Structure: the neglected ingredient of community treatment

Eighty patients in a locked, skilled-nursing facility that serves only psychiatric patients were studied. Of these, 78 were diagnosed as psychotic, 48 had overt major psychopathologic characteristics, and 33 had been physically assaultive within the past 12 months. A third had diagnoses both of psychosis and severe drug and/or alcohol problems. Fifty-eight were unmanageable in previous placements in open settlings. Four of five were resistant to taking psychotropic medications. Six were judged dangerous to themselves. Such patients are extremely difficult to manage in community settings where the need for structure is often overlooked; therefore, this facility, serves as an alternative to the state hospital. Structure is provided not only by security features but also by an intensive treatment and rehabilitation program. This type of facility is contrasted with the state hospital.