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practice

A solution-focused model and inpatient secure settings
Ernest Gralton
CONSULTANT FORENSIC PSYCHIATRIST IN DEVELOPMENTAL DISABILITIES, ADOLESCENT SERVICE, ST ANDREW’S GROUP OF HOSPITALS

Victor Udu
SPECIALIST REGISTRAR IN LEARNING DISABILITY PSYCHIATRY, COLCHESTER PRIMARY CARE TRUST

Shan Ranasinghe
ABSTRACT
There has been a significant expansion of secure psychiatric service provision in the UK, but little discussion about the most appropriate principles on which to base these services. There is longstanding tension between security and treatment that can be difficult to resolve. Solutionfocused ideas may provide a bridge between these two issues, by improving multidisciplinary working and providing an appropriate relationship style that optimises the delivery of care to forensic patients. ASSISTANT PSYCHOLOGIST

Background
The problems
Secure and forensic services present a number of unique problems that can test the models of mental health care provided by staff to patients. The nature of the risks they pose means that these patients can spend comparatively long periods of time in secure settings. They tend to be complex individuals with a variety of needs, and treatment can be lengthy (Badger et al, 1999). Improvements can be slow and erratic, with intermittent relapses. There are ethical issues for staff who look after these patients, particularly to do with the balance between care and control (Kaye & Franey, 1998). It can mean that staff groups can be artificially split into two main camps: those who are predominantly delivering therapy and those whose main role is to maintain security (Clarke, 1996; Durrant, 1993; McCann et al, 2000). These divisions can significantly accentuate the tensions between professional groups, and rank as the highest source of stress for staff working in secure settings (Whyte & Brooker, 2001). Forensic patients have typically had very negative relationships with parental and authority figures (McCann, 2000). Disorders of attachment are prevalent, particularly in patients with personality disorders (Frodi et al, 2001). Offending and antisocial behaviour can place additional stress on these already strained family relationships (Tsang et al, 2002). Levels of self-efficacy and self-esteem among these patients can be very poor (Rask & Hallberg, 2000). Impaired social ability may play a more significant role in offending than factors like intellectual ability (Kearns & O’Connor, 1988). Treatments targeting relational abilities have been shown to be effective (Goodness & Renfro, 2002). The adversarial nature of the criminal justice process can promote

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The British Journal of Forensic Practice • VOLUME 8 • ISSUE 1 • FEBRUARY 2006
© Pavilion Publishing Brighton Ltd

can easily become demoralised. feeling that they are making little progress towards living in the community. often with contrasting models of care and differing views on how they are best implemented (Mason et al. and the terms are often used interchangeably. Treatment model or treatment philosophy? Many health services say they have a model or philosophy that underpins the delivery of care.A solution-focused model and inpatient secure settings an authoritarian style of therapeutic interaction. The problems of staff ‘burn-out’ are well recognised in secure settings (Beer et al. A shared model is likely to improve the cohesiveness. Patients. a high degree of interpersonal skill is required to manage aggressive behaviour (Crowhurst & Bowers. needs to have a balance between examining past-related risk issues and activities that are more positive and future-focused. For the purpose of this paper we have defined both the philosophy and the model in mental health care as the set of principles that underlie the consistent delivery of treatment and guide the wider therapeutic interactions between staff and patients. A multidisciplinary team will come from a variety of backgrounds. These relationships can therefore reduce the patient’s capacity for logical and sensible thinking and increase the risk of aggressive behaviour (Whittington & Wykes. The perception of emotional interactions in the environment significantly affects brain function. They can further complicate patient/staff relationships. However. A ‘skill share’ model has been recommended for effective team management of difficult psychiatric patients (Tyrer. Patients with personality disorder. A philosophy can be defined as a system of theories on the nature of things or conduct. Philosophical ideas are useful in guiding the formation of appropriate relationships between patients and staff in health settings (Halpern. Unfortunately. particularly in forensic settings with patients with personality disorder. 2003). often related to histories of physical and sexual abuse. 2002). It may be important to have an underlying model or treatment philosophy in order to ensure consistency of approach. Delivery of some treatments (such as sex offender or arson treatment) can be additionally hampered by a patient’s inability to tolerate the negative cognitions and emotions associated with examination of past offences. there does not appear to be a clear distinction between a treatment philosophy and a model in psychiatric health care provision. 1998. Effective team working has been identified as important. 2001). 1996). particularly when safe patient restraint needs to be used. 1993). Confrontational relationships can be associated with very high levels of arousal and the re-experience of unpleasant emotions. 1993). in particular. However. 1997). Improved communication between staff and the opportunity to develop new working methods are associated with positive working relationships (Molyneux. 2003). Forensic psychiatric patients are more difficult to engage in group therapies and tend not to develop cohesive group dynamics (Stein & Brown. 2002). identify 25 The British Journal of Forensic Practice • VOLUME 8 • ISSUE 1 • FEBRUARY 2006 © Pavilion Publishing Brighton Ltd . morale and multi-disciplinary working of the team. 2000). Staff may fall into a degree of therapeutic nihilism when faced with the prospect of a long period of coping with a very disturbed and needy individual whose prognosis is perceived as poor. whereas a model describes a repeated pattern or a standard of excellence. Any treatment programme. 1991). Open communication and avoiding confrontation are key recommendations in relation to prevention of violence in inpatient settings (Royal College of Psychiatrists. There is concern about the lack of evidence on models for inpatient secure services (Crowhurst & Bowers. via the amygdala in the limbic circuit which controls anger arousal (Phillips. 1984). therefore. Models that explicitly guide staff in both planned and spontaneous interaction with patients improve the perceptions of an inpatient setting for both patients and staff (Furst et al. 1998). a confrontational style of interaction in some forensic settings is common (Kaye & Franey. Rask & Levander. In forensic populations there are also elevated levels of PTSD (Timmerman et al. 2001). 2002). too. Patients perceive that a significant proportion of aggressive incidents are precipitated by interpersonal stressors between themselves and staff (Ellen et al. 2001). In patients who spend long periods in secure settings it can be easy to recreate an authoritarian style of relationship via the process of transference (Felthous.

There are treatment models that have been used recently to underpin the philosophy of secure inpatient care. Patients involved in this process may have longstanding problems in communicating their needs effectively. Solution-focused interventions are felt to increase cohesiveness between staff. Solution-focused therapy Solution-focused therapy comes from a different tradition from that of many psychotherapies practised in forensic settings. 2003). 2003). 2000. It can be delivered to people of more limited cognitive ability. This model is promising. but the training is expensive and prolonged and it requires strong leadership to maintain (Wix. It is a flexible approach. 2001). 2000). It is also suitable for patients who have had cognitive decline associated with severe mental illness and active psychotic symptoms (Hagen & Mitchell. this goal may need to be broken down into smaller stages. concrete. The key is creating a climate where there is an expectation of change. assist staff/patient interaction and help set goals and improve outcomes when introduced into psychiatric inpatient settings (Mason et al. The stages need to be realistic. It was originally devised for borderline personality disorder. 2002). observable and significant to the patient. 1986). However. 1994). Solutionfocused work does not require the understanding of abstract ideas or sophisticated concepts. adolescents and patients with mild and moderate learning disability. It is therefore a key goal shared between patient and staff. but may be less complex to deliver. Hagen & Mitchell. but has also been applied as a treatment modality for patients in forensic mental health services (McCann et al. young offenders institutions and adult prison populations (Durrant. more interested in disrupting the ‘problem pattern’ that has proved ineffective and harmful. chronic patients take a long time to respond to programmes. Some attributes of solution-focused therapy may be useful in the strategy for preventing and managing malignant alienation. and the solutions lie in changing interactions in the context of the unique constraints that surround the person (DeShazer et al. Typically. 26 The British Journal of Forensic Practice • VOLUME 8 • ISSUE 1 • FEBRUARY 2006 © Pavilion Publishing Brighton Ltd . The approach is seen as a nursing rather than a multi-disciplinary model. 2001). Achievement is recognised as a beginning rather than an ending. 1993. and is critical of medical models of psychiatric care. and therapeutic optimism and emphasis on skill-building and using the patient’s own expertise as particularly important in service delivery (DoH. has been developed and implemented in some secure inpatient psychiatric services in Newcastle upon Tyne. 1989). 2001). Gingerich. and appears to be an effective therapeutic intervention for a range of presentations including inpatient psychiatric settings. Concern has been expressed that it does not give sufficient emphasis to the organic aetiology of many psychiatric disorders (Noak. A solution-focused model shares some features with DBT and the tidal model. 1997). Some of the key concepts Preferred future A ‘preferred future’ for patients in a secure forensic setting almost invariable involves moving on into a less secure setting and having more access to the community. based partly on the ideas of Hildegard Peplau. so stability and consistency of approach are important (Hall. The most notable has been dialectical behaviour therapy (DBT). including children. residential treatment for adolescents. Solution-focused brief therapy was developed in the US in the 1980s from research into disordered communication patterns in patients and families with schizophrenia. It is not so interested in ‘insight’. 2001. Iveson. The tidal model. attempting instead to have their care needs met in less appropriate ways (Watts & Morgan. This could be in the form of equating challenging behaviour with inability to seek help in other ways. 1994).A solution-focused model and inpatient secure settings dismissive or pessimistic attitudes among treating staff as unhelpful. This is a multidimensional humanist model with particular emphasis on empathic understanding (Barker. They have also been used as a model for supervision of staff working in mental health services (Triantafillou. It is an approach based on building solutions by exploring the patient’s own resources and developing realistic future goals.

A solution-focused model and inpatient secure settings Problem-free talk This indicates an interest in the person rather than the problem. Meaningful work can sometimes be done in just a few minutes. This can make them reluctant to seek solutions and can therefore complicate attempts at treatment. incremental improvements in a number of areas can cumulatively. It is unlikely that many of these complex patients are going to make substantial improvements in short periods of time. Exceptions A solution-focused approach recognises that many patients are already ‘doing’ at least a component of the solution to a problem. rather than trying to arrange repeated interventions to meet the needs of an intractable external problem. including forensic or secure services. Their capacity to maintain safe behaviour is acknowledged. even with infinite resources. Some of the needs. It can help break out of a cycle in which the patient presents with a ‘problem’ as the key to interacting with staff. However. There may have been times when a patient has been faced with a particular trigger or situation of increased risk and has maintained safe behaviour. It is important that patients are reminded of these times. Noticing suggestions Solution-focused therapy seeks to identify small positive changes. Nothing is too small to be remarked on. over time. A core component of the process of CPA is assessment of ‘need’ and planning undertaken to meet these needs. Some patients can find their personal identity substantially defined by their problem. Brief informal interactions are as important as formal psychotherapeutic interventions. The goal is to use these resources as a foundation. all working towards an appropriate preferred future. However. Even the most disturbed and damaged individuals have some resources that can be usefully engaged. and seek to generalise solution-focused behaviour into other areas. 27 The British Journal of Forensic Practice • VOLUME 8 • ISSUE 1 • FEBRUARY 2006 © Pavilion Publishing Brighton Ltd . So. the needs of forensic patients are often extensive and can seem overwhelming. Such improvements can make the difference between continued secure inpatient care and living in a supported community setting. particularly to do with issues external to the person (such as disrupted family relationships). It is important that these ‘noticing suggestions’ are regularly observed and communicated to the patient. Applying a solution-focused model The current framework for delivering psychiatric care. produce a meaningful transformation. The principles of the approach can be devolved to staff who have had little experience in delivering more formal therapeutic interventions. There may be concern that ad hoc interventions may interfere or not be compatible with work that is being undertaken by others. An entire programme including other psychotherapeutic or group interventions can be incorporated into a solutionfocused model. An advantage of the solution-focused model is that it remains neutral with respect to therapeutic interventions. and when these strategies are successful it can give patients a sense of mastery. and involves initial discourse with the patient on subjects other than the problem area. as small changes can herald the onset of larger ones. Staff dealing with these patients (especially nurses) need a framework to deal with the multiplicity of situations that can arise when other staff are unavailable. may be insoluble. A solution-focused approach would always seek to make goals achievable and the ‘needs’ relevant to the patient. particularly those that focus on examining past events. Resources Solution-focused methods are always looking for ‘resources’ (skills and abilities that the patient already has). is the care programme approach (CPA). particularly when these triggers occur. Any model must therefore be compatible with CPA. Staff often find that much of what they do that is helpful is already ‘solution-focused’ in nature. Recurrently discussing ‘needs’ for which there are no realistic solutions can be counterproductive to treatment. Solution-focused interventions are flexible enough to be delivered in very short timescales. a solution-focused approach would seek to help the individual patient use and develop the mature coping strategies they already have for dealing with the distress that these problems cause.

As CB is currently safe. but there is a need always to look for evidence of small improvements. This may have the effect of reinforcing desirable Conclusion The last five years have seen a significant expansion in secure psychiatric services. The goal of a solution-focused model would be to have as many staff as possible interacting in this way with patients as often as possible. These services posed particular challenges in rehabilitating a group of complex and difficult patients. 28 The British Journal of Forensic Practice • VOLUME 8 • ISSUE 1 • FEBRUARY 2006 © Pavilion Publishing Brighton Ltd . below. Noticing suggestions Staff should comment on positive changes by CB. since he will not be able to resolve his problem by emphasising deficits. BOX 1 An illustrative case behaviours which cumulatively could herald the onset of larger ones. attending his sessions and engaging with his treatment programme. for example on a shared interest. He is often embroiled in intra-familial disputes during phone conversations home and he feels the need to protect his mother who is in an abusive relationship. An illustrative case is shown in Box 1. He has a strong attachment to his mother and likes to have frequent visits. CB’s mother suffers from depression. Even a small improvement such as reduction in struggling during safe patient restraint can be helpfully fed back to the patient in a solution-focused way. CB is clearly not going to provide his mother with high levels of care. one could ask him ‘What has been helping you get by?’ or ‘How have you been stopping things getting worse?’. He should be given regular feedback and praised for his achievements. that is not related to the problem. DC is invited to think about or discuss the times when he has behaved or reacted appropriately and engaged in solutions. Solution-focused ideas deserve consideration in relation to the development of the underlying philosophy or models of these services. He reacts to setbacks by deliberate-self harm. In this vignette it would include his desire to leave hospital and move closer home. he needs to be reminded of these times and to reflect on the resources that he already has. CB. CB has a dysfunctional family relationship. and this feeds into low selfesteem and alienation. no matter how small. It is also important not to ignore and wait for unsafe behaviour. in a low secure unit. and this would usually trigger aggressive and unsafe behaviours. It is important to make guiding comments on maintaining and sustaining the achievement he has listed. not something imposed on him. Such guidance should be aimed at eliciting positives from CB himself. A guiding comment could be ‘You have been safe since…’ or ‘You are coping with things really well’. Exceptions DC’s attention is drawn to exceptions. Instead of saying ‘You should do this because I/we think you need to’. In order to achieve this. It would be unrealistic to expect large changes. Unfortunately.A solution-focused model and inpatient secure settings A solution-focused approach is particularly helpful for redefining the nature of the relationship between staff and patients. Exception questions include: • When are the times it does not happen to you? • When do you resist the urge to? • When are the times it bothers you least? Preferred future This should be something that CB wants. aged 18 years. This case is that of a patient. which invariably affects his observation levels and reinforces his feeling of inadequacy. CB’s preferred future is to settle close to home on discharge. and enters a more collaborative one. This is so that DC does not develop a personal identity that is bound up with the problem and does not use the problem as a ticket to engage. staff say ‘You need to do this because it will get you where you want to be’. Problem-free talk When using the solution-focused approach it is essential to approach DC initially with problemfree talk – to engage in conversation or discussion. these visits are often cancelled unexpectedly. and he rates his mother’s needs higher than his. CB will be expected to achieve successfully smaller goals such as maintaining safe behaviours. It ‘steps sideways’ out of an authoritarian and potentially confrontational relationship with a patient.

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