The Austen Riggs Center in Stockbridge, MA celebrates its centennial on July 21, 2019. This is a notable achievement for any psychiatric hospital, but the story of the evolution of Riggs and what it stands for illuminates major mental health trends of the last century, while choices made by the leaders of Riggs explain how a long-term psychoanalytic hospital that looked like a dinosaur actually turned out to be a mammal, surviving a mass extinction of other comparable hospitals. In the process, this small, hospital-based continuum of care that treats about 150 patients a year has become a beacon in American psychiatry, standing for a biopsychosocial psychodynamic approach to treating those with complex psychiatric problems; in 2019, it was once again ranked a “top 10” Best Hospital in psychiatry by US News and World Report. Hence, this is a story worth telling.
The origin story of Riggs begins in the late 18th century, when French physician Philippe Pinel introduced “Moral Treatment of the Insane,” as he freed patients in mental asylums from their shackles and chains, based on the recognition that patients struggling with mental disorders were suffering human beings who might recover if treated in a humane way. This stance, of building treatment on respect for the dignity and competence of those struggling with mental disorders, is a foundation of the fully voluntary “open setting” of Riggs, in which patients are free to come and go as they please, and are expected to take responsibility for themselves as a condition of treatment. The understanding that with freedom comes responsibility is the cornerstone of the open setting to which Riggs has been committed for a hundred years. The alliance negotiated with patients at the point of admission is taken seriously enough by both staff and patients that Riggs is able to work with many previously suicidal patients in an open setting—and achieve outcomes in which 75% of previously suicidal patients became free of suicide as an issue in their lives when followed up a mean of 7 years after admission.1
However, there is a more recent origin story that begins early in the 20th century, when Austen Fox Riggs, a Columbia-trained New York internist, developed tuberculosis. Pursuing a recommended “rest cure” in the countryside, Riggs and his wife, Alice McBurney Riggs, moved to her parents’ estate in the Berkshire Hills of Western Massachusetts. Her father, Charles McBurney, was also a Columbia-trained physician—a surgeon known for the eponymous “McBurney’s point”—the optimal location for surgical incisions to access the appendix.
For a while Dr Riggs seems to have struggled with his own adaptation to a chronic, life-threatening illness, but he soon became interested in the psychological problems of the local people employed at the McBurney estate. Dr Riggs knew about the “New Psychiatry” movement of the early 20th century, visited other therapeutic communities, and shaped his approach to treatment based on his experience and his readings, which likely included works by Sigmund Freud, who made his only visit to the United States in 1904 at Clarke University in Worcester, MA. Given considerable success working with employees with psychological problems using his brand of talk therapy and advice about how to live a balanced life, Riggs’ reputation grew. Soon, patients struggling with mental disorders from New York, Boston, and Philadelphia began coming to Stockbridge for treatment by Dr Riggs.
In 1919, Dr Riggs approached town officials because he was seeking to establish the Stockbridge Institute for the Study and Treatment of the Psychoneuroses. Stigma being nothing new even then, there was reluctance to approve such a name. However, town officials were satisfied with an alternate name, so the Austen Riggs Institute for the Study and Treatment of the Psychoneuroses, now the Austen Riggs Center, received its charter on July 21, 1919.
RIGGS BECOMES A CENTER OF PSYCHOANALYTIC EXCELLENCE
Riggs was one of a dozen or more private psychiatric hospitals that emerged from the “New Psychiatry” movement, perhaps the best known of which was the Menninger Clinic in Topeka, KS. Although 1 or 2 psychoanalysts joined the staff of Riggs earlier, the major move into psychoanalysis at Riggs occurred after the death of Dr Riggs in 1940 and the Second World War. In 1947, Robert Knight, chief of staff at Menninger and a president of the American Psychoanalytic Association, was hired as medical director of Riggs, bringing with him a dozen of the best and brightest young psychoanalysts from Menninger, including David Rappaport, Margaret Brenman, Roy Schafer, Merton Gill, and others. This group deepened the rigor of treatment at Riggs and published widely. Patients at Riggs still continue to receive 4-times-weekly psychoanalytic therapy provided by a doctor on the staff, as they did then.
An interesting side story involves Knight’s invitation to join the local Stockbridge Country Club, which did not accept Jews as members. Knight declined to join any club that his staff, many of whom were Jews, could not also join. The club quickly changed its admission policies and remains known as one of the county’s most open and egalitarian country clubs.
In the early 1950s, Knight hired another staff member, Erik Erikson, an innovative young psychoanalyst whose work shifted the focus of psychoanalysis from a narrow psychosexual view of psychopathology to a much broader psychosocial perspective that understood individuals not only in terms of intrapsychic life, but also as embedded in meaningful social contexts—from family to community to ethnicity and nationality. Erikson spent over a decade at Riggs, where his work with patients helped him begin the study of psychobiography, with publication of Young Man Luther and Gandhi’s Truth. Later, Erikson left Riggs to move into the social sciences as a member of the Harvard faculty, but he maintained his connection to Riggs until his death in the 1990s. In the 1950s, Erikson’s wife, Joan Erikson, a dancer and artist, developed an unusual activities program at Riggs that was not staffed by occupational or art therapists, but, rather, by actual artists and craftspeople who were teachers to patients who came to the “treatment free zone” of the activities program in the role of students seeking to develop their creative capacities. This acceptance of a role as a non-patient, for people who otherwise were patients in treatment, is a powerful cultural norm that distinguishes Riggs from other similar programs.
By the early 1950s, those seeking treatment at Riggs were younger than previous generations of patients and often quite rebellious toward authority, challenging the limits of an open setting. A crucial decision was made when, instead of attempting to restrict and control patients who were challenging staff authority, staff invited patients to enter a serious conversation about what kind of culture and community they wanted to create together at Riggs. Over time, a community structure was agreed upon, written up, and ratified by a vote of patients and staff. This structure gave patients authority over their own lives; authorized them to elect officers, run their community, budget money for activities, and engage those whose behavior was disruptive; and it allowed the patients to join the staff in a serious commitment to “examined living” within a therapeutic community. The same culture and commitments continue today with the help of periodic “Open Setting Seminars” that function almost like Constitutional Conventions to reassess and renegotiate the commitment to collaboration between staff and patients. Commitment to a culture that authorizes patients to be in charge of themselves and their culture makes the buildings at Riggs more than simply where patients eat and sleep while they receive individual 4-times-weekly psychoanalytic therapy and other individual treatments, but, instead, the locus of a therapeutic community in which patients are immersed in a 24/7 treatment environment. Riggs became a treatment system that relies on 3 pillars: (1) respect for the voice and agency of the patient, (2) the importance of relationships that continue over time as agents of change, and (3) relentless pursuit of the meaning of patients’ struggles and symptoms.2
FROM THE 1960s TO THE 1990s
One of the fellows training at Riggs in the 1960s was Aaron T. Beck, MD, who became interested in measuring change he observed in patients’ symptoms during psychoanalytic treatment. Beck continued to pursue this interest after his Riggs training. When organized psychoanalysis proved unwilling to fund his research interests, Beck took his ideas about measurement-based care to behavioral psychologists, who welcomed and supported him, leading to the development of cognitive behavioral therapy.
Under medical director Daniel Schwartz in the 1980s, Riggs began to join the world more fully, systematically adopting use of emerging psychoactive medications with patients, adopting DSM-III diagnoses, and contributing outcome research on DSM-III diagnostic categories.3 We learned that we were a center for the treatment of patients with borderline personality disorder—a condition about which Robert Knight had written early papers. Many of our patients with borderline personality disorder also had comorbid mood disorders, and, despite previous experiences of treatment failure, about two thirds of them had good outcomes with hospital stays that lasted an average of 15 months. However, the world was about to change, pushing Riggs and other private, long-term psychiatric hospitals into survival crises.
A CRISIS IS AN OPPORTUNITY
In the 1990s, managed care entered the health care scene in response to out-of-control inflation in health care costs and the failure of the Clinton health insurance initiative. Long-term private psychiatric hospitals that served as centers of excellence were particularly impacted, as managed care refocused inpatient stays on crisis stabilization rather than on helping patients grapple with underlying problems that interfered with successful use of outpatient treatment to achieve recovery. Inpatient length of stay decreased from months to a week or 2, with a concurrent shift to less expensive and, thus, less well-trained staff. While places such as New York Hospital’s Westchester Division, Timberlawn in Dallas, Boston’s McLean, and others shifted to the emerging short-term, crisis-focused model of inpatient care, Riggs did not. Resolute commitment to preserving an open setting was incompatible with the level of security and control required in a short-term, crisis stabilization-focused hospital setting.
Faced with a falling inpatient census, then medical director/CEO Edward Shapiro made a crucial and courageous decision. The mission of Riggs, Shapiro argued, was not to survive, but to stand for the recognition that some patients were unable to achieve recovery as outpatients and needed something more than outpatient treatment even if they were not in the kind of crisis that required short-term inpatient treatment. The world would either figure out that such an “intermediate” level of mental health care was needed, or Riggs would cease to exist.
Under Shapiro’s leadership, and committed to carrying out this mission, Riggs transformed itself into a hospital-based continuum of care, with most patients in a residential level of care, but with a range of programs from inpatient to residential to intensive outpatient. From the outside, Riggs had 8 different levels of care, but for patients within Riggs, the experience was virtually seamless, as they were followed by the same therapist, social worker, nursing staff, and other clinicians on the same treatment team throughout all levels of care from admission to discharge. Family and substance use disorder treatment were added to the clinical program. The median length of stay remained about 6 months, but now little or none of Riggs treatment occurred at an inpatient level of care. Within a year of this transition, Riggs was full and expanding its census, with a waiting list of 30 patients hoping to be admitted. The world was discovering what we suspected they would—that many patients failed even the best treatments. Many of these so-called “treatment resistant” patients needed an extended stay at an intermediate level of care between outpatient and inpatient so that they could return to outpatient treatment better able to use their sessions and function adaptively between sessions as they pursued recovery. They benefited from an extended immersion in an intermediate level of care to address underlying problems, such as the impact of comorbid disorders, early adverse experiences or recent trauma, and the chronicity or risk of recurrence associated with mental disorders.4 Riggs became a place where so-called “treatment resistant” patients became people taking charge of their lives. Soon Riggs was imitated, with significant expansion of residential programs around the nation. Further, the 2008 Mental Health Parity and Addiction Equity Act (or mental health parity law), in its 2014 “final rules,” specifically identified access to intermediate levels of care as part of the expected continuum of care for those struggling with mental health or substance use issues.
THE ERIKSON INSTITUTE FOR EDUCATION AND RESEARCH
Since the time of Dr Riggs, but especially in the years following the arrival of Knight, Erikson, and staff from Menninger, Riggs staff have had a significant commitment to scholarship and research as part of what it means to serve on the Riggs medical staff. Postresidency and postdoctoral fellowship training in psychoanalytic psychotherapy began in the 1940s. Riggs formally created the Erikson Institute for Education and Research in 1994 to house these training programs, along with Riggs’ research and local and national outreach efforts. In 2014, the 4-year fellowship for psychiatrists and psychologists was accredited by the Accreditation Council on Psychoanalytic Education as a program of psychoanalytic studies. Those who complete this fellowship program are trained psychoanalysts.
Recognizing that Riggs stood for a way of working that was worth exporting to the field, in 2006, then editor of the Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, Douglas Ingram, invited a series of papers from Riggs entitled “A View from Riggs: Treatment Resistance and Patient Authority.” These papers were later revised, new papers were added, and they were published in the first book on treatment-resistant disorders and their treatment.4
Through its research, teaching, and outreach, Riggs has had a significant impact on the contemporary mental health field over recent decades. Notable contributions and impacts include but are not limited to the following:
- Recognizing the emergence of the phenomenon of treatment-resistant disorders and their association with early adverse experiences, comorbidity, especially comorbid borderline personality disorder, and an excessively narrow biomedical treatment model.4
- Introduction of psychodynamic psychopharmacology, a “best practice” that focuses psychiatrists on the meaning effects of medications in addition to their biochemical effects. This helps psychiatrists understand how to prescribe, not just what to prescribe.5,6
- Expanding understanding of the psychoanalytic concepts of projective identification and enactment within mainstream psychiatry.7
- Introduction of psychodynamic treatment teams that work from a psychodynamic formulation to integrate an overall treatment plan, while using emerging intrateam dynamics, conflicts, and enactments as a lens to view patients’ intrapsychic and intrafamilial lives.8
- Describing the role of residential treatment and stimulating its expansion around the nation, including other psychodynamic programs, but also residential programs focused on cognitive behavioral therapy and dialectical behavior therapy.9,10
- Contributions related to the problem of suicide that range from exploration of mental states associated with suicide, to the use of the interpersonal meaning of suicide as a technical principle in work with suicidal patients, to the study of and response to the significant impact of patient suicide on clinicians.11–13
- Exploration of the meaning of money in psychodynamic treatment as both a reality and a metaphor for other limitations faced by a patient.14
- Advancing psychodynamic understanding and treatment of patients with psychotic spectrum disorders and trauma.15–17
- Broadening the clinical utility of projective psychological testing.18,19
- Challenging a biomedically reductionistic field by questioning assumptions that are not consistent with emerging evidence (eg, that genes=disease in common disorders like schizophrenia and depression, that most patients present with single disorders that respond to evidence-based treatments, and that pills are consistently superior to psychotherapy).20
- Standing for the importance of psychotherapy as part of the training and practice of psychiatrists, and for psychodynamic psychotherapy as part of treatment in the American Psychiatric and American Psychological Associations. Such work in the larger field includes founding the American Psychiatric Association Psychotherapy Caucus and developing the so-called “Y-Model” for teaching both shared elements across schools of therapy and evidence-based distinguishing features of cognitive behavioral therapy and psychodynamic therapy.21,22
- Working toward conflict resolution using psychodynamic large group systems approaches (eg, the International Dialogue Initiative).23
Although small in size, over the course of its 100 year history, the Austen Riggs Center has come to stand for an integrated psychodynamic way of working that bridges contemporary biomedical learning and psychoanalytically informed treatment in a robust biopsychosocial model of care that is largely supported by emerging evidence from psychiatric genomics and psychotherapy research. This is a particularly important approach to treatment for those struggling with complex psychiatric problems and treatment-resistant disorders. As it embarks on its second century helping patients reclaim their lives, Riggs will convene a centennial conference in September 2019 entitled “The Mental Health Crisis in America: Recognizing Problems, Working Toward Solutions.” For more information see www.austenriggs.org/centennial-conference.
1. Perry JC, Fowler JC, Bailey A, et al. Improvement and recovery from suicidal and self-destructive phenomena in treatment-refractory disorders. J Nerv Ment Dis. 2009;197:28–34.
2. Shapiro ER. A view from Riggs: treatment resistance and patient authority–XII: examined living: a psychodynamic treatment system. J Am Acad Psychoanal Dyn Psychiatry. 2009;37:683–698.
3. Plakun EM, Burkhardt PE, Muller JP. 14-year follow-up of borderline and schizotypal personality disorders. Compr Psychiatry. 1985;26:448–455.
4. Plakun EM, editor. Treatment Resistance and Patient Authority: The Austen Riggs Reader. New York, NY: Norton Professional Books; 2011.
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6. Mintz DL, Flynn DF. How (not what) to prescribe: nonpharmacologic aspects of psychopharmacology. Psychiatr Clin North Am. 2012;35:143–163.
7. Kayatekin MS, Plakun EM. A view from Riggs: treatment resistance and patient authority, paper X: from acting out to enactment in treatment resistant disorders. J Am Acad Psychoanal Dyn Psychiatry. 2009;37:365–381.
8. Krikorian SE, Fowler JC. A view from Riggs: treatment resistance and patient authority–VII. A team approach to treatment resistance. J Am Acad Psychoanal Dyn Psychiatry. 2008;36:353–373.
9. Shapiro ER, Plakun EMSharfstein SS, Dickerson FB, Oldham JM. Residential psychotherapeutic treatment: an intensive psychodynamic approach for patients with treatment-resistant disorders. Textbook of Hospital Psychiatry. Washington, DC: American Psychiatric Publishing; 2008:285–297.
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11. Tillman JG, Clemence AJ, Hopwood CJ, et al. Suicidality in high-risk psychiatric patients: the contribution of protective factors. Psychiatry. 2017;80:357–373.
12. Plakun EM. Psychotherapy with suicidal patients part 2: an alliance based intervention for suicide. J Psychiatr Pract. 2019;25:41–45.
13. Plakun EM, Tillman JT. Responding to the impact of suicide on clinicians. Dir Psychiatry. 2005;25:301–309.
14. Plakun EM. Jihad, McWorld and enactment in the post-modern mental health world. J Am Acad Psychoanal. 2002;30:341–353.
15. Belnap BAFromm MG. Turns of a phrase: trauma lessons through the generations. Lost in Transmission: Studies of Trauma Across Generations. London: Karnac; 2012:115–130.
16. Charles M. Trauma, Identity, and Social Justice. Psychoanal Cult Soc [Epub February 5, 2019]. Available at: https://doi.org/10.1057/s41282-018-0114-z
17. Charles MDowning DL, Mills J. Working with psychosis. Outpatient Treatment of Psychosis: Psychodynamic Approaches to Evidence-Based Practice. London: Karnac; 2017:55–78.
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20. Plakun EM. Psychodynamic psychiatry, the biopsychosocial model, and the difficult patient. Psychiatr Clin North Am. 2018;41:237–248.
21. Mintz D. Teaching psychoanalytic concepts, skills, and attitudes to medical students. J Am Psychoanal Assoc. 2013;61:751–770.
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