Catholic Health World Articles

In the gospel story of the Gerasene demoniac, Jesus encounters a man who could not be bound by shackles and chains or otherwise subdued. The man wandered among the tombs and the hillsides, crying out and cutting himself with stones.

“This is really a terrible situation of suffering,” said Andrea Thornton, a Catholic theologian and bioethicist and a mission director with Bon Secours Mercy Health. “Notice that the text gives us no explicit indication that he was ever violent against anyone but himself. He was restrained because people were afraid of his behavior, but the restraints did not work. Only Jesus could heal him with a compassionate encounter.”

Thornton told the story of the Gerasene demoniac to set the stage for a March 5 CHA webinar called “Promoting Human Dignity and Workplace Safety During Mental Health Crises in the Emergency Department.”

Thornton, a doctoral candidate at Saint Louis University, pointed out that the Catholic tradition could guide participants’ thinking about patients with mental health issues.

“We often identify more with the people in the community that exile this poor man, rather than with Jesus and the disciples,” she said. “But our mission challenges us to approach mental illness with courage and not fear.”

Every person who arrives in the emergency room, even if they are aggressive, bears the image of God, “and we must see them this way,” she urged.

Thornton said that one in five people admitted to the hospital for mental health treatment commits an act of violence during their hospitalization. She also pointed out there is tension between honoring individual good and the common good, and that sometimes short-term restrictions on a person’s liberty may be necessary for the safety of the group.

But, she added: “Any profound violation of human dignity as a sacrifice for the greater good is not justified.”

She acknowledged there are “serious costs” to not maintaining safety in hospitals. According to a  2023 survey, 70% of the adults surveyed said that U.S. hospitals needed to do a better job of providing security, and 39% said they would avoid a hospital for fear of violence.

“I think that’s very sobering,” Thornton said.

When it comes to treatment, she said that segregating patients with mental health issues  might increase feelings of isolation and may worsen their condition. Of all the organizational interventions she researched, she thought the “most exciting” one was the development of alternative access points, sometimes adjacent to the emergency department, where patients with mental health issues could enter.

As far as a personnel-related response, escalation code teams trained for mental health crises are helpful, but Thornton said those teams may need to be small and focused. “Part of the concern is a large show of staff might again overwhelm the patient and escalate them,” she said.

De-escalation techniques used by staff can significantly decrease the use of restraints on patients, she said. But a review of international literature showed that there isn’t a consensus on the definitions of de-escalation or aggression, and that some of the definitions are culturally relative, Thornton said. Training should focus on cultural sensitivity, she said.

Sometimes, she acknowledged,  restraints must be used, such as consciousness-altering medications, sedation, restraint chairs that allow the patient to sit upright, and seclusion in a safe room. Sedating someone until they are unconscious or restraining them while they are lying down should be used as a last resort, she said.

Thornton  pointed to one study suggesting that the first approach, if necessary, should be to use chemical restraints that keep someone conscious but help restore rationality.

“It allows someone the most liberty and (researchers) don’t consider it terribly intrusive to alter someone’s mood,” she said.

She called for more published research on  de-escalation techniques. She recommended that hospitals develop de-escalation teams and investigate alternative access points for patients with mental health issues.

“As people who extend the ministry of Jesus, we have responsibility to a moral imagination and to exercise that moral imagination,” she said. “Never get stuck in the us versus them framework.”

Thornton recognized it’s tempting to get caught up in news coverage of workplace violence, especially in health care. She said: “We need to be on the front lines of really exercising this imagination to find a communal solution that works for everyone.”