Austen Riggs Center
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|Austen Riggs Center|
|Affiliated university||Harvard Medical School, Yale School of Medicine|
|Speciality||Open psychiatric care center|
|Lists||Hospitals in Massachusetts|
The Austen Riggs Center is a psychiatric treatment facility founded in 1913 in Stockbridge, Massachusetts.
Founding – 1946
A New York City internist who repaired to the bucolic countryside of Stockbridge while suffering from tuberculosis, Austen Fox Riggs developed an innovative treatment regimen that both anticipated the rise of psychosomatic medicine and therapeutic psychology, and forged a new direction for the residential hospital.
Interested in the way that troubling thoughts and emotions might be bound up with organic disease, Riggs was influenced by the mental hygiene movement (also known as the social hygiene movement). He developed his residential model after observing a physician in Bethel, Maine named John George Gehring, who treated patients through strict daily regimens and treatments through suggestion.
Opening in 1913 as The Stockbridge Institute for the Study and Treatment of the Psychoneuroses, the Institute incorporated in 1919 as the Austen Riggs Foundation. Coinciding with the creation of the Menninger Foundation in Topeka, Kansas, Riggs grew quickly; it had 100 patients by 1924, with average stays of four to six weeks. A staff of doctors handled no more than 10 patients each, and physicians in training joined regular staff meetings and conferences. A series of “green books" summed up Riggs’s "precepts for successful living" and Riggs encouraged a sense of community; an associate from the 1930s said that patients were encouraged to be “a valuable member of a united team.”
Unlike more theoretical approaches to treatment, Riggs tended to an earthy practicality. A skilled craftsman himself, Riggs had what a colleague described as a “deep and almost Puritanic conviction that feeling must be kept under constant surveillance and control by doing.” His hospital featured an extensive occupational therapy shop equipped for weaving, carpentry, painting, and other handicrafts, and rooms for games and recreation. Riggs also had what he called “10 commandments” of successful living.
Though he denounced what he called Freud’s “mental gymnastics,” and criticized the Vienna doctors’ emphasis on sexual conflicts as the root of neurosis, Riggs’s practices bore commonalities with the emerging field of psychoanalysis. He believed neurotics to be troubled by the “residues of past experience,” and that they would heal in part by self-knowledge and adaptation to practical realities. Where Freud spoke of defense mechanisms, Riggs once said that a patient “cannot be deprived of the protection of his neuroses.” Where Freud spoke of coming to grips with the ordinary unhappiness of the world, Riggs spoke of the problem of “magnifying suffering by making a personal quarrel with pain.” The American Journal of Psychiatry has called Riggs’ system “a fully integrated conceptual system of ego psychology” that preceded Sigmund Freud’s attention to the field by ten years. Riggs also read Freud in the original German, as well as Pierre Janet and Jean-Martin Charcot in French. Riggs’s books included Play: Recreation In a Balanced Life, Intelligent Living and Just Nerves. The New York Times described him as an “internationally known psychiatrist” who was “widely known to the general public for his books.” 
In 1947, Dr. Robert P. Knight, the former chief of staff of the Menninger Foundation came to Riggs as medical director. A friend of Anna Freud’s  and a star of the burgeoning world of American psychoanalysis, Knight emphasized talk therapy and rehabilitation, and avoided common practices in psychiatric hospitals of the time, including electroshock, insulin coma, and lobotomy. Knight regarded medications as useful to “lessen distress, improve the patient’s behavior and increase his accessibility to psychotherapy,” but believed that ultimately a patient’s troubles “must be worked out in treatment, if it is ever to be worked out at all.” A president of both the American Psychiatric Association and the American Psychoanalytic Foundation, Knight was an authority on borderline personality disorder, which he said referred to patients who were “quite sick but not frankly psychotic.” Under his direction Austen Riggs began to receive more seriously ill patients, and to explore ways to put into practice Knight’s ideas that borderline patients needed a combination of structure and freedom in order to negotiate their own path toward health.
One major element of this culture began early in Knight’s tenure, when, facing some turmoil with a younger patient population, he convened a conference of patients and staff to work out philosophy and procedures of a therapeutic community.
By 1948, Knight had brought with him what the scholar Lawrence J. Friedman has called “the creative core of Menninger’s clinical psychology department and its research staff,” including David Rapaport, Roy Schafer, and Merton Gill (who wrote the text Diagnostic Psychological Testing) and Margaret Brenman-Gibson, the first non-physician to receive full clinical and research psychoanalytic training in the United States
In 1951, Erik Erikson joined the staff at Riggs, completing a team that, according to an article in the Harvard Gazette, “turned the grand experiment of treating very troubled patients in an open therapeutic community into a Golden Age of conceptual and clinical inventiveness.”  According to Friedman, Erikson “compared Riggs to the safe sanitarium in the Alps that Thomas Mann had characterized in The Magic Mountain.” During the Eriksons’ residence in Stockbridge, Joan Erikson, an artist and dancer, directed the Riggs’ Activities Program, which she expanded to include theater, dance, painting, sculpture, woodwork, gardening, and music. She also founded a formal Montessori kindergarten for local families, in which Riggs’ patients could apprentice — a program that continues today. According to Erikson biographer Daniel Burston, the Activities Program “became a unique, engrossing, and deeply healing experience for patients, which stood in stark contrast to the enforced passivity, boredom, and/or utter self-absorption that prevails in many treatment settings.” The theater program at Austen Riggs was also influenced by William Gibson, the playwright known for The Miracle Worker. While in Stockbridge, Gibson wrote a novel called The Cobweb, set at a posh psychiatric hospital, which was turned into a film starring Richard Widmark and Lauren Bacall.
Erikson pointed out that the Activities Program played a major role in preventing patients from succumbing to a narrow, negative identity produced by immersion in the “patient role.”  He credited his wife’s work with teaching him the “curative as well as creative role of work,” which he found to be prominent in the life of Martin Luther. Erikson also used his experience at Riggs to pursue the ideas he developed in his book Childhood and Society, which proposed a series of eight normative crises in every life, with potential at each stage for healthy growth and integration — and also pathologic development and mental illness.
In 1967, after Knight’s death, Dr. Otto Allen Will, Jr., formerly of Chestnut Lodge, came to direct Austen Riggs and brought his understanding of early attachment problems and psychotic vulnerability to the treatment program. According to his New York Times obituary, “Dr. Will was one of a small number of psychoanalysts who devoted their careers to trying to understand psychotic patients through long, intensive, therapeutic relationships with them.” The Times noted that Will wrote in more than 85 papers how psychotic thought states might be changed using only psychotherapy. Will retired in 1978 as medical director at Austen Riggs but continued on the hospital's board until his death.
Dr. Daniel P. Schwartz, the former director of the Yale psychiatric hospital, directed Austen Riggs from 1978–1991, and oversaw the hospital in an era in which both managed care and biological psychiatry came to dominate the field, and in which many legendary hospitals focusing on long-term psychotherapy – including Chestnut Lodge, the McLean Hospital, the Westchester Division of New York-Presbyterian Hospital, Timberlawn, Sheppard Pratt, and Menninger’s —changed their missions considerably.
1991 – June, 2011
In 1991, Edward R. Shapiro assumed the role of medical director/CEO of Austen Riggs. An authority on family and organizational systems, Shapiro expanded Riggs’ focus on working with family members to facilitate patients’ treatment, and increased the number of social workers on staff from one to eight. Shapiro also emphasized Riggs as a resource for “treatment resistant” individuals, who were unable to be treated successfully elsewhere. Under Shapiro’s leadership, Riggs increased its residential capacity from 56 to 73, and expanded the options for more cost-effective step-down programs. Shapiro retired in June, 2011.
Dr. James L. Sacksteder is the Medical Director/CEO at the Austen Riggs Center. A board certified psychiatrist, Dr. Sacksteder has been a dedicated clinician whose commitment to the Austen Riggs Center spans more than thirty years.
Dr. Sacksteder has written over twenty articles and book chapters on the treatment of anorexia nervosa, long-term psychoanalytically-oriented psychotherapy of severely disturbed patients, narcissism, object relations theory, and ego psychology. He is co-editor of Attachment in the Therapeutic Process with Daniel P. Schwartz, M.D. and Yoshiharu Akabane, M.D.: (International University Press, 1987). Dr. Sacksteder was a lecturer at Smith College School of Social Work for over twenty years.
Dr. Sacksteder received his M.D. from Northwestern University Medical School. He completed a psychiatric residency at Strong Memorial Hospital at the University of Rochester School of Medicine and Dentistry before completing a Fellowship and Advanced Fellowship in Psychoanalytic Psychotherapy at Riggs.
Within psychiatric circles, Austen Riggs stands out in two major respects. First, at a time of rapid decrease in psychotherapy —just 29 percent of office-based visits to psychiatrists involved psychotherapy in 2004-5, down from 44 percent in 1996-97  — the Center organizes its treatment around intensive psychodynamic psychotherapy with a psychiatrist or clinical psychologist. The value of the “talking cure” was bolstered in 2008 by a meta-review of 23 studies involving 1,053 patients reported in the Journal of the American Medical Association. The study found that psychotherapy, given as often as three times a week, relieved symptoms including anxiety and borderline personality disorder better than many shorter-term therapies. Though medication is administered to a vast majority of Riggs' patients, the Center follows the principles of "psychodynamic psychopharmacology," which means that it pays attention to the demonstrated ways in which relationships between patients and mental health professionals impact the efficacy of medication.
Riggs’ second distinction is its long-term residential treatment in an era of managed care that emphasizes short-term hospitalizations and outpatient treatment for the seriously mentally ill. And unlike many hospitals that restrict the freedom of its patients, Riggs is entirely open, with patients free to come and go as they please. The hospital has no locked wards, seclusion rooms or privilege systems. This environment encourages patients to take charge of their treatment.
The minimum stay at Riggs is six weeks and the median stay is six months. Some patients receive residential treatment for several years, before stepping down to outpatient programs. Following the reorganization of the Menninger Foundation in 2003, The New York Times described Austen Riggs as the last of the "elite private hospitals, often in bucolic settings," where patients can spend "months or years sorting out their lives" with treatment including intensive, long-term psychotherapy. The Austen Riggs Center focuses its attention on individuals with serious mental illnesses for whom repeated treatments in outpatient settings have proved ineffective. The psychiatric terms for such patients are “treatment resistant” or “treatment refractory,” and the growing awareness of such individuals is reflected in the 800 percent rise in citations on the subject from 1999 to 2009.
On its website, Riggs identifies candidates for treatment there as people who have been “caught up in treatments that are at an impasse, characterized by chronic crisis management and interrupted by frequent short-term hospitalizations.” In an article published on lifesciencesworld.com, the director of admissions at Austen Riggs, Dr. Eric Plakun, said:
It’s fair to say that many patients who come to us are sick unto death. They’ve been through all the state of the art treatments. And the treatments have failed, so they are desperate and hopeless and deeply distrustful. They’re often on a dozen or more medications. And they often have one or another dramatic story — having jumped off some high bridge that everyone would know, or having survived an overdose or even a gunshot wound.
In 2007, the article noted, more than forty percent of incoming Riggs patients had made a serious suicide attempt before admission.
The goal of treatment, the Riggs’ website declares, “is to help individuals in such a struggle take charge of their lives more fully so that they may return to more productive treatments and more fulfilling engagement in the outside world.” The typical census for Austen Riggs is about 70 patients. For the initial six-week treatment period, the fees are approximately $1,000 a day, which can be adjusted, according to need, as much as 25 percent. Costs are significantly reduced in step-down settings at Riggs. Without insurance coverage, the average cost to a patient at Riggs — including four-times a week psychotherapy, groups, activities, medication, housing and meals — is about $600 a day.
A study in the Jan. 2009 issue of Journal of Nervous and Mental Disease reported on the outcomes of 226 Riggs' patients who were followed for 15 years. Among 79 who made at least one suicide attempt in the 6 months before admission, 77.2% were estimated to be free of suicidal acts by a median of 7.18 years. Among 156 individuals with suicidal ideation, 50.6% attained sustained recovery at a median of 8.69 years.
- The Riggs Story. The Development of the Austen Riggs Center for the Study and Treatment of the Neuroses, by Lawrence S. Kubie, M. D. (New York: Paul B. Hoeber, Inc., 1960).
- ”Austen Fox Riggs: His Significance to American Psychiatry of Today ”, by John A.P. Milett, M.D.
- Dr. Austen F. Riggs, Psychiatrist, Dies,” The New York Times, March 6, 1940
- “Friend of Anna Freud’s,” The New York Times, May 1, 1966
- ”Borderline States,” by Robert P. Knight, in Current and Historical Perspectives on the Borderline Patient, edited by Reuben Fine (The Society for Psychoanalytic Training, 1989).
- Friedman, p. 260
- Burston, p. 41
- Young man Luther: a study in psychoanalysis and history, by Erik H. Erikson, p.8
- “Otto Allen Will Jr., 83, Psychoanalyst, Is Dead” The New York Times, November 22, 1993.
- Steenhuysen, Julie, "Move over Freud: Psychiatrists embrace pill power," The New York Times, August 4, 2008
- “Psychoanalytic Therapy Wins Backing”, by Benedict Carey, The New York Times, October 1, 2008
- "Psychodynamic Psychopharmacology: Addressing the Underlying Causes of Treatment Resistance", by David Mintz, M.D., Psychiatric Times, July 27, 2009.
- “Avoiding Extinction: Successful Private Psychiatric Hospitals In The Opening Decade Of The Twenty-First Century, by Jeffrey L. Geller, M.D., M.P.H.
- Our Treatment Approach austenriggs.org
- Famed Psychiatric Clinic Abandons Prairie Home by Erica Goode, The New York Times, May 31, 2003
- Improvement and Recovery From Suicidal and Self-Destructive Phenomena in Treatment-Refractory Disorders; by Christopher J. Perry et. al, The Journal of Nervous and Mental Disease, January 2009 - Volume 197 - Issue 1 - pp 28-34
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