Providing care for those suffering from serious mental illness had been a legitimate function of state government since 1766 when the first psychiatric hospital opened in Virginia. This practice remained in effect and virtually unchanged for approximately 200 years.

But in 1955, major changes in mental-health treatment were on the horizon. The introduction of new medications like Haldol, Prolixin and Navane to treat the serious and difficult symptoms of schizophrenia and the drug Lithium to treat manic-depressive patients brought hope to the field of psychiatry. There was now new potential for those reduced to a lifetime of institutionalization. That potential meant deinstitutionalizing many patients. It also meant placing emergency responders on the frontlines of situations involving the mentally ill.

Deinstitutionalization is a long-term trend wherein fewer people reside as patients in mental hospitals and fewer mental health treatments are delivered in public hospitals. This trend is due directly to the process of closing public hospitals and the ensuing transfers of patients to community-based mental health services. It moves patients to more health care settings in a larger geographic area.

Deinstitutionalization also illustrates evolution in the structure, practice, experiences and purposes of mental health care in the United States. The ideology goes that it is inhumane to keep people confined to a hospital or institutional setting when the advent of new medications would allow them to live within mainstream society. The result was a decrease in the average of occupied state hospital beds from 339 to 29 per 100,000 persons.

In 1963, two significant laws were passed that accelerated the concept of deinstitutionalization. The first was the Aid to the Disabled Act that made the mentally ill eligible for federal financial support in the community setting. The second was the Mental Retardation Facilities and Community Mental Health Centers Construction Act. It was amended in 1965 to provide grants for the initial costs of staffing the newly constructed centers. These funding sources coupled with new medications, new alternative methods of dispensing those medications and better access to outpatient counseling gave rebirth to deinstitutionalization.

Some believe that deinstitutionalization has been and continues to be successful. Perhaps one of the brightest spots of the effects of deinstitutionalization is that the mentally ill have gained a greatly increased measure of liberty.

“There is often a tendency to underestimate the value and humanizing effects for former hospital patients of simply having their liberty to the extent that they can handle it (even aside from the fact that it is their right) and of being able to move freely in the community,” Richard Lamb wrote in Deinstitutionalization and the Homeless Mentally Ill. “It is important to clarify that, even if these patients are unable to provide for their basic needs through employment or to live independently, these are separate issues from that of having one's freedom.”

Even if they live in community-based rehabilitation facilities, the facilities are not locked, and the patients generally have access to community resources. The residents can hold jobs and enjoy amenities while interacting with mainstream society.

Others feel that deinstitutionalization was and is a failure. Studies show that the concept simply has taken the mentally ill out of hospitals and placed them into prisons due to their inability to live within societal norms and the misunderstanding of mental illness. Additionally, a distinct parallel is drawn between the homeless problem and deinstitutionalization. Research shows that many of the homeless have mental-health problems such as drug addiction. Homeless shelters do not have the ability or the facilities to treat the mentally ill, yet are put into this precarious position on a daily basis.

The community at large lacks the basic understanding of mental illness and fears the influx of these individuals into its neighborhoods. Whether it is the homeless person panhandling for money or food, the community-based facility operating next door, or the crimes committed by the mentally ill, mainstream society fears stigmatic associations resulting from deinstitutionalization.

Certainly this is due partly to a long history of stigmatizing the mentally ill. Consider today's entertainment media. One Flew Over the Cuckoo's Nest gave us permission to laugh at the mentally ill, while many of the slasher movies play on and reinforce our fear of them.

Yet nearly everyday in this country, emergency responders must face issues of mental illness. Furthermore, emergency responders often are placed into a position they are not adequately educated to handle when societal problems associated with mental illness occur. Fiction aside, it was emergency responders who had to separate a 35-year-old Kansas woman from the toilet seat she'd been on for as long as a month. She had not left her boyfriend's bathroom for two years and refused medical treatment from first responders.

Police and fire professionals are many times a community's first response to these concerns. In Beloit, Wis., interaction with mental illness is often a result of illness, injury or crime. Illness or injury can be a result of drug or alcohol abuse, physical abuse or exposure to environmental factors such as weather. Crime issues are a result of theft, prostitution, illegal drug issues, behavioral problems when interacting with public, and violent crimes like battery and homicide.

The fire service has a history of being inundated with consistent requests for service by individuals receiving treatment for mental illness but have no obvious medical emergency. At times, these situations are remedied simply by reassuring the patient; other times, the patient is taken to local emergency departments where the burden is extended. The hospital staff is very familiar with many of the individuals who use the public health system on a consistent basis. The hospital staff's frustration is manifested from not being able to make a difference and often having to return these people to the streets, where many of their problems originate. If the patient is not harmful to himself or to the public, neither the police nor the hospital has the right to impose further treatment. This problem continues and the frustrations born from this interaction create the stigmas associated with responding to issues of mental illness. The fire and police departments are already busy with other responsibilities and can become annoyed when dealing with the obscurity associated with mental illness issues.

All indications show deinstitutionalization continuing and evolving. This situation will call on all public-service leaders to join together to approach this challenge from unique perspectives. Today, perhaps the two most important concerns of mental illness are human rights and public stigma. Those who suffer from mental illness have the right to a quality life. But the question that begs answer is can an individual suffering from mental illness and not receiving adequate care and treatment experience a quality life? Studies continue to show how untreated or mistreated mental illnesses conflict with societal norms. As a result, stigmas are born and stereotypical attitudes reinforced. Coupling the lack of societal understanding and acceptance with the lack of adequate treatment, it appears the evolution will have a negative result. Education, diagnosis and adequate treatment access will turn the evolution to a positive direction.

To best respond to issues surrounding problems presented by the mentally ill within our communities in a safe, practical and effective manner, and to ensure individuals seeking assistance are treated with the respect that maintains dignity and human rights, fire service leaders must educate their personnel and provide for them the resources needed when these situations arise. Better understanding of the problem at hand will lead to better treatment and response to the needs of those afflicted. In many communities, first-hand information of problems related to mental illness are as close as a local law enforcement agency. Police officers often deal with the problems related to mental illness on a daily basis. Police officers also can target specific areas where homeless people typically stay or the common areas used to sell and use illegal drugs. As mentioned, some homeless people might suffer from a mental illness. When considering factors such as scene safety, environmental or weather concerns, just knowing general locations can help responders better prepare in the event of an emergency.

Fire service leaders must partner with mental-health professionals such as physicians and nursing staff working in the psychiatric field who can bring a wealth of experience and knowledge that can be used for better understanding of special needs. Public-health and social-service agencies are additional resources for the emergency responder. In the event of an emergency concerning a known or perceived mental-health issue, these agencies have a practical knowledge for identifying and handling such problems and the network for additional resources.

Lastly, do not underestimate the value of individuals diagnosed with a mental illness. While on an ambulance run many years ago, I spent one hour in a hospital emergency department waiting room talking with a gentleman who had been diagnosed with a host of mental illnesses. In that hour, he gave me a wealth of information regarding the inherent problems in obtaining treatment and the tendencies of homelessness, drug and alcohol abuse, and crime that has stuck with me to this day. Many people diagnosed with and treated for mental illnesses are very aware of the problems and can provide a unique perspective to the emergency responder and assist in erasing the stigmas often associated with mental illnesses. Public-health officials can connect responders and persons willing to discuss their illness. People diagnosed with mental illness have a high regard for firefighters, paramedics, EMTs and police officers and are more than willing to help the people who are willing to help them. Learning about their illnesses and ways to better respond to their emergencies will help provide an increased quality of life.

---

Timothy Curtis serves as the assistant fire chief of Beloit, Wis. He holds an associate's degree in fire science, a bachelor's degree in management and communications, and a master's degree in executive fire service leadership. He graduated from the U.S. Fire Administration's Executive Fire Officer Program, and was awarded the Chief Fire Officer Designation from the Commission on Fire Accreditation International.