when we prioritized shelter and treatment over agency, choice and place-making. Social order, although relevant and useful in many contexts, can sometimes constrain the imagination and limit responses to safer and more dominant narratives, even with good intentions. That there is a social world does not have to be aligned to the customs of the day and that culture, freedoms and the notion of safety can be experienced in a non-typical way to take some get used to.
The notion of challenges, efforts in integration
Engagement with lived experience experts can often support this journey and challenge notions of care and responsiveness. Often, homeless people form affiliations with local support circles that include local homeless people, restaurants and pets, which gives them a sense of belonging. Equally important, and perhaps more important among the many truths, is the narrative of oppression, scarcity, abuse, exposure to adverse weather conditions, and the exacerbation of symptoms associated with psychosis. Consequently, we will not find these problems in pure and rigid binaries. It will take more than the small amount of effort currently being done, to flesh out the narrative and texture of the phenomenon with the complexity it deserves.
Notable among the several efforts in India that have supported some communities re-entering HPMI are collaborations between the National Health Mission, Tamil Nadu Health Department, Institute of Mental Health, Banyan, Azim Premji Foundation and local civil society organizations. This results in access to emergency care and recovery centers (ECRCs) in district hospitals. This integration serves two purposes.
The first breaks the hegemonic dominance of large asylum-style treatment spaces that preserve the stereotyped identity of the mentally ill. More importantly, this service increases the number of people rapidly, ensuring last-mile proximal care and crisis response in scattered areas. Overcrowding, limited human service professionals, use of restraint, and poor personal attention have an impact on the global care ecology, as in India.
The transformation that allows the adaptation of design and social architecture in this context finds care in smaller units, with sufficient staff, and provides personal attention and better medical care to overcome the common comorbidities found among those who suffer.
While recent policy changes show progress, they also demand deeper engagement and long-term commitment. We must also critically examine when and what rights are stripped away, examine the attitudes and practices of the community and professional care and develop leadership and governance systems that are adaptive, dynamic, thoughtful and address complex dilemmas and contested issues.
In this context, especially among those who choose to sleep rough despite treatment options, the symbolism of appearance – matted hair or shaved head – should be carefully considered. As Obeyesekere notes, a shaved head can mean rejection, when seen in context, from the widows of Vrindavan to the residents of mental hospitals, and should not be immediately associated with mental illness. Thus, our approach must be one of ongoing engagement, drawing on a framework for recognition that respects individual agency. While the results of interventions can be significant and distressing in real life, coercive treatment often produces poor results.
The problem with institutional space
Meanwhile, about 37% of people living in State psychiatric facilities and other care homes experience long-term needs, with an average duration of six years. Most of them have a history of homelessness and are usually brought into the system as a result of police and court intervention. In 2017, the Supreme Court of India, in response to public interest litigation, ordered the state government to implement rehabilitation measures. In this context, the Department of Empowerment of Persons with Disabilities, under the Ministry of Social Justice and Empowerment, has proposed guidelines for rehabilitation homes. Unfortunately, the imagination of community re-entry paths for people living in psychiatric facilities remains closed: in semi-institutional or trans-institutional options that transfer custodial existence from one place to another. Furthermore, these considerations are limited to the conceptualization of who is “cured” and therefore “ready to be disposed of”, imposing deterministic expectations of who has the right to live in society. Besides keeping a distance from social resources and participation on the same terms, the institutional space is at risk of failing to experience the same in terms of reduced quality of life and violation of rights.
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 these breakthrough options for people with disabilities and clinical needs. In addition, more than 700 people have accessed housing support and social care through the collaborative ‘Home Again’ in nine states in India, the first pilot in 2018 is a research trial with the support of Grand Challenges, Canada, and improved in partnership with Rural India. Support Trust. It has also been adopted by the Government of Tamil Nadu and other stakeholders nationally. For those moving from hospital, with mild to moderate disabilities, hostel-like co-living facilities that represent better social capital and security, rather than rehabilitation homes, may be considered.
Reframe measures support
Protection and social support measures for homeless people with mental illness require a radical change and reframing from paternalistic interventions to strategies focused on freedom. A monthly priority disability allowance or a work allowance of ₹1,500, however meager, can be a critical lifeline for those pushed to the edge of the social hierarchy. By overcoming bureaucratic hurdles to secure Aadhar and facilitating banking access for HPMIs, we are paving the way for financial inclusion and economic empowerment.
This financial documentation and scaffolding, however, must be complemented by a more imaginative and holistic approach. In parallel, structural problems such as discrimination and violence, segregation and deprivation, must be dealt with decisively. For this purpose, social care and post-discharge support should be strengthened and integrated in the District Mental Health Program. As a result of initiatives led by state and non-state actors, service engagement among 800 mental health service users discharged from the ECRC in three years was 75% after discharge, which is higher than the global experience.
Advancing economic justice requires confronting systemic barriers, increasing the perspectives of marginalized groups, and creating transformative models that accelerate inclusion. Labor participation, if facilitated thoughtfully, is a powerful tool for reclaiming economic space. Traditional employment models and vocational training initiatives are often not only disconnected from contemporary economic realities but fail to embrace individual agency, power and aspirations. However, they default to a narrow understanding of productivity and consistency. Against this background, social cooperatives, where groups of individuals encourage the exchange of labor, offer a good way of 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 to release a policy that will incorporate many of these pragmatic and learned approaches.
It is our hope that this multifaceted approach will challenge the reductionist view of HPMI as a recipient of charity in order to be freed from its circumstances. Instead, they support a framework that respects agency, respects their choices, and supports their right to claim their 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 been working with homeless people with mental illness (HPMI) for three decades. Supriya Sahu is the Additional Chief Secretary to the Government of Tamil Nadu, Health and Family Welfare. With contributions from Lakshmi Narasimhan, Director, The Banyan