Examined Living: Reflection, Responsibility, and Learning in an Open Therapeutic Community

In her first post, “Open Setting: Empowering Patients Through Responsibility and Freedom,” Heather Churchill, PsyD, explored how the open setting at Austen Riggs Center rests on a fundamental belief: that patients are capable of meaningful responsibility, choice, and participation in their own treatment.

This second post takes a closer look at one of the core practices that makes that philosophy possible—examined living.

Examined living is an ongoing, community-wide process of public reflection on the meaning of behaviors, choices, and interactions—among both patients and staff. It is grounded in an attitude of open curiosity: a willingness to notice what is happening, tolerate uncertainty, and try to make sense of it together.

Rather than viewing behavior as something to be managed or controlled, examined living invites the community to reflect on impact, meaning, and context. Feedback is given and received openly, and group dynamics are explored when they contribute to patterns that undermine learning, freedom, or the integrity of the open setting.

A defining feature of examined living is that staff members are not exempt from reflection. Staff choices and behaviors at work are also open for examination by patients and colleagues alike. This openness affirms that the work at Austen Riggs is not about addressing pathology in patients but about understanding human dynamics wherever they appear.

Inviting reflection on staff actions helps prevent staff anxiety or irrationality from being unconsciously projected onto patients. Instead, it creates a shared language for understanding reactions, missteps, and emotional responses as part of a living, learning system.

To see examined living at work, consider the experience of Mark*, a patient who came to Austen Riggs seeking to understand the destructive impact of his anger on his relationships.

When Mark first arrived, his angry outbursts frightened other patients. Some asked staff to intervene and contain him. Rather than taking over, staff encouraged patients to speak directly to Mark about their experiences of him, while also inviting Mark to explore what might lie beneath his anger. At the same time, the community reflected on how group dynamics might be contributing to the situation.

As these conversations unfolded, Mark began to recognize that his anger was rooted in feeling rejected by others. Entering interactions already defensive and hurt, he often created the very experience he feared. Other patients shared not only how frightening his behavior felt, but also how it reminded them of angry figures in their own lives.

With staff support, some patients identified with Mark’s anger and explored their own struggles with rejection. Others acknowledged feeling jealous of his ability to express feelings they kept hidden. Gradually, the group began to see that Mark had taken on a role—expressing anger on behalf of others who felt unable to do so themselves.

Once this dynamic was named, Mark felt less alone and more connected. Other patients also began to express anger more openly, expanding the emotional range of the community as a whole.

Staff also examined their own responses, recognizing that they had at times withdrawn in the face of Mark’s anger out of fear of becoming its target. Naming this allowed staff to intervene more actively—not by suppressing anger, but by noticing it, wondering about its meaning, and helping the group reflect on its impact.

This shift helped both Mark and other patients feel more contained, not through control, but through thoughtful engagement. Responsibility was shared rather than displaced onto staff authority.

The belief that a patient community can assess problems and address them constructively is not something that is learned once and retained forever. It must be rediscovered again and again.

Both patients and staff may feel deeply ambivalent at times, especially when anxiety rises and the wish for staff to “take over” becomes strong. Allowing the process of examined living to unfold requires the entire community to tolerate uncertainty and resist the familiar assumption that staff are always capable and patients are always dependent.

Examined living challenges that split. It demonstrates that both patients and staff can be capable or irrational at different moments, and that mutual dependence is essential. We rely on one another to see what we cannot see alone—and to keep learning, even when it is uncomfortable.

Together with the principles described in our first post, examined living forms the emotional and ethical core of the open setting at Austen Riggs Center. It is not a technique, but a way of living in treatment—one that treats reflection, responsibility, and relationships as central to psychological growth.

*Mark is a fictionalized patient, used for illustrative purposes