A View From Riggs: Treatment Resistance and Patient Authority—Introduction to Paper VI: “Working With Family Resistance to Treatment” by Ave Schwartz

The moment I first read Schwartz's article, I knew I could best introduce it and its message by telling a true story that has become a part of Austen Riggs lore. As the story goes, one day many years ago a new patient was being admitted to Riggs. As he and his family unpacked the car and carried belongings to his room, the new patient was repeatedly scolded, infantilized, ordered around, and criticized by his well-meaning but rigid and anxious parents. The process that unfolded was observed by a member of the nursing staff and another patient who had been at Riggs for some time, a young woman with schizophrenia who rarely spoke. When the family had completed its task and drove away, the usually silent young woman with schizophrenia turned to the nurse and said tersely, “Looks like they admitted the wrong one again.”

In spite of the genuine love families generally feel for the individual being admitted for their “treatment resistant” disorder, this story illustrates the way families can contribute to a patient's problems. The equilibrium of a family system may well depend on the patient being assigned that role in some complex way. The current contribution to the series of articles about what we are learning on behalf of the field about work with treatment resistant patients focuses on the way family systems issues may contribute to the presentation of a patient as treatment resistant. Further, it again illustrates the importance of the three elements we have identified as fundamental to successful treatment of patients with treatment refractory disorders: attention to patient authority, to the importance of relationships, and of the discovery and elucidation of often hidden meaning. Schwartz shows us how engaging family dynamics through a carefully negotiated interpretive relationship, and finding the meaning of that which unfolds in the process, can help shift