Inclusiveness and Intangibles in the Open Setting



This article appears in the Spring 2016 (Vol 9, Issue 2) ARC News.

The Riggs community of patients and staff work together in an open setting that is devoid of locks or privilege systems. Listening, questioning and “opening things up” are values central both to the clinical work at Riggs and to the way the Riggs community of patients and staff work together in an open setting that is devoid of locks or privilege systems. It is “the intangibles that allow us to keep it open,” says David Mintz, MD, team leader and staff psychiatrist at Riggs.

“Patients come to us because they have an entrenched way of doing things,” says Mintz, who continues, “Part of the work is to introduce creativity and play and something that’s not so serious, but is, at the same time, very serious” in terms of the impact on individual lives.

One of the opportunities for serious creativity and play for the entire Riggs community came in the form of the Open Setting Seminar, led this year by Mintz. The seminar is a periodic Riggs community exploration of our commitment to maintaining an open setting and of the importance of patient authority and responsibility in such a setting.

When asked to lead the seminar, Mintz saw it as an invitation and opportunity to “poke at the sacred cows” at Riggs. He explains, “When ‘We should do this,’ gets passed on to the next generation and turned into ‘Thou shalt do this,’ it can be sapped of its creativity and liveliness” and he felt it was important to reaffirm the values and goals of the open setting. The seminar offered a forum to examine how members of the community work together, including how staff may take over rather than support patient authority or how patients may take the open setting to mean freedom without responsibility.

Over the course of four weeks (after four weeks of planning), meetings and reading groups explored a wide variety of topics related to the open setting. One of the seminar’s more illustrative activities found its origins in the wish of some patients to have more non-verbal ways to participate. Patient and staff members of the Riggs community were given individual puzzle pieces (painted by Instructor in Visual Arts Mark Mulherrin and cut and framed by Woodworking Instructor Edouard Vaval) with their name on the back and invited, over the course of the seminar, to find their piece’s place in a larger puzzle without knowing what the resulting picture would reveal.

“It was the perfect metaphor for the larger struggle humans have to join communities,” says Mintz and the activity raised questions about who feels and does not feel included in a community. “Feeling excluded is a role certain patients and staff members take up on behalf of the community,” says Mintz, who goes on to say that “it is the job of the community to think about that person who feels like they are not part of the community”— what their role is, why they feel excluded, what the function of feeling excluded serves for the community. Mintz hopes that Riggs staff and patients came out of the seminar feeling that each one of them truly is an important part of this community.

Patients and staff were given puzzle pieces during the open setting seminar and asked to place their piece in a large puzzle.The image that emerged from the puzzle pieces was an illustration of a Norse myth about the Fenris Wolf, which serves as a fitting metaphor for the approach to work and treatment at Riggs. A destructive force capable of ending the world, the Fenris Wolf was only finally held not by chains, but by gossamer threads of intangibles. “We have recognized that only the intangibles, the bonds of human relationships, of words and understanding, may be strong enough to contain the destructive forces operating in many of our patients,” says Mintz. While the puzzle was missing some pieces in the end, the picture was clear. When asked what he learned from the Open Setting Seminar, Mintz answered, “The most important thing I learned was [that it was] important for me to say [to staff and patients] ‘I want you here— this process won’t work as well without you.’”