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Mental Health Matters
The newsletter of the ISBA’s Mental Health Law Section

June 2019, vol. 5, no. 4

In re Linda B.: Analysis and implications

Introduction and Summary

Many people with mental health conditions receive treatment in facilities that have not traditionally been considered “mental health facilities.” These facilities include emergency departments, medical or surgical units of general hospitals, and nursing homes. More people are receiving inpatient psychiatric care in these types of facilities because: (1) the number of state-operated inpatient beds has declined by 95 percent during the past 60 years; (2) many general hospitals do not have inpatient psychiatric beds; and (3) persons requiring inpatient care for non-psychiatric conditions may also need psychiatric care.

Until recently, there was some uncertainty about whether the Mental Health and Developmental Disabilities Code (hereinafter “MHDD Code” or “Code”) applied to patients receiving mental health treatment in non-traditional facilities.1 This uncertainty has existed particularly with regard to voluntary admissions. However, a recent decision of the Illinois Supreme Court, when coupled with existing state law and legal precedents, has now removed that uncertainty. As will be discussed in detail below:

  1. In In re Linda B., 2017 IL 119392, 91 N.E.3d 813( Ill., 2017), the Illinois Supreme Court determined that all persons receiving inpatient mental health treatment are in a “mental health facility” under the definition provided by the Code.
  2. The legislature only included one definition of a “mental health facility” in the Code, and it applies to the entire Code, including the provisions for informal and voluntary admission.
  3. No one may be admitted to a “mental health facility” except under the provisions of the Code.
  4. The United States Supreme Court has unanimously held that voluntary admission to a mental health facility implicates a liberty interest that is protected by the Due Process Clause of the 14th Amendment.
  5. The legislature’s reasons for requiring specific procedures for informal and voluntary admission to mental health facilities apply to non-traditional settings, in addition to dedicated inpatient psychiatric facilities.
  6. The Illinois Appellate Court has held that the Code applies to persons receiving mental health treatment in nursing homes.

Therefore, patients cannot be provided with mental health services in emergency departments, medical or surgical units of general hospitals, or nursing homes unless they have been admitted to such a facility pursuant to the provisions of the Code. While the scope of the law as clarified by Linda B. might seem overly broad to medical and legal practitioners, this problem can be addressed through specific amendments to the Code.

Analysis

1. In Linda B., the Illinois Supreme Court determined that all persons receiving inpatient mental health treatment are in a “mental health facility” under the definition provided by the Code.

In In re Linda B., the Illinois Supreme Court interpreted the definition of “mental health facility” in the Code to include persons receiving mental health treatment in all inpatient settings, including non-traditional ones, for the purpose of involuntary admission to those facilities. Specifically, the Court stated that “in those instances in which a facility¼provides psychiatric treatment to a person with mental illness¼it qualifies as a ‘mental health facility’ for the purpose of the Mental Health Code’s application.”2

Therefore, patients are in a “mental health facility” if they are receiving mental health services in those locations.
In reaching that decision, the court emphasized that the legislature’s definition does not state that a facility must have a primary purpose of treating individuals with mental illness, so a non-specialized medical unit is not precluded from being a mental hospital merely because it primarily treats physical injuries. In fact, the court explicitly rejected this “primary purpose of care” test when it was proposed by the state.3 Thus, a patient is still in a “mental health facility” regardless of any separate non-psychiatric medical treatments that the patient may have been receiving previous to or concurrently with mental health treatment in the same location.

However, the type of treatment provided to the patient is still relevant in determining how to label the facility. Specifically, the court decided that where a facility “provide[s] the [particular] individual [with] mental health services,” it “is a mental health facility.”4 Therefore, the administration of psychiatric treatment to a particular patient creates a “mental health facility” for that patient.

The court considered the scope of the definition provided in the Code, which states that a “mental health facility” is:

[A]ny licensed private hospital, institution, or facility or section thereof, and any facility, or section thereof, operated by the State or a political subdivision thereof for the treatment of persons with mental illness and includes all hospitals, institutions, clinics, evaluation facilities, and mental health centers which provide treatment for such persons.5

Ultimately, the court emphasized the separate categories that the legislature intentionally included in the definition, as well as its purposeful use of the word “any” as evidence that the definition encompasses all such treatment settings. Application of the Code cannot be escaped by claiming a certain label or alternative primary purpose if mental health services are being administered in that treatment facility. Rather, the Court held that the Illinois legislature’s definition of “mental health facility” is broad in scope. This definition encompasses a much more diverse set of locations than traditional inpatient treatment facilities like state hospitals and specialized psychiatric wards. Thus, emergency departments, medical or surgical units of general hospitals, nursing homes, and other locations that provide inpatient mental health treatment fall under its umbrella.

2. The legislature only included one definition of a “mental health facility” in the Code, and it applies to the entire Code, including the provisions for informal and voluntary admission.

The Code only contains one definition of a “mental health facility.”6 The legislature intended for this definition to apply to the entire Code, and it additionally did not include separate definitions in distinct parts of the Code. The limitations of rights and concomitant protections listed in the Code are applicable to a broad range of patients, so the definition of “mental health facility” must be similarly inclusive for patients to meaningfully receive such protections.

The legislature’s intent to protect all mental health patients, and not merely involuntarily admitted patients, is evident through the broad protections established for all patients in the Code. The rights listed in Chapter II, Article I apply to all “recipients of services.” The phrase “recipient of services” itself is broadly defined in the Code to include all patients who are receiving mental health services, and the concepts of “mental health services” and “treatment” also are broadly defined.7 If the legislature intended to define these concepts broadly, then the definition of “mental health facilities” must be similarly inclusive.

Moreover, Linda B. clarifies how the Code’s broad definition applies in existing settings for inpatient mental health treatment, rather than creating a new definition of “mental health facilities.” Consistent with Linda B., the Illinois appellate court has invalidated emergency room admission practices that ignore the Code’s provisions, and it has reinforced that this policy comes from the legislature rather than as a new invention of the court.8 In In re Wilma T., the court invalidated the involuntary commitment of a patient in an emergency room setting when medical professionals disregarded the procedures for admission to a “mental health facility” specified in the Code.9 Furthermore, the dissent highlighted that the definition of “mental health facility” is mandated by well-established definitions and procedures contained within Illinois statutes when it remarked that the majority’s analysis “constitutes [nothing] other than a recitation of existing¼law.”10 Likewise, Linda B. merely recounts the existing law in the Code, clarifying its application to types of treatment facilities as their use becomes more prevalent.

3. No one may be admitted to a mental health facility except under the provisions of the Code.

In In re Gardner, the Illinois appellate Ccourt held that the Code provided the only legal authorization for admission to a mental health facility.11 The Code states: “A person may be admitted as an inpatient to a mental health facility for treatment of mental illness only as provided in this Chapter¼”12 In Gardner, the court held that, “[b]y enacting Section 3-200 [of the MHDD Code] the legislature has clearly provided that the MHDDC is to be the exclusive means by which a mentally ill person is admitted to a mental health facility.”13

The court explained that alternative admission procedures would frustrate the legislature’s intent “to prevent the warehousing of disabled adults in substandard conditions when they do not qualify for entry into a mental health facility under the direct control of the State.”14Most importantly, the court reasoned that, “the Code contains an elaborate and complex system of procedures designed to protect the rights of the mentally ill. In bypassing the procedures for involuntary commitment set forth in the Code, the trial court has denied respondent the rights guaranteed under the provisions.”15 Thus, admissions procedures other than the ones provided by the Code are not only unlawful and void, but they can also result in serious rights deprivations where patients are denied the protections that the legislature intended to provide.

4. The United States Supreme Court has unanimously held that voluntary admission to a mental health facility implicates a liberty interest that is protected by the Due Process Clause of the 14th Amendment.

Voluntary patients, in addition to involuntary patients, can experience rights deprivations while they receive mental health treatment. As acknowledged in the Code itself, patients may experience deprivations related to restrictions on their communication with others by mail, telephone, or in-person visitation, their ability to refuse medication, restrictions on property ownership and control, and deprivations of their physical liberty, including forcible seclusion and restraint.16 Admission to an emergency room for maladies outside of the field of mental health treatment does not carry the same risks.

In Zinermon v. Burch, the United States Supreme Court unanimously held that voluntary admission to a mental health facility implicates a liberty interest protected by the Due Process Clause of the 14th Amendment.17 The majority held that Burch, a voluntarily admitted patient, was “deprived of a substantial liberty interest,” that the agents responsible for his commitment incorrectly exercised the “power to deprive mental patients of their liberty,” and that his claim demonstrated a “violation of his procedural due process rights.”18

Although the dissent did not believe that a due process violation occurred in the particular facts of the case, it upheld that voluntary admission does in fact implicate a liberty interest protected by the Due Process Clause. This agreement is evident from the dissent’s opening words: “Without doubt, respondent Burch alleges a serious deprivation of liberty¼”19 Hence, voluntary patients must be admitted according to the Code to protect the liberty interest identified by the Supreme Court in Zinermon.

5. The legislature’s reasons for requiring specific procedures for voluntary admission to mental health facilities apply to non-traditional settings, as well as dedicated inpatient psychiatric facilities.

The legislative history of the Code demonstrates that the reasons for requiring specific procedures for voluntary admission to mental health facilities also apply to non-traditional settings. The legislature explained that the Code includes procedures that help the patient to “understand his rights, particularly in a situation where a long-term period of inpatient treatment may be required¼”20 Voluntarily admitted patients also need to receive accurate information regarding their rights and treatment options.

Specifically, the Code provides for periodic review of voluntary patients’ records to reassess the need for continued hospitalization, as well as a procedure for securing reaffirmation from patients of continued desire for voluntary inpatient care.21 The legislature intended for this provision to create better monitoring of “the treatment relationship” and to “assure that treatment continues on a consensual basis.”22 Non-traditional facilities must also monitor treatment relationships and obtain valid consent.

In fact, the legislature’s concern is perhaps even more pressing in non-traditional settings. Patients may be even less aware of the extent of their rights and liberty limitations in an environment that does not as blatantly signal that it is a site for administering mental health treatment as a dedicated inpatient psychiatric facility. Ultimately, the Code’s history demonstrates that the legislature intended for these admission procedures to apply to non-traditional facilities if they provide inpatient mental health treatment.

6. The Illinois appellate court has held that the Code applies to persons receiving mental health care in nursing homes.

The Illinois appellate court previously ruled that the Code applied to persons who receive mental health care in nursing homes in In the Matter of Guardianship of Muellner v. Blessing Hospital.23 In this case, the court found that a trial court may not grant a guardian the power to admit a nonconsenting ward to a mental health facility for treatment as a voluntary patient. To reach this holding, the Muellner court interpreted the same statutory definition at issue in Linda B.24 The court found that the nursing home’s behavioral unit “qualifies as a ‘mental health facility’ under the Mental Health Code,” and that admission must therefore “proceed under the Mental Health Code.”25 While Muellner specifically finds that a nursing home’s behavioral unit is a mental health facility, Linda B. clarifies that this holding extends to all patients receiving inpatient mental health treatment in nursing homes.

Conclusion

Ultimately, Linda B. determines that all persons receiving inpatient mental health treatment are in a “mental health facility.” The Code contains only one definition of a “mental health facility,” and that definition applies to the admission procedures contained in the Code. No other definition may be applied to admit patients to a mental health facility. Voluntary patients, in addition to involuntary patients, have a constitutionally-protected liberty interest at stake in being admitted to a mental health facility. As such, voluntary patients must also be admitted according to the provisions in the Code, as the Code was expressly formulated to protect such liberty interests.

Linda B. clarifies that the scope of the legislature’s definition is broad, and the legislature itself provides justifications for this breadth. These justifications are not only relevant to protecting patients in traditional settings, but they are also relevant to protecting patients in the types of non-traditional settings that are becoming more heavily utilized by providers of inpatient mental health care. In addition, nursing homes are specifically included in this mandate as a result of existing case law. Therefore, patients cannot be provided with mental health services in emergency departments, medical or surgical units of general hospitals, or nursing homes unless they have been admitted to such a facility pursuant to the provisions of the Code.

The scope of the law as clarified by Linda B. might be overly broad, but it is possible to narrow it through legislative amendment. Without narrowing the scope of the law, the burdens upon healthcare providers and some types of patients could be substantial. One course of action to pursue would be to entirely prohibit the admission of any patients to non-specialized facilities for inpatient psychiatric care. The State of Washington adopted such a law to avoid “psychiatric boarding” in locations like emergency rooms and acute care centers.26
However, this course of action is not likely a viable solution for the State of Illinois, as the number of psychiatric beds available in inpatient facilities is severely deficient to provide for the number of patients who require treatment. Furthermore, Illinois is not likely to have the requisite funding available in its budget to provide for vast expansion of state mental health treatment facilities. Thus, if this course of action is pursued, many patients with mental health conditions will be unable to receive mental health treatment.

Instead, healthcare providers and legal practitioners should consider amending the Code to specifically exclude some patients to make the law more practical in its application to non-specialized facilities. While many reasons might bring patients to these locations for treatment, most cases can be placed into one of three distinct categories. First, a person might be admitted to a non-psychiatric unit for the sole purpose of non-psychiatric medical care, and during that admission, mental health treatment might also become necessary or appropriate, as was the case for Linda in Linda B.

Second, a person might be admitted to a non-psychiatric unit specifically for the purpose of receiving mental health treatment. This practice can occur because the patient was transported to a facility that did not have a psychiatric unit or had already filled all of the beds in its psychiatric unit, and it also had no option to transfer this patient. Patients in these two categories receive mental health treatments that they have not previously consented to receive, and thus, for the reasons articulated in the Code and repeated in the case law presented above, the Code should continue to apply to them.

However, the burden upon non-specialized providers of mental health treatment can be substantially lessened by carving out a third category of patients from the Code. A vast majority of patients are admitted to non-specialized facilities solely for the purpose of receiving non-psychiatric medical care. Many patients received mental health treatment prior to their admission to a non-psychiatric unit and that mental health treatment must be continued during their hospitalization.

Assuming that they received the requisite protections when these treatments were previously initiated, these patients have already provided valid consent and have been afforded adequate protection. Nonetheless, non-psychiatric facilities would still be required to comply with the Code before providing them with their ongoing mental health treatments under existing law. This requirement hinders non-traditional facilities in their primary function of providing non-psychiatric treatment. Carving out these patients not only helps facilities provide better care, but it also relieves burdens upon patients by obviating the need to readmit them before they can receive treatments to which they have already consented and might require immediately. As the potential benefits to both healthcare providers and patients outweigh the cost of removing the protections provided by the Code to this category of patients, and because this category is substantial, it would be valuable carve them out of the Code through a specific legislative amendment.


Rebecca Boorstein, is a J.D. candidate from the University of Chicago School of Law.

1. 405 ILCS 5/1-100 et seq. (West 2016).

2. In re Linda B., 91 N.E.3d 813, 823 (Ill. 2017).
 

3. Id. at 822.

4. Id. at 823.

5. Id. at 823, citing 405 ILCS 5/1-114.

6. 405 ILCS 5/1-114.

7. Id. at 5/2-100, 1-123, 1-115, and 1-128.

8. In re Wilma T., 2018 IL App (3d) 170155, ¶¶ 15-20.

9. See Id. at ¶ 19.

10. Id. at ¶ 31.

11. 121 Ill.App.3d 7, 459 N.E.2d 17, 20, 76 Ill.Dec. 608 (4th Dist. 1984).

12. 405 ILCS 5/3-200.

13. In re Gardner, 459 N.E.2d at 20.

14. Id.

15. Id. at 20.

16. 405 ILCS 5/2-100 et seq.

17. 494 U.S. 113, 118-20 (1990).

18. Id. at 138, 139.

19. Id.

20. Governor’s Commission for Revision of the Mental Health Code of Illinois, 39 (1976).

21. 405 ILCS 5/3-404.

22. Gov. Comm’n. at 42.

23. 335 Ill. App.3d 1079, 782 N.E.2d 799, 270 Ill.Dec. 240 (4th Dist. 2002).

24. Id. at 802.

25. Id. at 802-03.

26. In re the Detention of D.W., et. al. No. 90110-4.