Keeping the Open Setting “Open” during the COVID-19 Pandemic
In March, Massachusetts Governor Charlie Baker declared a state of emergency for the Commonwealth in response to the growing COVID-19 pandemic. The order was for all non-essential businesses to close, for residents to limit unnecessary travel, and recommendations were given about social distancing. Designated as an essential behavioral healthcare facility, the Austen Riggs Center is adhering to the state guidelines. Riggs stopped taking new admissions, began using video conferencing for some group and individual meetings, restricted visitors from coming on campus, and instructed patients that they could no longer travel back and forth from the outside community to the Riggs campus. Many patients live on the Riggs campus and others live in community step-down programs. Patients had to decide to be either “in or out.” If they chose “in” they would have to move to a room on the Riggs property. If they chose “out” they were not able to come onto the Riggs campus, but would have meetings with their clinicians, treatment team and groups through video conferencing. The intent was to minimize the exposure of Riggs patients to others who might carry the virus. As essential workers in a hospital, staff were able to travel from home to work, but were strongly encouraged to “shelter in place,” and follow other suggested precautions.
The open setting at Austen Riggs puts the patient in charge of their treatment and their lives. Patients make treatment choices based on their own needs in close collaboration with staff. There is a deeply held belief about the importance of relationships and community. Patients are part of a therapeutic community where they can learn about themselves and how they impact one another. Amid the pandemic, Austen Riggs has had to balance the need to follow state guidelines, while maintaining the treatment philosophies imbedded in the open setting. The commitment to community and staying safe is everyone’s responsibility. Although patients have the freedom to come and go by walking to town or by traveling in their own vehicles, they have followed the governor’s request to “stay at home.”
At Riggs the existing problems that patients present with are enacted in the open setting, which provides a microcosm for patients to learn about themselves. The coronavirus pandemic has led to cascading secondary major disruptions and losses; these include restrictions on travel, social distancing and isolation, separation from friends and family, uncertainty about the future, and changes in usual routines. Patients at Riggs are subject to the same stresses that citizens in the rest of the country are faced with, however, some are impacted to a greater degree because of existing psychiatric difficulties.
Three hypothetical examples offer perspective on how the pandemic has exacerbated patients’ psychosocial challenges as they strive to recover. For example, a patient with depression, past trauma, and issues with identity is struggling to maintain social connections and obtain employment. Their fear of returning to the workforce has contributed to a sense of hopelessness with the knowledge that jobs will be harder to find because of increased competition. Another patient dealing with long-standing social anxiety, relationship difficulties, and dependency, is stuck in their inability to envision and move toward creating a fulfilling life. The uncertainty about the future has led to increased anxiety and despair, essentially halting forward movement. In another example, a patient who feels like they are a failure despite past accomplishments, is caught in a life where self-defeating behaviors have contributed to loneliness and suicidality. The person experiences increased isolation, and without access to their social connections, feels that nobody cares, and life is not worth living.
With a new layer of challenges to overcome, the task for patients is to cultivate resilience. Patients are working to achieve a sense of meaning in the current changes, find ways to self-calm, discover hope, and form attachments. Developing resilience is also context dependent; communities that work together with effective leadership tend to fare better in a time of crisis. Although patients continue to struggle in predictable ways, the coronavirus provides opportunities for patients to learn about themselves. Psychiatric treatment that is conducive to this growth is imperative.
As this country has struggled to find a cohesive strategy to slow the spread of the coronavirus there has been tension about how to “open” the country up in order to avoid economic devastation and return to some form of normalcy. A community strategy that by design is adaptive to the science of the virus and builds on individual and community resiliency is more likely to succeed. Sweden, for example, has left its schools, gyms, bars, and restaurants open throughout the pandemic. They have emphasized social distancing and protection for their most vulnerable citizens. The “Swedish model” has taken an approach to the pandemic that matches elements of their culture. It is based on collective responsibility, trust in their citizens, and confidence in leadership. Their goal is to contain the virus without bringing their economy and social life to a standstill. It is unclear which country or strategy will work best in fighting the novel coronavirus and Sweden’s effort to tackle the virus is controversial, but a strategy that fits with its country’s values will likely be more effective.
The Austen Riggs community of patients and staff is cultivating resiliency by building on the principles of the open setting. Riggs has implemented safety precautions prescribed by the state and has encouraged patients and staff to share the responsibility to protect the community from the coronavirus. In partnership with each other, there is a COVID-19 committee for staff, and one established by patients. Members of these committees have worked together to coordinate a strategy that has worked for the community. By encouraging patients and staff to share the responsibility to protect the community from the coronavirus, Riggs has continued to provide quality psychodynamic treatment while at the same time avoiding any incidence of the virus among the patients. (Two staff members tested positive for it, but immediately entered isolation.) Under strict safety protocols, we resumed admitting patients on May 11 (for more details, visit: www.austenriggs.org/admission-with-quarantine), and have adapted to a new normal where we can continue to provide treatment, endure economically, and stay safe.
Riggs patients are confronted with the evolving changes due to the pandemic and the uncertainty these changes bring to their treatment and their place in the outside world. The depth of emotions and the meaning of each patient’s experience as they face these challenges is critical to their treatment. There are opportunities for continued growth, not only specific to the effects of the pandemic, but also in relation to each individual patient’s unique struggles that brought them to Riggs.