The Open Setting
Entering the open setting here at Riggs produces a kind of culture shock—this holds for patients, for their families, and for new staff. As a psychiatric hospital, Riggs is unique, and it is the open setting that makes it unique: no locked wards, no security guards, no pass system. Patients have cars, hold jobs, come and go to college, sit (or work) in the coffee shop down the street. Before I came to work at Riggs more than four decades ago, I had spent three years working at a new tribal college on the Rosebud Sioux Reservation in South Dakota, an area of sixty by one hundred miles, with a population then of six thousand members. Coming from the east coast, I was fresh out of graduate school and naïve about the culture and history of the Lakota. Culture shock was an everyday experience for me. I did not think it would be when I came to work at Riggs, but it soon became clear that the open setting made everything different about this psychiatric hospital and it was, in its own way, as complicated as the setting I had left.
It takes perhaps a year for new staff to begin to feel in tune with the open setting. The label “open setting” can be misleading, as if it meant “anything goes.” It does not. The open setting is the systematic manifestation of a structure of values and expectations about being human. The logical opposite of “open setting” is “closed setting,” meaning locked doors and use of coercion, and only rarely do we require coercion (i.e., the local police) for safety reasons. The actual, practical opposite of “open setting” is violence in speech or action. The open setting designates the practice of a voluntary community whose members enter with a commitment to non-violence. Patients with a significant history of violent behavior are not admitted.
The foundation of the open setting consists of a trio of factors spelled out in The Riggs Reader, a volume edited by our Associate Medical Director Eric Plakun, MD, published in 2011. The first factor is patient authority. Patients come here voluntarily, stating what they want from their treatment, and staying voluntarily as long as they can or need to stay. Responsibility for choosing this treatment ensures that the patient’s voice is (or should be) always consulted about major treatment decisions such as change of programs, change in medications, and periodic assessment throughout the course of treatment. Patients are responsible for maintaining the boundaries of their treatment. We learn from our patients, and they learn from one another, about the importance of divergent voices and viewpoints in shaping a voluntary community whose lapses and deficiencies point to a continual work in progress.
The second factor is the importance of human relationships in the practice of the open setting. A human being is always in relationship to someone, past or present, or to some “other” in the mind. Patients at Riggs enter into a wide range of relationships over time. At the center of the treatment is the relationship with one’s therapist, who meets with the patient four times weekly. This is an intensely dyadic relationship that is anchored in the broader context of the nursing provision of care, the family work, and the Therapeutic Community Program. Having people that matter can be crucial in the treatment at certain stages and for certain patients for whom human relationships have been mostly a war zone to flee from. In time, patients learn that when they feel unsafe, disorganized, or suicidal they can turn to staff and talk about it rather than taking action.
Family relationships, even going back several generations, are almost always a crucial aspect of treatment in the open setting. In working with the family, and from the very first day, a certain amount of education is necessary about the open setting and the culture it constitutes for the treatment. Most families, like new staff, are not familiar with the open setting, although many are drawn to it following multiple treatments in locked units. Families are told about the risks of the open setting so that they may share the anxiety held by the staff and patients regarding responsibility for maintaining safety.
Families, in effect, are asked if they are willing to share in the work of the open setting, and this expectation then governs the family’s need to know something about how the treatment is going.
The third factor that grounds the open setting is the affirmation that human action is meaningful. Human behavior is essentially symbolic and referential, as pointing to, as aimed at an addressee, an other, the community as other. Behavior in an open setting is part of a text that must be read aloud. Behavior in itself is mute and needs us to interpret its meaning. The meaning is often complex and communal and so we all must give voice to its interpretation, which will remain ambiguous and never fully articulated. No one of us has the encompassing perspective to say completely what a piece of behavior means. Everyone in the open setting occupies a specific place in the structure that provides an opportunity to speak from that place in a way that is distinctive. We need all voices to engage in a meaningful understanding of the patient’s actions. The structure that enables such understanding- speaking is the Therapeutic Community Program (TCP). The daily effectiveness of the open setting requires the persistent stamina of community members to ensure the transmission of values to new patients and new staff. The TCP is a complex, layered structure of large and small group meetings, including process groups, work groups, a patient government system, and joint staff-patient committees, which together promote a culture of “examined living” and reflective feedback among patients. In this way, the TCP is a daily arena of social learning about oneself and others. It is also a vehicle for assisting patients to interpret their own behavior, especially when it appears to be a repetition of previous behavior. An overall goal of treatment is the development of growing communicative responsibility for negotiating relationships that are part of life at Riggs, but also lie beyond this community and reach into the wider world.