CLINICAL HANDBOOK OF SCHIZOPHRENIA

The Milieu34. Emergency, Inpatient, and Residential Treatment 347Although some residential programs are specifically designed for patients with schizophrenia,such patients frequently represent only a fraction of the population of a residentialtreatment facility. This can provide challenges in terms of the milieu, because patientswith schizophrenia do better in environments with less expressed emotion, which is oftendifficult to achieve in a facility with a mixed clientele. Additionally, some patients withother diagnoses may be disturbed or frightened by patients with schizophrenia who areovertly paranoid or disorganized. Some facilities deal with this issue geographically, byplacing more agitated patients in different areas of the facility, or through staffing, byhaving more, or more experienced, staff members take greater responsibility for the moreagitated or seriously ill individuals.Length-of-Stay IssuesJust as it is important to design inpatient programs with the length of stay in mind, soit is with residential programs. The greater lengths of stay in residential programs allowthe implementation of more involved and lengthier programs in comparison withthose found in an inpatient unit. Another important difference between inpatient andresidential programs is that the residential program structures can make use of themore home-like environment to address daily living issues directly. Many programshave patients involved in cooking, cleaning, shopping, and other activities, and someprograms have field trips, on which patients learn to make better use of availabletransportation modalities. Even so, specific goals should be tracked, and dischargescarefully planned.Choosing a Treatment ProgramChoosing an appropriate residential treatment program can be critical in preventing deteriorationof the patient’s condition, avoiding hospitalization, and providing stability forthe patient. Many factors affect the choice of residential treatment, such as safety, severityof symptoms, overall patient functioning, medical problems, and the ability of the patientto cooperate with treatment. Psychiatric and medical services provided by different programsvary from one setting to another. Some patients need structured and more supervisedservices, whereas others require limited or no supervision. Finally, to increase thechances of success, family and patient preferences should be accommodated wheneverpossible.When deciding among programs, one should keep in mind that the final goal of anyresidential program is to enable patients to have a life in the community, even if they needconsiderable support for that lifestyle. Patients should be able to take responsibility fortheir lives, look after their food and housing needs, and manage their medications, and begiven every opportunity to be creative, productive human beings. Many residential programswhose objective is to lead patients to greater independence should be person-centered.In a person-centered approach (Rogers, 1983), the individual is deemed trustworthy andis considered to know best the directions of his or her life and to be capable of making decisionsthat lead to a better way of living. The power of the treatment team is transferredto the patients as he or she articulates and pursues the direction his or her own life is totake. Team members effectively become sensitive consultants that through empathy andcareful listening facilitate the patient’s way toward independence.