CLINICAL HANDBOOK OF SCHIZOPHRENIA

34. Emergency, Inpatient, and Residential Treatment 345Physical Restraint and Seclusion PoliciesRestraint refers to physically restraining individuals—and not chemical restraint, which isgenerally considered an invalid or poorly defined concept. The use of physical restraint isan acceptable treatment modality, but it should be used after all less restrictive modalitieshave been carefully considered. Restraints should be individualized, and the least restrictivetype of restraint should be used for the shortest possible period of time, with frequentreassessment of the ongoing need for it. Acceptable uses for restraints include preventionof imminent harm to the patient or others when alternative means are ineffective or inappropriate;prevention of disruption of the treatment program, or of violence or damage tothe environment; decreasing stimulation of the patient as a part of the treatment plan, orat the request of the patient, if the clinical treatment team is in agreement.Care must be taken to ensure that the rights and dignity of the patient are upheld,and that the patient is a part of the decision-making process to the greatest extent possible.Seclusion rooms can be used for multiple purposes, including isolation and reductionof sensory stimulation of the patient for short, temporary periods (time-outs), as well assettings for the use of physical restraints. Although restraints may be administered in a seclusionroom, they can also be used in other settings, as is often the case for patients withschizophrenia who are in general medical or intensive care unit settings.Once the decision is made to utilize restraints, the process should be carried outquickly and effectively, with adequate staff present to ensure safety. The team of individualsinvolved should have experience and training in the relevant processes. Orders shouldbe time-limited, and should never be administered on an as-needed basis. Observationshould be frequent (or constant, in some cases), and documentation should be regularand thorough. Furthermore, documentation should provide justification for the continuingneed for restraint.RESIDENTIAL TREATMENT OF SCHIZOPHRENIAResidential Treatment ProgramsResidential programs offer a form of care that is intermediate between intense stabilizationorientedinpatient treatment and the more maintenance-oriented approaches of outpatienttreatment. Thus, although the primary focus of inpatient programs is on stabilization anddischarge, the focus of most residential programs is on improvement—to the point thatthe patient can be maintained in an outpatient setting. Therefore, a residential programoffers settings with lesser levels of restriction and longer stays than an inpatient program.In fact, the increasing availability of residential programs may have been an importantfactor in acute psychiatric hospitalization stays being much shorter than in the past, butwith equivalent or even better overall outcomes (American Psychiatric Association, 2004;Johnstone & Zolese, 1999).Treatment of chronic mental illness in residential treatment facilities is perhaps oneresponse to the worldwide attempt to deinstitutionalize patients with these illnesses.Institutionalization failed to give patients a proper chance in life to become productive inthe community. Today, institutionalization is generally considered only a temporary solution,whereas integration into society and the community has become the crucial goal oftreatment. Nevertheless, the naive idea that deinstitutionalization itself is the golden solutionhas failed, because it simply places a group of marginalized people back into societywithout preparing them. “The classical paradigm of social psychiatry postulating thatdehospitalization automatically generates social integration has proven to be wrong, and