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Care for the Psychiatric Patient: Historical Basis for the Treatment of the
Mentally Ill
By Karen Askew, RN, BSN, ACM

Within U.S. hospital emergency departments (ED), many psychiatric patients are considered “frequent fliers,” as they are regularly
re-admitted to the same facility. Such patients can be resource intensive, and are often held in the ED for extended periods of time until
they are able to be placed. Some of these challenges can be attributed to the patient’s mental illness. However, the significant body of
both state and federal regulations that govern the treatment of psychiatric patients can also create challenges and barriers to providing
efficient care.

In practice, these factors present a myriad of challenges to the were revised and re-written and asylums across the U.S. closed their
case manager responsible for the patient, as the case manager doors. The Texas Mental Health Code, for example, now states that
must develop an efficient plan of care which takes into account mental health treatment must be provided in the “least restrictive
the unique considerations and challenges associated with setting” (Chapter 571, Sec 004). This code also states that the least
psychiatric care. To effectively manage this patient population, a restrictive appropriate treatment setting for a mentally ill patient is
case manager must be familiar with the regulations governing the the setting that:
treatment guidelines for psychiatric patients in medical hospitals. 1. Is available
Understanding the origin of these regulations can help unveil the
intent of the regulation, and render them more understandable 2. Provides the patient with the greatest probability of
and applicable to daily practice. This article will provide a improvement or cure
historical context for the current standards and regulations 3. Is no more restrictive of the patient ’s physical or social
governing the care of psychiatric liberties than is necessary to
patients, and the patterns provide the patient with the most
established as a result. Under the current “need for treatment” effective treatment and to protect
statute, health care providers are often adequately against any danger the
A Landmark Case patient poses to himself/herself or
restricted from holding mentally ill others2
The current structure of
commitment law and the ensuing patients to ensure they receive the Under such revised legislation,
effect on the psychiatric patient treatment they require... strict criteria and procedure must
population can be largely be followed by healthcare providers
attributed to the Supreme Court in order to require an individual to
case of O’Connor v. Donaldson, a landmark decision in mental submit to confinement.
health law. O’Connor v. Donaldson pitted the plaintiff, Kenneth
Donaldson, against the Florida State Hospital at Chattahoochee. Impact on the Patient
Donaldson, who was civilly committed to the state mental hospital Restrictions on confinement and treatment of mentally ill
for 15 years, argued that he was not mentally ill and was a danger to patients enacted as a result of O’Connor v. Donaldson have, in many
no one. Furthermore, Donaldson argued that if he was in fact cases, resulted in the postponement of treatment for the patient.
mentally ill, he received no treatment for his alleged illness. The longer the patient’s treatment is delayed, the more severe their
The central issue the court identified in the case was a patient’s situation can become, and too often these patients are stabilized
fundamental right to liberty. The court held that a diagnosis of and released only to be readmitted to the ED numerous times; this
mental illness does not, in and of itself, empower the state to is a situation with which case managers and social workers are
confine a person if they are not a danger to them self or others. The often familiar. Too often this cycle of stabilization, discharge, and
case also affirmed the right to treatment, meaning that a patient is readmission has grave consequences for the patient.
entitled to be given treatment that would provide him or her the One unfortunate reality of the court’s decision is that it has
opportunity to be cured or to improve their mental condition.1 allowed many who are mentally ill to transition into the community
with little to no structure, support, or system for follow-up. For
Far-Reaching Effects those that are ill-equipped to function in society, this lack of a
Although the court’s decision was widely praised for the support structure combined with inadequate preparation has
plaintiff involved, it has had far reaching consequences for the allowed them to become more vulnerable to exploitation and
treatment of the mentally ill, and has resulted in drastic changes in abuse. These factors also contribute to a high rate of homelessness
commitment law. among the mentally ill. In 2007, the U.S. Conference of Mayors
Following the Supreme Court’s ruling, mental health codes conducted a survey of 23 metropolitan areas. According to the
continued on page 11

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Care for the Psychiatric Patient: Historical Basis for the Treatment of the Mentally Ill (continued from page 10)

report, 30% of the homeless populations surveyed had documented
mental illness.3, 4
Though the legislation enacted as a result of O’Connor v.
Donaldson has had a number of negative implications for patients,
the benefits of this landmark decision must not be overlooked. As a
result of the case, and its ensuing legislation, the mandate for states
to provide treatment for those confined due to a psychiatric
diagnosis was created. This mandate prevents mentally ill patients
from being “warehoused” in poor conditions with no treatment or
hope of release.
Furthermore, the Supreme Court’s decision validated that each
person deemed not dangerous has an absolute right to live how
they choose, allowing many – who may previously have been
confined to institutional life – the chance to experience their
fundamental right to freedom.
restrictions often cause as they manage patients with mental illness.
It is also imperative that healthcare practitioners, who have
witnessed firsthand the restrictions placed upon the treatment of
mentally ill patients, are alert and remain constantly aware of
opportunities to act as an advocate in support of revising the
current statutes.
Karen Askew, RN, BSN, ACM, has been the Director of Quality Care
Management at San Jacinto Methodist Hospital in Baytown, TX since
2005. She earned her BSN from the University of Alabama at
Birmingham, and is currently pursuing her MSN in Nursing
Leadership at the University of Texas Medical Branch in Galveston,
TX. Her nursing career spans more than 33 years in acute care
services, and she has worked in hospital case management for the
past 14 years.

Conclusion
Under the current “need for treatment” statute, health care
providers are often restricted from holding mentally ill patients to
ensure they receive the treatment they require, even with the
knowledge that the patient’s decision to not receive treatment is
being made with diminished decision making capacity. With these
factors in mind, it is imperative that case managers understand the
restrictions imposed on providers as a result of the revised
legislation, and proactively prepare for the barriers these
References
1 U.S. Supreme Court, O’Conner v. Donaldson, 422 U.S. 563 (1975). http://
supreme.justia.com/us/422/563/case.html (accessed on 8-14-09).
2 Texas Mental Health Law http://www.megalaw.com/tx/top/txmentalhealth.
php (accessed on 7-6-09).
3 Audi, C., (2009, April) Helping the Homeless http://helpinghomeless.
wordpress.com/2009/04/09/mental-illness-and-homelessness/ (accessed
on 7-6-09).
4 O’Sullivan, A., Caughlan, J., Roberts, L., Dela Torres, L., Dixon, J., Holoman,
K., et al. (2000, Oct) Mental Illness, Chronic Homelessness: An American
Disgrace, Healing Hands 4(5), 1-5.

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