Why Take the Risks to Preserve a Completely Open Setting?

By David Mintz, MD

Over the last two decades, there have been considerable pressures across American mental health care, to close and lock psychiatric facilities. This has been driven by reimbursement models that hold hospital treatment to be unnecessary, unless the patient requires incarceration. Further pressure to close treatment settings derive from a litigious culture which promotes a defensive practice of medicine. In the face of these pressures, however, we at Riggs have maintained the highest commitment to the preservation of a completely open setting. Why take these risks?

In Norse mythology, it was foretold that the Fenris Wolf, the monstrous spawn of the Trickster God, Loki, would one day devour the sun and the moon, and bring about the end of the world. The gods sought to chain the wolf, and commissioned the dwarves to make the heaviest chain ever known, forged from the strongest metals. The wolf strained against his fetters, and easily broke them. The dwarves made a still larger chain, and, again, the wolf easily broke his bonds. The dwarves’ third effort, however, was not made of metal, but of intangibles. Only this gossamer thread was strong enough to hold back the destructive force that would destroy the world.

To me, this myth captures the wisdom that is “The Open Setting.” At Riggs, there are no locks to restrain the patients, no bars on the windows, no privilege system. I think, that like the myth of Fenris, we have recognized that only the intangibles, the bonds of human relationships, of words and understandings, may be strong enough to contain the destructive forces operating in many of our patients.

We have created something precious here, which, like the dwarven filament, is both delicate and powerful. In the open setting, patients have a place where they are seen, known, and extended the dignity that goes with freedom and choice. In using the treatment and its freedoms, patients who may seldom have found something in their lives worth valuing, discover a precious opportunity that they do not want to squander. I have seen, again and again, the wonder of a chronically self-destructive patient who learns to forestall treatment-endangering actions in order to preserve treatment. Often, they did not know they could do it, until they found something worth protecting. The thread of containment begins to be woven.

In place of the locked door, patients learn how their actions, symptomatic and otherwise, reverberate throughout the social order. At Riggs, patients, who often have felt profoundly alone, are known deeply and engaged as responsible partners in the venture of recovery. Agreements are made, with staff and peers, to share, explore, and understand destructive impulses, rather than to enact them. So-called “private” actions are revealed as meaningful and impactful to others. When the onus of safety falls not on metal, but on intangibles, patients can feel their bonds with others, not as imprisonment, but as connection. The gossamer fetters are strengthened.

I fear that the culture of the locked door that pervades mental health care does far more harm than good. The locked door symbolizes a patient’s inability to be responsible for themselves. Infantilizing, it can be something that has to be fought, or acquiesced to, and cannot be joined. The locked door tries to keep patients alive behind the locked door. The open door helps them learn how to claim their lives and find value on either side of the door.

The myth of the Fenris Wolf is, in its depths, true. The real myth is that locks and bars make us safe.