Finding a Place to Stand: Dr. Ed Shapiro on Voice, Authority, and the Family System

STEVE: Hello and welcome to another episode of the PPI Podcast brought to you by the Purposeful Planning Institute. My name is Steve Legler, and I’m happy to be your host for this episode. Today’s guest is Dr. Ed Shapiro, the former longtime CEO and medical director of the Austin Riggs center in Stockbridge, Massachusetts. Dr. Shapiro has many decades of experience dealing with families like those many PPI members deal with and in a relative as a relatively new member, we wanted to ask him to share some background of what makes his work special and a bit different from what many of us might expect. We had a prep call recently, and I’m excited to jump back into some of the topics we began to explore in the hopes of providing something useful to the PPI membership community. Dr Shapiro, welcome to the PPI Podcast.

EDWARD: Thank you very much. Glad to be here.

STEVE: So I think the most appropriate place to start is Austin, Riggs. It’s been in the Berkshires in Western Massachusetts for many decades

EDWARD: And six years.

STEVE: Oh, boy. And so what makes it special, or what is? What is Austin Riggs’ claim to fate?

EDWARD: Austin Riggs Center is constructed to take patients who don’t respond to the usual psycho, psychological, and psychiatric treatments, medications, CBT, the usual structures that increasingly the field is using, don’t work for patients like this, and when they get into trouble, they need something else. The patients who come to Riggs are overwhelmed with traumatic symptoms, with struggles with their families, with finding a place to live in the world, and they have had trouble most of their lives with people in authority. Some of that comes to them because of the nature of their upbringing. Some of it comes because of the nature of their hard wiring. They’re different than their families in many ways, and families struggle to work with them, and they come to Riggs, and they have a wide range of ways of beginning to learn how to take charge of their lives, not just surrendering to people who tell them what the best thing is to do, not surrendering to families who tell them how they’re supposed to be, but actually discovering a life that they’re in charge of. To do that, we have three ways of their transmitting what they’re struggling with. One is intensive psychotherapy, where they meet with a therapist four times a week. When it makes sense, their families are involved. They have a psychiatrist providing psychopharmacologic treatment, but they’re also involved in a therapeutic community, and for many of our patients, their behavior is out of line, and so their behavioral interactions with other people are sources of information. Belonging to a community allows them to test out what they’re struggling with, see how they relate to other people and how other people relate to them, and then bring it back into the psychotherapy. And there’s a third aspect of Riggs, where we treat them simply as grown-up people, civilized citizens, where they’re not in the patient role. They work with a group of staff who don’t know their histories, who don’t treat them as patients. They work as assistants in a nursery school. They work as artists in our art studio, as partners. They have jobs on campus where they are paid like anybody else gets paid, and they, at the same time as they’re struggling and learning about their struggles in their intensive work, they’re living as citizens in the town of Stockbridge. Some of them take up roles in our Riggs theater, which is overseen by Shakespeare and Company around here, and they put on plays that people from the outside community participate in. They have all kinds of ways of getting a perspective on a range of issues that they’re struggling with. That’s what we do uniquely.

STEVE: It sounds like a real, immersive experience that is probably different from what most people might expect. You said something about, at the beginning of your answer, that, you know, it’s unlike, or for people who don’t respond or didn’t respond well to other attempts. So it made me think, is this kind of like a last resort, or are some people lucky enough to find it early on?

EDWARD: Some people find it earlier on, but about half of the patients who come to Riggs have survived near lethal suicide attempts.

STEVE: Okay.

EDWARD: So, this is serious business that we’re involved in, and so they come anxious about their lives, their families are anxious about their lives, and since it is a completely open setting where patients are responsible, the staff is anxious. So, the staff, the family, and the patients manage that anxiety together, with an authorization from us to our patients that they’re actually competent, grown-ups working on trying to understand something they haven’t gotten any perspective on in their lives.

STEVE: So, where does the aspect of, when you call it, label this, human systems, help me understand that? Because I know people talk about a family system, but now there’s a broader, I guess, the human system, and I guess it all has to do with the way you treat humans, like a human.

EDWARD: Well, it’s even more complicated than that. Human beings are, one way to think about them, is that we are all open systems as individuals, and the way we connect to other people is through the communication of feelings. As human beings, we’re sensitive in responding to the feelings of other people, and a human system that pays attention to that kind of communication means that everybody who works at the Austin Rick Center is connected to the primary mission to try to help our patients assert the maximum competence they can, so they can take charge of their lives. It’s a mission that everybody, from a different perspective, from the chef in the kitchen to the nursery school teacher to the psychotherapist to the nurse, everybody is working on maximizing patients’ authority.

STEVE: So, taking charge of their lives. So, I was thinking about your recent book, Finding a Place to Stand. You talk about individuals finding their voice and authority, and it is, I’m guessing, that’s something that’s always been kind of pent up inside them, but they haven’t had the expression for it, creating the conditions to allow that to emerge.

EDWARD: Yes, yes, and to gain some perspective on it, and to recognize that the symptoms that our patients come in with—despair and aggression and overwhelmed problems—are efforts to communicate, and once they begin to get a language for that kind of communication, and to put it in perspective, they increase their authority and their capacity to take a stand.

STEVE: So these are likely, I’m guessing, family members whose voices of authority haven’t been heard because they’ve been overshadowed or didn’t fit. I mean, there’s something about the identified patient. Often in families, I know John A. Warnick, the founder of PPI, calls them the designated difficult one. And are these the types of people that more often end up at Austin Riggs? And is that kind of like a specialty—now learning how to tap into these people who haven’t been heard?

EDWARD: You’re speaking my language. The designated patient is our form of the designated difficult one. So, the phone, your founder had the right formulation. People, in one of the ways family systems manage feelings, is they spread them out so that somebody represents, for example, the angry one or the passive one or the depressed one or the pain in the ass—whatever label gets located somewhere. The system colludes to stereotype that person. Sometimes it comes, it shows up with an angry father or a passive mother, and that kind of pairing is a solution that stabilizes a chaotic system. When you begin to unpack those delineations, you find out that the father isn’t just angry, he’s also sad. And the mother isn’t just passive, she’s also angry. And the complexity of people begins to emerge in family treatment, so that people who are stuck in the designated patient role have more space to discover the more complex side of themselves.

STEVE: Yes, so some of these people have assumed a role within the system just because they were the person sort of designated into that role, but it’s not really them. And sort of separating them from that role and looking deeper into who they really are sounds like it’s part of what you’re working on here.

EDWARD: It is hard, but it’s not that it’s entirely not them, because the people who get stuck in these roles give a little signal that they’re willing to take on that role, and they need to recognize that too, so that they can take charge of that aspect of themselves.

STEVE: One of the aspects of the families that a lot of PPI members deal with is that there is often a large amount of financial resources. And, you know, those can be great. And people say, you know, people have said, “I’ve had money, I’ve had no money; it’s always better to have money,” and it’s easy to be blasé about this, but when wealth acts as a shock absorber and people are expected to become flourishing adults, sometimes things get in the way. Is that part of where people end up coming to your care?

EDWARD: Most of the patients we see have that kind of dilemma in their family. Sometimes it’s because the parents have been so enormously successful that the challenge presents a kind of frustrating limit for the child growing up, that they feel they can never reach. Sometimes it’s because the parents have made their success because of trauma and poverty in their own childhoods, and they’re trying to make it up to their children, and by doing—by providing everything—providing everything is not necessarily good for a child. And we have seen many patients who get lost in too much wealth without the structure necessary to think about their responsibility for it. It’s such a common presenting problem, which is why we do family treatment. I’ve spent a lot of time consulting to family businesses and working with families who are transferring wealth. The dynamics of the family are enormously powerful in those situations. Quite often, when they’re passing over family businesses, for example, the children feel an obligation that doesn’t match actually who they are, and they struggle with that and sometimes get lost in substances and other ways of trying to manage something they don’t fully understand.

STEVE: And so I think I heard you say you deal in family therapy. So you would be dealing not just with the designated patient, but also have family members attending with them, and you’re working with them as a group.

EDWARD: When it’s possible. There are some patients who refuse to have family contact, and in our effort to put patients in charge of their lives, we respect that. But we say to them, in our view, families are resources, and we will help you manage whatever tensions come up in the family meeting. We encourage you to try to use that resource, because when you solve some of these problems, children find that they’re actually not so angry at their parents after all. When the parents’ complexity emerges from those delineated roles, and they find out what the parents are struggling with, it makes an enormous difference. So quite often, families come in with what you’re calling the designated difficult person, and they leave with a recognition that there are a range of difficult people in these families, and they can learn how to talk to one another.

STEVE: There was something in my notes here about behavior as communication, and so I think that you’re always looking for as much information to understand the complexity of the situation. And I guess you’re talking about the fact that there’s lots of observable things that people are doing that help you understand where they are. And I guess that helps you get them unstuck sometimes.

EDWARD: Well, this is one of the tensions that Riggs has with the field, because the field primarily focuses, if I can make a generalized statement, on reducing the intensity of patient symptoms—a perfectly reasonable thing to do, because their symptoms get them into terrible trouble. But what we have learned is that patients express their struggles through behavior: like they piss people off, or they steal, or they use drugs, or they try to kill themselves, as a way of expressing something that they’re up against that they can’t get their mind around, that is overwhelming them. They can’t think about it. So we use psychopharmacology as well to reduce the intensity of symptoms. But that’s not the end point. We reduce the intensity so they can sit in a room with a psychotherapist and begin to think about what they’re feeling, rather than acting it out. We use the community to try to provide a range of human resources where patients can behave however they behave, and people can respond to it in a way that the patients can think about. Everything in the system is designed to help them understand they are trying to say something about what is overwhelming them, that comes from their past, that they don’t have language for. Once people have language for their behavior, they’re in charge of it.

STEVE:  And they are coming to you, and you put them in an environment where they’re outside of where they had all their symptoms, and you’re trying to create like a laboratory for them to live in as just another person, yes, with no locked doors, and with agency and authority over their own lives, and treating them as an adult, which perhaps they haven’t had enough of, even if they’ve reached a certain age.

EDWARD: Exactly right. And we’re also in a very small town of Stockbridge, Massachusetts, so patients take up roles in the community. They step down to our programs. They work in various shops and businesses locally, and they become part of the community.

STEVE: And that’s—I haven’t heard of this anywhere else. I’m not an expert in this particular domain, but it sounds like a very unique situation that you have, that you’ve been doing for a century now, and obviously with some kind of success, that people keep coming back. Is there a history of people? I know that when we talk about, you know, rehab places—and I know this is not necessarily that—that people go in and then they, you know, six months later, they’re back again. Have you had different kinds of experience where people might come for a while, but once they leave, they are well on their way to being better and not having to return?

EDWARD: I think that’s true for most of our patients. There are some patients who leave after a period of time, go back out and work in their lives, get married or get into families, and find that they run up against something they haven’t paid enough attention to, and they, since they feel strongly about this place, come back to it. I think, you know, the evidence of that is that we have an alumni association, and every three years we have an alumni reunion. To come back to your psychiatric hospital for an alumni reunion is, I think, unique. We had 100 former patients at the last one.

STEVE: Wow. So there’s definitely something special going on there. So let’s bring this to the other PPI members who work with families, where there may be people who could be in need of this. And what is the advisor-clinician partnership, or how do our worlds of advisors to families work or overlap with yours? And how can we make people aware of these things? How does this work?

EDWARD: Well, you must see, because all of your people are helping people transfer wealth, you must see places where that transfer is fraught because of the family dynamic. I mean, helping a family address an intense family dynamic about something so massive as the transfer of generational wealth takes expertise. So I would think that there’s a conversation to be had between the people who are doing this and people like me who do it for a living. There are techniques that can help your advisors when meeting with families, where you can slow down the intensity of the interaction. There are some initial engagement techniques that are useful so people can begin to think together. But some of the troubles we see need more than what people advising on wealth transfer are typically trained for, and that is where we are most appropriate.

STEVE: So I know I’ve been in this situation in a room with a family, and I think a lot of PPI members can identify with it, where you start to feel like this is getting a little bit out of my depth. And so the scariest part of that is, I don’t know what to do. And so if we can sort of change that answer to say, well, at least I have an idea that I can explore and then connect with people at Austin Riggs and find out—is that usually the first step? Would an advisor reach out, or would a family member or someone from the family office maybe be the first one to reach out to you?

EDWARD: That’s a very interesting question. I think most of the people that reach out to us are the families. If I looked at the range—sometimes it’s the patient, sometimes it’s the referrer, but most of the time it’s the family.

STEVE: So, a family member, but not the person who will be coming for treatment.

EDWARD: Well, I mean, I don’t have the exact numbers, but my guess is that it’s probably 40–30, or 50–30: families, patients, and the rest referrals.

STEVE: That’s interesting, because there’s this concept in our space that some people talk about a “family champion,” who’s a person who might not necessarily have authority or whatever, but they’re the one that cares the most about the family remaining together and remaining healthy and having everyone flourish. And people are going to be listening to this; they will not see that you’ve been nodding or started nodding as soon as I said the word “family champion.” So what did that—how did that resonate with you?

EDWARD: Not infrequently, it’s a sibling—a sibling who recognizes that their brother or sister is out of line or getting lost, and they worry about them. They don’t like the way the parents are treating the sibling, and they try to take care of them as best they can. And then they begin to look for resources. So that happens not infrequently.

STEVE: I’m—that’s intriguing, because in one way it’s not surprising, and also it feels like, “If Dad’s making me do this, I’m going to resist a lot more than if it’s my sister.”

EDWARD: That’s exactly right. If I’m going to fight with my father, I don’t care what he suggests; I’m going to rebel against it.

STEVE: Well, yeah, if he suggested it, it’s more likely that I’m going to reject it.

EDWARD: Right.

STEVE: Okay. And so when we as advisors are with a family and we’re kind of stuck, and we might have this idea that we want to fix the family—and that’s probably way over our pay grade—this might be where the yellow flag is being raised and slowly turning red, to reach out.

EDWARD: Actually, we don’t fix families either. They fix themselves.

STEVE: Okay.

EDWARD: And the fact that people are caught up in a heated, impossible, irrational struggle doesn’t mean that they don’t have more internal resources than they’re showing. If you can slow down the intensity of the fight and get people out of fixed roles, families have a lot of competence at re-establishing the ways in which they love each other, which are the sustaining forces that can be rediscovered in families in trouble.

STEVE: I love that part about slowing things down, because it’s often, you know, things come to a boil, and then there’s so much anxiety in the room that nothing positive can happen. And even the most rudimentary facilitator training tells you to call a timeout or get people to cool off or take a break.

EDWARD: Well, hang on—let me interrupt you. I don’t think a break is a good idea, but I do think that early intervention, where the consultant or the person who’s managing this takes up the role of traffic cop, is not a good idea. “Let’s stop here and think about what just happened. What makes you so angry?” Just a couple of questions encouraging a reflective space about the intensity of the feeling is a very useful early technique that I encourage your people to use.

STEVE: Noted.

EDWARD: Taking a break or going away is a loss of an opportunity.

STEVE: Okay, so instead of taking a break, it’s to stop it and sort of force people to look at it and talk about it and think about it as a family about what’s going on. Often things will be happening and people won’t even realize why they happen.

EDWARD: And not only that, but when those intense things happen, it’s usually between some couple or maybe even three, and then the sibling is off on the side watching it. And so if you say, “Stop—what do you notice?” the sibling might take the opportunity to say, “This is what I see.”

STEVE: Okay, so someone who is part of the system, but not necessarily one of the combatants in what’s going on in the moment, will add a different perspective that can sort of calm the system down.

EDWARD: If the advisor creates an open space.

STEVE: Okay. So someone has to be running that meeting in a way to allow these things to happen.

EDWARD: That’s Wow.

STEVE: Dr. Shapiro, this has been great. Do you have any final thoughts for our members before we conclude this episode? I think you’ve shared so much fascinating stuff. Any final words for us?

EDWARD: Well, I know—I mean, you all know better than I do—that this is a period in lives where the largest, massive generational transition of wealth is taking place. So there’s a lot of need that I hope your staff and people will think about how to use.

STEVE: Excellent. Thank you so much, Dr. Shapiro, for joining us and sharing your experience with our listeners.

EDWARD: My pleasure. Thank you.

STEVE: Listeners, please like and subscribe. I’m Steve Legler. Until next time.