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Homelessness and Mental Health Narasimhan, L.

2018

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citation for published version (APA) Narasimhan, L. (2018). Homelessness and Mental Health: Unpacking Mental Health Systems and Interventions to promote Recovery and Social Inclusion.

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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.

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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

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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

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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 from local implementations to shape public policy and practice and bridge the know-do gap in working with this unique constituency? In this article we describe the work of The Banyan in Chennai, most familiar to us through our professional association, to answer this question.

The Banyan: A continuum of care for homeless people with mental illness The Banyan, founded in 1993, began as a rescue, crisis and rehabilitation centre for homeless women with mental health issues, and has over the last twenty-five years, expanded to offer a range of comprehensive mental health solutions for people who are either homeless or living in a state of abject poverty. This first shelter facility offered a residential community in a home, family-like environment to the niche constituency of homeless women with mental illness. Within a year of starting Adaikalam, that was initially envisioned as a long-term safe space for 30 women; we had already reached

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out to over 70. As women recovered, their expressed needs of journeying back to their families emerged and reintegration as a methodical process of enabling women to trace back their roots, with even minimal details of their origins such as the name of a village, was instituted. The experience of successful family reintegration led to the realised that poverty and lack of localised care rather than abandonment was the reason for homelessness. Continuity of care emerged as a priority.

From 1996 onwards, The Banyan expanded capacity by constructing a new premises and began to offer multiple aftercare options for those who had left the shelter. In response to diverse pathways out of the facility sought by clients, reintegration expanded options for self-discharge, employment, living in group homes and referrals to non-mental health institutions. Multidisciplinary care, with departments, clinical processes and referral systems, was strengthened. This included critical time interventions, medical care, psychiatric reviews, psychological and social interventions such as the use of therapeutic community approach, case management, access to work and social engagement options, and comprehensive discharge planning leading to reintegration with families/communities of choice and continued aftercare.

Quality systems within institutional care to focus on micro-level details such as the privacy and dignity in bathing process, availability of minimum assets such as brush, fitted coordinated clothes and so on, were introduced. We also initiated service user audits, access to an external human rights committee and therapeutic community meetings. Several service users became part of the organisation's workforce, and user-led initiatives such as support group meetings and peer counselling or social enterprises were encouraged. Adaikalam or the Transit Care Centre, now called the Emergency Care and Recovery Centre (ECRC) operates as a tertiary care facility that assists homeless women with mental illness in achieving their desired social recovery outcomes by offering multidisciplinary interventions that are personalised and collaboratively planned. The ECRC has reached out to nearly 2000 homeless women with mental illness over twenty-five years.

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Between 2004-2015, in response to the needs of a growing number of long- stay clients at the ECRC, we developed inclusive living options that support the socio-economic-political participation of users with low to high levels of disability. These include Clustered Group Homes (CGH) (a row of group homes co-located with our sister academic concern, The Banyan Academy of Leadership in Mental Health) and Home Again (rented accommodations in the community shared by 4-5 women with graded levels of support offered by a personal assistant). 200 women access these options to experience the lives they desire. The Shelter for homeless men with psychosocial needs was collaboratively set up with the Corporation of Chennai as an alternative, user- initiated service contact option that offered in a smaller facility of 30 beds integrated mental health and social care within an inclusive ambience that included after-school academic support, livelihood training, a balwadi (creche) for the broader community. 270 men have accessed the services of The Shelter.

By 2012, with a more nuanced understanding of the complex causation pathways that led to homelessness among people with mental illness which went beyond lack of localised access to care, we consolidated our community mental health projects in urban and rural geographies under NALAM, a well being oriented approach, combining early identification and clinical care with broader community engagement and socio-economic welfare interventions, delivered through a network of grassroots mobilisers, outpatient clinics and community-based activities. 10,000 people have benefitted from NALAM since the start of our first outpatient clinic in 2003.

Work participation and engagement constitutes a critical part of services across all projects and range from opportunity to earn incentive making a product in-house, employment in kitchen, security, housekeeping, data entry, reception and hospitality, or in external factories, homes, offices, beauty parlours, and user owned micro businesses such as a petty shop, a laundry unit and so on. The varied options consolidated under a unified Skills Development and Social Enterprise wing. 40% of people who are in our care are employed, either internally or externally. During the course of The Banyan’s journey, some women have arrived at our facility along with their children or have later reunited as single parents. Through NALAM and Home

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Again, Children living with parental mental illness (CPLMI) are offered mentorship and academic support.

The Banyan’s evolution from a shelter to a comprehensive mental health system that spans services across the lifespan, from prevention to crisis intervention, has been in response to better articulation and understanding of needs of service users who are doubly disadvantaged with mental illness and homelessness. Given the current scenario of mental health in India, with deficits in availability, accessibility and appropriateness on the one hand, and unprecedented opportunities to fill these given the newly enacted acts in mental health and disability, what are the implications and prospects emerging from The Banyan’s experience? How can these be translated into a larger agenda for mental health policy and practice so that we can move towards newer socio-economic realities for homeless people with mental illness?

To answer these questions, we begin by presenting data of homeless women with mental illness who were offered care at The Banyan Emergency Care and Recovery Centre between 2014-2017 (up to September 2017) maintained by The Banyan’s Monitoring and Evaluation Systems. Reintegration of homeless women with mental illness and the extent of continued care have been examined as outcomes.

Reintegration and Aftercare outcomes of the Emergency Care and Recovery Centre Primary diagnoses of Psychosis and Schizophrenia Between 2014-2017, The Banyan offered critical time interventions for 203 women who were homeless at the Emergency Care and Recovery Centre (ECRC), of whom 196 were diagnosed with a mental illness (Table 7.1). Table 7.1 describes the background characteristics as available at the time of admission. The diagnosis was determined over the course of stay. The mean age of women rescued by The Banyan during this period was 40.5 (SD=9.94), with over half of them from Tamil Nadu (59.11%) followed by Andhra Pradesh (8.37%) and Bihar (7.39%). Psychosis not otherwise specified (37.44%) and Schizophrenia (29.06%) were the most common diagnoses. Lack of food and adequate water intake during period of being homeless may cause altered mental health status temporarily. Five women were found to

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have no psychiatric symptoms during their stay - 2 discharged themselves, 1 was assisted in tracing family, 1 was assisted to find another institutional facility, and 1 of them chose to continue living with us.

Co-occurring health conditions More than half the population (52.2%) additionally had physical health conditions that required attention anaemia, skin lesions and infected wounds, tuberculosis, cancer, dyslipidemia and hypothyroidism. In most cases, more than one condition was diagnosed. Anaemia was the most common diagnosis (40.9%). Five women were HIV positive at time of admission.

Critical Life Events Systematic data on history of homelessness and critical incidents are not available for the entire sample. However, a survey conducted for a study of factors associated with homelessness among women accessing our outpatient clinics revealed that 32.36% of them had experienced homelessness, and the odds of homelessness among women with mental illness increased with low educational attainment, living in an urban area and negative experiences with close kin (breaking of a steady relationship, abuse, separation due to marital difficulties and abandonment). Early analysis of data from a qualitative study (currently in progress) at The Banyan to understand narratives of illness and recovery among homeless women with mental illness presents a pervasive experience of sexual violence and structural barriers:

“... And if I speak about it, the middle part of my head really hurts. Because they threw so many stones at me. Like a mad lady, they were throwing all the stones at me. Please don't tell X that they raped me; she will feel very bad.” -P

“When I was young, a person raped me before marriage, I was probably seven or eight years old during that time. He was from my village. And had an elderly brotherly relation to me' I did not even know what was happening to me. That's why so many problems in my family after marriage. I couldn't have sexual relations with my husband” -A

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“When we were on the road, my mother wouldn't let me go out even a little bit. The police beat her, her hand still is twisted, and she was worried about me. She would keep me in her lap and say, if you are going to get killed, only I should kill you" -R

“I wandered, and two people on the streets said they would give me food and then they misbehaved with me. This has happened a lot of times with me. Once I conceived and had to have an abortion done” -L

“The owner of the shop would always keep his hands on my stool, on top of my head, and below my bums. I didn't like such treatment from him" -M

“My mother didn't have much cash. So, we were using public bathrooms. Still, we are using public bathrooms built by the village panchayat. We haven't built a bathroom in our house yet. We find it quite difficult since we have to walk quite distances to go for bathroom” -S

“In our childhood, we used to suffer a lot. .. Around 200-300 sq ft and one common room and all of us would sleep together. There was no bathroom. We used to go to a forest…...One of my brothers used to have sex with me and spoke very badly about me to my fiancé which spilt my life completely” - G

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Table 7.1: Background characteristics of women admitted to the Transit Care Centre, The Banyan 2014-2017 (n= 203) M SD Age 40.5 9.94

N % Diagnosis Psychosis NOS 76 37.44 Schizophrenia 59 29.06 Bipolar Disorder 31 15.27 Intellectual Disability 21 10.34 Others 7 3.45 No Psychiatric Symptoms 5 2.46 Alcohol Use Disorder 2 0.99 Not yet diagnosed 2 0.99

Concurrent Physical Health Conditions Yes 106 52.22 No 97 47.78

Marital Status Married 103 50.74 Single 30 14.78 Unknown 28 13.79 Widowed 22 10.84 Separated 18 8.87 Divorced 2 0.99

Religion Hindu 165 81.28 Muslim 17 8.37 Christian 15 7.39 Unknown 6 2.96

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N % State of Origin Tamil Nadu 120 59.11 Andhra Pradesh 17 8.37 Bihar 15 7.39 Others 45 22.17 Unknown 6 2.96

Primary language spoken Tamil 120 59.11 Hindi 43 21.18 Telugu 20 9.85 Others 18 8.87 Unknown 2 0.99

Reintegration Table 7.2 summarises admissions and discharges between 2014-2017. Over three fourths (75.35%) were discharged during the same period, with a majority returning to family or independent living through self discharge (60.6%). 15.76% of women who required long-term care options were referred mostly to other institutional facilities followed by The Banyan's inclusive living options for long-term care. Our Clustered Group Homes (CGH) facility had run short of space to accommodate more people, and in 2014 with the initiation of Home Again, women who required continued care with high to moderate levels of support were referred to this service located in urban and rural neighbourhoods. 38 women continue living at the ECRC, and within this 19 of them have lived with the institution for over 1 year and are expected to require long-term care options. Therefore, the proportion of women from the 2014-2017 cohort with long-term care needs is 27% (55). Only one death due to natural causes and age was reported, and nine women walked out of the ECRC facility, and their whereabouts and current status are unknown.

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Table 7.2: Admissions and Discharges from the Emergency Care and Recovery Centre (ECRC) 2014-2017 n=203 N % Admissions 203 100.00 Discharges 155 76.35 Reunited with family 117 57.64 Referred to Other Institutional Facilities 18 8.87 Referred to The Banyan's Clustered Group 4 Homes facility for Long Term Care 1.97 Referred to The Banyan's Home Again for 10 Long Term Care 4.93 Self-Discharge 6 2.96 Deaths 1 0.49 Left on their own account 9 4.43 Continue living at ECRC 38 18.72

A year on year examination of reintegrations reveals that rate of reintegration has improved since 2014 (Table 3). While in 2014 only 20.51%, reintegrated back to the family within the first year of their admission to ECRC, by 2017 54.29% of women, who sought admission, recovered and reunited with their families. Overall we also see a declining trend in average number of days women stay at the ECRC before making the journey back to their homes. Several factors could have potentially contributed to this improved reintegration rate as well as lower average length of stays. There were minimal incremental changes to ECRC's ethos of care and processes based on user audits. These included quality enhancements and protocol development across phases of care ranging from critical time interventions to psychological and social care interventions such as livelihood facilitation, legal aid, assertiveness training and confidence building to be able to assume valued social roles. However, the size of the facility changed from 171 average occupancy in 2014 to 100 in 2017. More significantly, the proportion of

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people with one or more year stays in the total population reduced over time from 80% in 2014 to 19% in 2017.

Table 7.3: Clients reintegrated from ECRC and Length of Stay by Year of Admission Length of Year stay (in of Reintegrated % (N) days) Admissio Admission n s N Year 1 Year 2 Year 3 Year 4 Mdn (IQR) 12.82 2014 39 20.51 (8) 30.77 (12) (5) 2.56 (1) 396 (419) 2015 62 24.19 (15) 35.48 (22) 8.06 (5) 0 303.5 (409) 2016 67 34.33 (23) 19.40 (13) 0 0 252 (289) 2017 35 54.29 (19) 0 0 0 77 (61)

Aftercare coverage Of those discharged, 141 returned to living arrangements outside of The Banyan's residential options (ECRC, CGH and Home Again) either to their family, living independently or in other institutional facilities (Table 7.4). Five women have returned to ECRC as the families were unable to care for them. Four women went missing from the family or institutional facility, and there were three deaths including one by suicide. 57.45% of women continue to receive ongoing care through our aftercare services either through outpatient clinics, postal medication or care partners in the country. Excluding readmissions, women missing from home, those who do not need medication, deaths and readmissions who fall beyond the purview of these services or cannot receive them anymore, the effective aftercare coverage is 65.85% (81 out of a total 123 women). An equal number of people receive continued care services at outpatient clinics which includes clinical reviews, case management, social care (disability allowance and securing state entitlements) and home visits, and through postal medication, which includes delivery of medication every quarter based on yearly reviews and phone-based follow up. Only a minority (7.8%) have been referred to local services as paucity of local mental health services that can offer post-discharge care, to

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minimise risks of re-hospitalization or homelessness, continues to be a challenge - seven continue treatment at local civil society organisations, three access government mental hospitals and one prefers a private facility.

Table 7.4: Current Aftercare Status of Clients discharged to families/facilities outside The Banyan 2014-2017 (n= 141) N % In Aftercare 81 57.45 Postal Medication 33 23.40 Outpatient Services 37 26.24 Aftercare Network Partner 11 7.80 No contact 42 29.79 No medication needed 6 4.26 Missing 4 2.84 Deaths 3 2.13 Readmission 5 3.55

Despite enrolment into an aftercare service with a plan for continued care at the time of discharge, we have lost contact with 46 women, more than a quarter, who have exited ECRC. 31 of such women are from Tamil Nadu. Systematic data on reasons for service disengagement are unknown. Feeling better, migration and switching to another service provider are the most common reasons that emerge from a routine examination of dropout from outpatient clinics of The Banyan. Ceasing treatment when people feel better without waiting for clinicians to titrate or step down as per protocol is often observed in many chronic diseases such as diabetes and asthma (Bosley, Fosbury, & Cochrane, 1995). Similarly, discordance between user-carer expectations for recovery and gains they experience precludes a tendency to seek other avenues that they hope will result in more meaningful outcomes (Shepherd, Boardman, & Slade, 2008).

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Overall, ECRC as a multidisciplinary intervention beginning from critical time interventions, clinical and social care at the facility leading up to exit pathways of choice has been successful in assisting over three-fourths of those who receive such services to return to their family or to live in the community independently. Further, a prospective study of outcomes among women with long-term care needs enrolled in the Home Again intervention involving housing with supportive services reveals a significant effect of such an intervention when compared to as usual care in institutional settings with increased community integration (participation in home, at work and in the community) and reduced disability. Globally housing interventions for homeless people with mental illness have demonstrated reduced days on the streets as an outcome. The experiences of The Banyan in implementing personalised services to support homeless women with mental illness with diverse needs, symptom status and disability levels is unique in its impact on social recovery outcomes such as return to work, pursuing lived experiences with personal meaning social roles and social inclusion. Home Again (INR 8000 per person per month with high support, INR 1500 per person per month for Independent living), the Clustered Group Homes (CGH) intervention (INR 10000 per person per month), both cost lower than ECRC (INR 14000 per person per month). Given their inherent inclusive nature of living and gains for quality of life for those with low to high disability, these approaches are feasible options to adopt for people who may need these to prevent long-term incarceration and stays beyond a year in tertiary facilities. Aftercare in this continuum of care operating within constraints of limited localised services has continued to engage with two-thirds of women returning home to assist them in sustaining recovery and preventing recurrent hospitalisation or episodes of homelessness.

Lessons and implications for the mental health sector Address crisis of people with long-term care needs Despite all efforts The Banyan undertakes to reintegrate people back to families or enable them to live independently, there remains a cohort that requires long-term service support. In 80% of these cases, we have been unable to reunite women because of lack of information for two reasons: half of such women have high disability while others do not wish to return to environments where they have experienced violence. In a minority of cases

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families, which already face deprivations, are ill-equipped to care for people with mental illness especially if they are not actively contributing to the household income or are visibly deviating from normative expectations of appearance and behaviour in the neighbourhood. Institutional mental health facilities across the country are looming under this invisible crisis of people incarcerated for long years. The right of people with mental illness to live lives of their choosing as any other citizen in a democratic nation is severely compromised by extending their stays in closed facilities beyond the acute phase of illness. In February 2017, the Supreme Court of India issued an order directing the Centre to develop a policy for long stay service users in mental hospitals in response to a petition that highlighted the issue. Mixed experiences of deinstitutionalisation in the Western nations during the 1970s and the current reality of sizeable long stay populations of homeless people with mental illness in prisons in the United States, ought to serve as a warning for us to not adopt a rapid discharge policy in haste. Our experiences with Home Again, studied prospectively with an as usual care group receiving institutional care, demonstrate that with adequate and appropriate supports and emphasis on a high quality of life for people with mental illness, even those with high disability encounter gains and return to social roles and participate in the socioeconomic fabric of communities. We recommend the development of a carefully thought out policy that draws out individualised rehousing options, whether through reintegration with family, housing with supportive services or independent living with employment, while parallelly investing in supportive community care resources.

Comparison of limited background characteristics available at the time of admission between those who return home successfully and those who continue long term does not reveal any significant differences. However, this may be because the differences lie in household characteristics, carer attributes and more thorough data on history and trajectories of mental illness and homelessness. Research to uncover reasons for these diverging realities among homeless people with mental illness may assist in better planning and service provision including mitigating risks for long-term disability.

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Large-scale institutional mental health transformation State mental health facilities need to be extricated from the vestiges of the colonial era and refreshed in their social architecture that includes ethos, systems and processes of care, and not merely in infrastructure or academic and research capacities. Due to power imbalances being tipped unfavourably towards people with mental illness, Maj (2011) extrapolates on the need for rights fostered care provision, without which delayed remission, stagnant symptomatology and amotivation become realities. Spatial reorganisation and infrastructure investments must directly impinge on service user’s opportunities to pursue recovery, in such a way that liberation of self, is possible without constraining the needs that may present because of the illness. The potential consequence of such ‘built environments’ is mirrored by Evans (2003) who prospectively links social ecologies to better psychosocial outcomes. In The Banyan's experience, in a bid to do more the institutional facility grew too large and disproportionately with long stay users. Rationalising ECRC's bed strength and incrementally enhancing institutional capacities to be user centred and accountable has contributed to better quality care and faster recovery and return to families for homeless women with mental illness. Therefore the discourse on mental hospitals, which undoubtedly suffer from deep-rooted hegemony but can evidently support recovery if the locus of care is reoriented, needs to move away from deinstitutionalization to critical questions of what size should such hospitals be, what should be the staffing structure and most critically what will be the driving philosophical non-negotiables permeated as culture at all levels that assure service users are full participants in the process of recovery. It becomes critical to identify leadership that can drive this transformation across the country and negotiate the difficult terrains of spaces that languish in years of apathy. Such an effort has the potential for long-ranging consequences for the mental health sector in India, with improved outcomes among people with mental illness, reduced stigma and discrimination with increased personal evidence of positive recovery gains, and increased staff morale.

Rethinking human resource structure The Banyan's services are primarily delivered by a trained and supervised lay cadre or a non-specialist workforce who are themselves drawn from difficult socio-economic circumstances. Over years, experiential experts, service users

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and carers, have come to occupy many of these roles as peer advocates in the system. There is increasing evidence from across the world that a wide variety of interventions may be successfully delivered with high fidelity by appropriately trained and supervised lay workers who do not necessarily possess professional qualifications in mental health (van Ginneken, Jain, Patel, & Berridge, 2014). The ‘feasibility of such local partnerships’ and ‘task sharing models’ can help in bringing in ease in service delivery and reduce workload burden as well as address key logistical challenges that may crop up with a one-sided dependence on specialists (Mendenhall et al., 2014). Further, for services to take cognisance of social determinants of mental health and conscientiously deliver interventions to address these, roles of various disciplines other than psychiatry such as social work within the mental health system need to be invigorated to depart from a fallacious and often default physician assistant roles to that of specialists who offer inputs derived from their disciplines. Establishing cross-sectoral linkages with existing cadre of poverty alleviation and disability programmes to offer mental health care may be necessary to quickly increase availability of staffing for upscaling of services. Addition of negotiator roles at the grassroots level in both institutional and community settings to assist people in navigating care resources, both clinical and social, may become pertinent for achieving gains on the social justice front. Effective mental health delivery also requires cultivating leadership and management among human resources so that staff can sustain quality, fidelity to original goals and adapt and innovate services in response to changing realities and new emerging needs.

Early intervention and strengthening support networks: Community mental health with a development agenda As much as crisis intervention is a priority, prevention of people with mental illness lapsing into homelessness needs to be pursued. Prognostic value of early intervention in psychotic disorders is well established in literature - length of untreated psychosis is associated with chronicity and poor outcomes (M. Marshall, S. Lewis and A. Lockwood et al., 2005; see also Craig et al., 2004) while intervention at the critical early phase of onset predicts social and vocational functioning (Perkins, Gu, Boteva, & Lieberman, 2005). Specialised early intervention services that run in liaison with primary care such as TIPS, RAISE, OPUS and LEO have demonstrated positive gains of better

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functioning, reduced inpatient care use and independent living (Johannessen et al., 2000; Rosenheck et al., 2016; Petersen et al., 2005; Craig et al., 2004). The District Mental Health Programme may be mandated with a focused early identification component especially among vulnerable populations followed by intensive specialist team engagement with identified individuals in community care settings for a 2-5 year period followed by transfer to maintenance teams and appropriate escalation in the event of loss of gains. Similarly, people discharged from tertiary care/inpatient settings, those with a history of homelessness and those running a chronic course with unremitting symptoms or absolute poverty require specific attention and consistent engagement to support their living in the community and reduce the use of inpatient resources.

If identification and provision of care are essential, as are efforts to make sure that people do not spiral down the trapdoor of homelessness or illness. Interconnecting clinical pathways to grassroots mechanisms such as routine engagement by a community-based mobiliser leads to development of social protective networks that may mitigate some of the risks. Ginneken et al. (2014) discuss on how latitudinal diffusion of resource intensive operations to more catchment areas, alongside reorientations of primary caregivers, can aid in walking away from ‘biomedical models' to ‘a process of thinking' needed for lengthened well being. Stakeholder engagement that connects beyond the user-carer combine - members of general public, post office, auto drivers, village health nurses, neighbours, balwadi (creche) teachers-anyone who will be able to yield relevant influence and create further valid linkages of care, within their roles, have to be identified and maintained in interpersonal contexts. A study by Glanz et al. (2008) documents the ‘direct' effects and the ‘buffering' effects of such exercises in social relationships - ‘helps in managing uncertainty' and ‘validating emotions', leading to less psychological distress. [ Causation pathways for homelessness among those with mental health issues are multivariate and occur more often than not when a combination of social deprivation and disadvantage persists alongside mental illness. Seng et al. (2012) suggest that lack of access due to intersectionality may impinge upon users lives to such an extent as to push them into a state of ‘double jeopardy'. Social factors such as hunger, violence, discrimination lead to enduring social

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liabilities. Health systems that seek out those at risk but offer only biomedical solutions, neglecting the individual illness narratives of social disadvantage and heightened vulnerabilities, may not be sufficient to prevent or address homelessness among people with mental illness. Read (2010) posits that social causation explains how poverty causes psychosis while social drift accounts for how poverty is involved in its maintenance. In our particular experience with women, gender-based violence and disempowered status of women emerge as risk factors. Removing poverty and structural violence which are significant contributors to both mental ill health and homelessness must form a part of public health priority through intersectoral agreements and collaborative delivery with social sector department even if the health system does not directly implement such measures.

The economic, social and moral costs of unaddressed needs of people with mental illness are enormous with unemployment, lost productivity of both user and carer, higher costs of health care and welfare spending as those with mental illness are disproportionately poor. As a nation, our collective goal of economic and social prosperity can never be met until we remain oblivious to the peripheral existence of homeless people with mental illness. Public investments in early and appropriate development assistance - universal access to food, health, education and basic income - and unyielding focus on social justice can lift people out of poverty and establish an egalitarian ecology that presents opportunities for the most marginalised groups to thrive.

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