Chapter 7.Pdf

VU Research Portal Homelessness and Mental Health Narasimhan, L. 2018 document version Publisher's PDF, also known as Version of record Link to publication in VU Research Portal citation for published version (APA) Narasimhan, L. (2018). Homelessness and Mental Health: Unpacking Mental Health Systems and Interventions to promote Recovery and Social Inclusion. General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal ? Take down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. E-mail address: [email protected] Download date: 30. Sep. 2021 Chapter 7. Homelessness and Mental Health Care: Lessons from The Banyan’s Experience in Chennai, Tamil Nadu Abstract 150 million Indians, or 1 out of every 10 individuals, are living with some form of mental ill-health (Gururaj et al., 2016). While there are no nationwide approximations of homelessness among those with mental illness, 1.7 million people were living without a home according to the Census of 2011, considered a gross underestimation. Prevalence of serious mental disorders is significantly higher among homeless people when compared to the general population. People with mental illness living on the streets in India are ensnared into a disenfranchised, invisible, fringe existence that is more often than not predicated by a background of extreme poverty and critical life incidents. Few responses with an emphasis on social care have emerged in the Indian context, predominantly led by civil society actors, to tackle the crux of this complex nexus between mental illness and homelessness. This paper describes the experience of The Banyan, India in developing a continuum of care for homeless people with mental illness. More specifically, the Emergency Care and Recovery Centre which offers crisis intervention to reintegration services for homeless women with mental illness is examined. It frames within the narratives of these experiences, implications for mental health policy and practice for an extremely marginalised population. In particular, prospects for issues of long-term care and inter-sectoral service integration for the homeless population are considered in the light of recent developments in progressive disability and mental health legislation in India, that offer unprecedented opportunities to catalyse such niche innovations into a countrywide mental health system. 87 Background In the last decade, mental health has witnessed a rapid and substantial increase in burden of disease, contributing to over 13% of years lost due to ill health (Vigo, Thornicroft, & Atun, 2016). 150 million Indians, or 1 out of every 10 individuals, are living with some form of mental health issue (National Mental Health Survey, 2016). Less than 10% of people with common mental disorders and only 40-50% of people with schizophrenia are estimated to be accessing any form of care (Patel et al., 2016). Mental health is chronically underfunded and under-resourced in India. While the District Mental Health Programme (DMHP) initiated in 1982 has finally been extended to cover a majority of the districts in the country, it predominantly offers specialist camps failing to offer much of the envisioned community-based care under the limited public health infrastructure (Mental Health Policy Group DMHP, 2012; see also Jain & Jadhav, 2009). Forty-three state-run mental health hospitals and psychiatric units in district hospitals in India offer between them 20,000 beds in the public sector, less than 2 for every lakh of the country's population (Murthy, Kumar, Desai, 2016). The recent report by the National Human Rights Commission, that has been monitoring the quality of mental hospitals following a Supreme Court directive over a decade earlier, indicates that despite infusion of investments as Centres of Excellence in infrastructure, there is a long way to transforming several hospitals into human rights compliant spaces of care (Murthy et al., 2016). Further services are left crippled by lack of human resources, in terms of quantity with insufficient psychiatrists, social workers and psychologists (Murthy et al., 2016) and quality as staff work and train under overburdened systems that persist with simplified medicalised orientation (Jain & Jadhav, 2009). Within this sobering scenario, homeless people with mental illness represent an even more marginalised population. While there are no nationwide approximations of homelessness among those with mental illness, 1.7 million people were living without a home according to the Census of 2011, considered a gross underestimation. A systematic review of studies conducted in Western countries found the prevalence of serious mental disorders to be significantly higher among homeless people when compared to the general population (Fazel, Khosla, Doll, & Geddes, 2008). Poverty, mental illness and homelessness interact in a vicious, unrelenting, often recurrent cycle. Poverty 88 represents a significant risk factor for mental health issues (Sullivan, Burnam, & Koegel, 2000; see also Read, 2010) and for rendering people with mental illness from a particular stratum homeless (Hudson, 2005). Ethnographic observations by Parkar et al. (2003) showcase how environmental and social contexts and intersecting afflictions play a substantive role in shaping up mental health responses. In their study across several cities, Draine et al. (2002) conclude that poverty moderates the relationship between mental illness and social problems such as unemployment, crime and homelessness. Morrow et al. (2012) juxtapose the possibility of women with mental illnesses, in postcolonial India, being abandoned, not necessarily on the streets, but within domestic spheres, where they are made to exist, tied down without treatment possibilities, due to lack of mobility, care and pervasive culture. Housing instability in combination with schizophrenia increases risks of homelessness (Drake et al., 1991). Global literature in other low-medium income countries indicates a significant association between stressful life events among people with mental illness and episodes of homelessness. Complex, multiple trauma accompanies the experiences of homeless people with mental illness, sexual abuse beginning from childhood, death of parent/primary carer, violence in intimate partner relationships and so on (Vázquez & Muñoz, 2001). Such trauma is often further exacerbated when people with mental illness move away from their homes and live in adverse environments on the streets, with limited access to food, safety and in a state of compromised health. In a resource scarce environment, people caught at the intersection of homelessness and mental illness can only choose between almost inevitable long-term incarceration in state mental hospitals, criminalisation under state beggary acts to continually re-enter beggar's homes or life on the streets. Nearly half of the estimated long stay service users in state mental hospitals in India have a history of homelessness. Desai et al. (2006) point out that involuntary admission of homeless people with mental illness is an existent truth, wherein ‘ethical dilemmas' are conflated with a pressing need to provide ‘clinical services' leading to restrictive care, chronicity and subsistence of illnesses. Yet for social justice to be truly achieved in this country, their complex histories and needs demand a humanistic and comprehensive response that enables them to participate fully in their lives and society. Civil 89 society responses in India, such as Iswar Sankalp (Kolkata), Koshish (Mumbai), Ashadeep (Guwahati), and some state-run institutions such as NIMHANS (Bangalore), IHBAS (Delhi), Government Mental Hospital (Ahmedabad), present a contrasting experience and offer a sliver of hope for homeless people with mental illness to more than just exist. Recently, some literature describing outcomes from services delivered by psychiatric units in medical colleges has emerged (Tripathi et al., 2013; see also Singh, Shah, & Mehta, 2016; Gowda et al.,2017). However, Saraceno et al. (2007) note how such initiatives are not complemented by a ‘swelling public opinion on mental health needs' which can materialise as the much needed catalysing push for greater bureaucratic action. The Mental Health Act of 1987 has been replaced with newer progressive legislation, the Mental Healthcare Act 2017 intended to be compliant with the United Nations Convention on Rights of the Disabled (UNCRPD). Mental health features more substantively beyond being merely listed as a disability in the new Rights of Persons with Disabilities Act 2017. The Mental Health Policy formulated a few years ago dedicates a section to the issue of homelessness among people with mental illness. These developments present an unprecedented opportunity in the form of intent. Besides catalysing public opinion towards action, what implications may be drawn

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