The Open Setting
In the past month at Riggs we held our biennial “open setting seminar” in which we study our community, paying particular attention to the unique challenges of working in a completely unlocked psychiatric hospital. Everyone at Riggs is invited to participate in the seminar, including patients in all programs and staff in all roles (psychotherapists, housekeepers, teachers, administrators, cooks, nursing staff, etc….). We gather in various groups, some composed of people who do similar work and others mixed with people in very different roles, and on some days everyone joins in one large group. Participation is voluntary and not everyone comes, but those who do carry the experience back into our day-to-day work, enlivening and nourishing the system. This is one way we aim to foster a therapeutic culture that is at once stable and adaptable.
Discussions are rich and varied; here are a few examples. In one group of patients and clinical staff, we discussed “behavioral expectations” regarding acceptable conduct in the community. Although at one time established by consensus, these expectations routinely devolve into “rules,” and we find ourselves drawn into stereotyped roles like “rule-enforcer” or “rule-breaker.” Patients in this group spoke eloquently about experiences of breaking “rules” that they actually believe in upholding, and about the value of talking with others about the implications of what they had done. The open setting depends on this sort of shared commitment to understanding the meanings of actions. Patients and staff alike have a stake in maintaining a social environment that supports our work – the work of interpersonal learning in the milieu as well as the potentially unsettling work of deep psychotherapy.
In one of the large group meetings, participants grappled with the idea of “community.” What sort of community is this? Is it a therapeutic community for the patients or something more like a small town? Some people related uncomfortable experiences in which they felt hurt by the way others spoke to them. Some wished for less differentiation: a support staff person wanted access to more clinical information and a patient wished staff would be more personally self-revealing. A staff member pointed out that staff are here primarily to serve the patients. A fellow then observed that he is also here to learn, which led others to note other ways that staff benefit from being at Riggs. While our organizational structure provides essential guideposts for working in role, giving and receiving are complicated and multi-directional.