Clinical Work

Importance of Relationships

Developing fulfilling relationships is not only a goal for many people who come to Riggs, it is also an integral part of the treatment program itself. By better understanding how they relate to others - including family members, peers, therapists and other staff - during the course of their work here, patients experience directly the importance of relationships in contributing to lasting change. 

Relationships in which trust and concern are built over time form the glue that holds the community together. The program at Riggs is fully voluntary and there are very few restrictions to individual freedom. Not only do we not lock, restrain or seclude patients; as far as possible we avoid the coercion inherent in systems of privileges and restrictions that other psychiatric settings often employ. Instead, patients manage themselves though their membership in a network of relationships. We encourage members of the community to speak as directly as possible about their experiences of each other, to enable everyone to learn about the many ways they affect others. Over time, as connections deepen, people also begin to care about one another. They recognize, sometimes for the first time, how much others really matter to them, and how much they matter to others. Life in the open setting involves considerable responsibility – for oneself, to one another and to the wider community. Staff and patients have an obligation to work together to create and sustain a safe enough environment for people to risk revealing themselves and engaging with others while they work to change.

Therapeutic Relationships

At the center of the clinical work is the relationship with the psychotherapist, who is dedicated to understanding the individual as deeply and fully as possible, in order to further that person’s self-understanding. Therapy often begins with patients telling their life stories, at their own pace, on their own terms. A therapist’s careful, sensitive listening can itself offer relief. As the story unfolds patient and therapist develop shared perspectives on the patient’s struggles, developing new ways of understanding difficult experiences. During this process, the relationship between the two quite often becomes a part of the work. People repeat old patterns in new situations. Focusing on these recurrences as they happen in therapy allows them to be studied in an especially immediate way. What was previously just lived without thought is now available for reflection and revision. Psychotherapists at Riggs have relatively small caseloads, enabling them to devote themselves to knowing a few people remarkably well.

While the relationship with the psychotherapist focuses most intently on patient’s internal world, there are many other clinicians who engage with patients in other ways specific to their disciplines, including social workers, psychopharmacologists, substance abuse counselors, community workers and teachers. They may provide more practical, educational, or symptom-focused interventions, but across the continuum all staff are sensitive to the wealth of potential meanings contained in interpersonal encounters. The treatment teams meet twice weekly in an effort to integrate clinical staff members’ varying experiences into a coherent understanding of each person.

Relationships with Nursing Staff

The work of intensive psychotherapy doesn’t stop when the session ends and the patient leaves the therapist’s office. Patients often develop important relationships with members of the nursing staff, who are available around the clock. Nursing staff members help patients manage between sessions, offering emotional support, education and guidance in the tasks of daily living, and helping to foster supportive connections in the therapeutic community. Nursing staff members eat meals with patients and have informal conversation in common areas. In more formal meetings they help patients plan their day, cope with their feelings and otherwise navigate the Riggs community. In this process they come to know patients unusually well, often developing deep connections that are soothing and grounding as the difficult experiences of intensive treatment inevitably occur. Because of these strong connections, nurses often notice when people are becoming distressed and they can intervene flexibly to prevent or respond to crises. 

Family Relationships

A person’s life story begins in the family, where we have our earliest important relationships. Personal stories often, when examined more carefully, contain family stories that span generations. Patterns of trauma, loss, disappointment and failure as well as of success, joy and achievement recur in familiar ways. Some family stories are told and re-told a thousand times; others are transmitted unconsciously. For example, a parent may behave in a way that communicates anxiety in particular situations; in this way  his or her child may learn that these situations are dangerous, without the sources of anxiety ever spoken aloud. Such feelings persist long after the original experiences are forgotten, and can be encoded in an individual’s psychiatric symptoms and repeated in future relationships and with future generations.

Families use a variety of shared strategies to maintain stability, sometimes helpfully, and sometimes in ways that interfere with the development of one or more members. What appears to be an individual problem often has roots in the family system. In addition, coping with a serious psychiatric disorder in one member creates tremendous strain on others. Most patients work on understanding family experiences in their individual psychotherapy, but, for some, active participation by the family members is valuable.  We offer family therapy to assist family members to understand one another and the family system better, leading to more harmonious and satisfying relationships. Even when family members do not participate in active treatment themselves, their understanding and support is crucial. Social workers experienced in family systems provide liaison contact with families as needed.

 

Relationships with Each Other

The relationships that patients have with each other are central to the therapeutic process at Austen Riggs. Some come here from painfully tumultuous social situations, while others have been isolating in their homes. It may take these people longer to feel comfortable enough to attend their first group meeting or to join a social event. But connections do form when people are in close proximity and gradually people realize they are a part of a community. After a while, most people find they have something to offer that others welcome, and they begin to risk new ways of engaging, challenging old beliefs and revising old habits.  

At Riggs, unlike hospitals focused on crisis intervention, people have time to get to know each other. Our patients bring their strengths and skills along with their troubles, and these enable them to make valuable contributions to each other and to the community. We do not separate people into units focusing on particular disorders, recognizing that people are different and similar in much more complex ways than a diagnosis implies. What they will offer and exactly how they will benefit from their relationships is impossible to predict or prescribe.

Related Resources

 

David Mintz, M.D., Team Leader/Staff Psychiatrist talks about the effects of medication relating to the quality of the doctor-patient relationship.

 

Charge Nurse, Karen Kalish, R.N., talks about the patient's relationship with nursing staff.

 

Dr. David Flynn, Associate Director of Admissions explains the importance of sharing information during the three-hour admissions consultation.

 

Director of Clinical Social Work, Cathleen Morey talks about assessing the family dynamics.

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