practice
A solution-focused model and
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. Solution-
focused ideas may provide a
bridge between these two
issues, by improving multi-
disciplinary working and
providing an appropriate
relationship style that
optimises the delivery of care
to forensic patients.
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The British Journal of Forensic Practice • VOLUME 8 • ISSUE 1 • FEBRUARY 2006
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
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
© Pavilion Publishing Brighton Ltd

an authoritarian style of therapeutic interaction. 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, 1984). Patients perceive that a significant
proportion of aggressive incidents are precipitated
by interpersonal stressors between themselves and
staff (Ellen et al, 2003). Open communication and
avoiding confrontation are key recommendations
in relation to prevention of violence in inpatient
settings (Royal College of Psychiatrists, 1998).
However, a high degree of interpersonal skill is
required to manage aggressive behaviour
(Crowhurst & Bowers, 2002). Unfortunately, a
confrontational style of interaction in some forensic
settings is common (Kaye & Franey, 1998; Rask &
Levander, 2001).
The perception of emotional interactions in the
environment significantly affects brain function, via
the amygdala in the limbic circuit which controls
anger arousal (Phillips, 2003). Confrontational
relationships can be associated with very high levels
of arousal and the re-experience of unpleasant
emotions. These relationships can therefore reduce
the patient’s capacity for logical and sensible
thinking and increase the risk of aggressive
behaviour (Whittington & Wykes, 1996). In
forensic populations there are also elevated levels of
PTSD (Timmerman et al, 2001), often related to
histories of physical and sexual abuse. They can
further complicate patient/staff relationships,
particularly when safe patient restraint needs to be
used.
The problems of staff ‘burn-out’ are well
recognised in secure settings (Beer et al, 1997).
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. Patients, too,
can easily become demoralised, feeling that they are
making little progress towards living in the
community. Forensic psychiatric patients are more
difficult to engage in group therapies and tend not
to develop cohesive group dynamics (Stein &
Brown, 1991).
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
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A solution-focused model and inpatient secure settings
examination of past offences. Any treatment
programme, therefore, needs to have a balance
between examining past-related risk issues and
activities that are more positive and future-focused.
Treatment model or treatment philosophy?
Many health services say they have a model or
philosophy that underpins the delivery of care.
However, there does not appear to be a clear
distinction between a treatment philosophy and a
model in psychiatric health care provision, and the
terms are often used interchangeably. A philosophy
can be defined as a system of theories on the nature of
things or conduct, whereas a model describes a
repeated pattern or a standard of excellence. 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.
It may be important to have an underlying
model or treatment philosophy in order to ensure
consistency of approach. Philosophical ideas are
useful in guiding the formation of appropriate
relationships between patients and staff in health
settings (Halpern, 1993). There is concern about
the lack of evidence on models for inpatient secure
services (Crowhurst & Bowers, 2002). A multi-
disciplinary team will come from a variety of
backgrounds, often with contrasting models of care
and differing views on how they are best
implemented (Mason et al, 2002). Improved
communication between staff and the opportunity
to develop new working methods are associated
with positive working relationships (Molyneux,
2001). A ‘skill share’ model has been recommended
for effective team management of difficult
psychiatric patients (Tyrer, 2000). A shared model
is likely to improve the cohesiveness, morale and
multi-disciplinary working of the team. 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, 1993).
Effective team working has been identified as
important, particularly in forensic settings with
patients with personality disorder. Patients with
personality disorder, in particular, identify
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A solution-focused model and inpatient secure settings
dismissive or pessimistic attitudes among treating
staff as unhelpful, and therapeutic optimism and
emphasis on skill-building and using the patient’s
own expertise as particularly important in service
delivery (DoH, 2003).
There are treatment models that have been used
recently to underpin the philosophy of secure
inpatient care. The most notable has been
dialectical behaviour therapy (DBT). It was
originally devised for borderline personality
disorder, but has also been applied as a treatment
modality for patients in forensic mental health
services (McCann et al, 2000). This model is
promising, but the training is expensive and
prolonged and it requires strong leadership to
maintain (Wix, 2003).
The tidal model, based partly on the ideas of
Hildegard Peplau, has been developed and
implemented in some secure inpatient psychiatric
services in Newcastle upon Tyne. This is a multi-
dimensional humanist model with particular
emphasis on empathic understanding (Barker,
2001). The approach is seen as a nursing rather
than a multi-disciplinary model, and is critical of
medical models of psychiatric care. Concern has
been expressed that it does not give sufficient
emphasis to the organic aetiology of many
psychiatric disorders (Noak, 2001).
Solution-focused therapy
Solution-focused therapy comes from a different
tradition from that of many psychotherapies
practised in forensic settings. It is not so interested
in ‘insight’, more interested in disrupting the
‘problem pattern’ that has proved ineffective and
harmful.
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 an approach based on
building solutions by exploring the patient’s own
resources and developing realistic future goals.
The key is creating a climate where there is an
expectation of change, and the solutions lie in
changing interactions in the context of the unique
constraints that surround the person (DeShazer et
al, 1986). Typically, chronic patients take a long
time to respond to programmes, so stability and
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© Pavilion Publishing Brighton Ltd
consistency of approach are important (Hall,
1989).
It is a flexible approach, and appears to be an
effective therapeutic intervention for a range of
presentations including inpatient psychiatric
settings, residential treatment for adolescents,
young offenders institutions and adult prison
populations (Durrant, 1993; Gingerich, 2000;
Hagen & Mitchell, 2001; Iveson, 2002). Solution-
focused work does not require the understanding of
abstract ideas or sophisticated concepts. It can be
delivered to people of more limited cognitive
ability, including children, adolescents and patients
with mild and moderate learning disability. It is
also suitable for patients who have had cognitive
decline associated with severe mental illness and
active psychotic symptoms (Hagen & Mitchell,
2001).
Some attributes of solution-focused therapy
may be useful in the strategy for preventing and
managing malignant alienation. This could be in
the form of equating challenging behaviour with
inability to seek help in other ways. Patients
involved in this process may have longstanding
problems in communicating their needs effectively,
attempting instead to have their care needs met in
less appropriate ways (Watts & Morgan, 1994).
Solution-focused interventions are felt to
increase cohesiveness between staff, assist
staff/patient interaction and help set goals and
improve outcomes when introduced into
psychiatric inpatient settings (Mason et al, 1994).
They have also been used as a model for
supervision of staff working in mental health
services (Triantafillou, 1997). A solution-focused
model shares some features with DBT and the tidal
model, but may be less complex to deliver.
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. It is therefore a key goal shared
between patient and staff. However, this goal may
need to be broken down into smaller stages. The
stages need to be realistic, concrete, observable and
significant to the patient. Achievement is
recognised as a beginning rather than an ending.

Problem-free talk
This indicates an interest in the person rather than
the problem, and involves initial discourse with the
patient on subjects other than the problem area. It
can help break out of a cycle in which the patient
presents with a ‘problem’ as the key to interacting
with staff. Some patients can find their personal
identity substantially defined by their problem.
This can make them reluctant to seek solutions and
can therefore complicate attempts at treatment.
Exceptions
A solution-focused approach recognises that many
patients are already ‘doing’ at least a component of
the solution to a problem. 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, particularly
when these triggers occur. Their capacity to
maintain safe behaviour is acknowledged, and
when these strategies are successful it can give
patients a sense of mastery.
Noticing suggestions
Solution-focused therapy seeks to identify small
positive changes. It is important that these ‘noticing
suggestions’ are regularly observed and
communicated to the patient. Nothing is too small
to be remarked on, as small changes can herald the
onset of larger ones. It is unlikely that many of
these complex patients are going to make
substantial improvements in short periods of time.
However, incremental improvements in a number
of areas can cumulatively, over time, produce a
meaningful transformation. Such improvements
can make the difference between continued secure
inpatient care and living in a supported community
setting.
Resources
Solution-focused methods are always looking for
‘resources’ (skills and abilities that the patient
already has). Even the most disturbed and damaged
individuals have some resources that can be usefully
engaged. The goal is to use these resources as a
foundation, and seek to generalise solution-focused
behaviour into other areas.
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A solution-focused model and inpatient secure settings
Applying a solution-focused model
The current framework for delivering psychiatric
care, including forensic or secure services, is the
care programme approach (CPA). Any model must
therefore be compatible with CPA. A core
component of the process of CPA is assessment of
‘need’ and planning undertaken to meet these
needs. However, the needs of forensic patients are
often extensive and can seem overwhelming.
Some of the needs, particularly to do with issues
external to the person (such as disrupted family
relationships), may be insoluble, even with infinite
resources. Recurrently discussing ‘needs’ for which
there are no realistic solutions can be
counterproductive to treatment. A solution-focused
approach would always seek to make goals
achievable and the ‘needs’ relevant to the patient.
So, rather than trying to arrange repeated
interventions to meet the needs of an intractable
external problem, 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.
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. There may be concern that ad
hoc interventions may interfere or not be
compatible with work that is being undertaken by
others.
An advantage of the solution-focused model is
that it remains neutral with respect to therapeutic
interventions, particularly those that focus on
examining past events. An entire programme
including other psychotherapeutic or group
interventions can be incorporated into a solution-
focused model, all working towards an appropriate
preferred future. Brief informal interactions are as
important as formal psychotherapeutic
interventions.
Solution-focused interventions are flexible
enough to be delivered in very short timescales.
Meaningful work can sometimes be done in just a
few minutes. The principles of the approach can be
devolved to staff who have had little experience in
delivering more formal therapeutic interventions.
Staff often find that much of what they do that is
helpful is already ‘solution-focused’ in nature.
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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. It ‘steps sideways’ out of
an authoritarian and potentially confrontational
relationship with a patient, and enters a more
collaborative one. Instead of saying ‘You should do
this because I/we think you need to’, staff say ‘You
need to do this because it will get you where you
want to be’. 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. 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.
An illustrative case is shown in Box 1, below.
BOX 1 An illustrative case
This case is that of a patient, CB, aged 18 years, in a low
secure unit. CB has a dysfunctional family relationship.
He has a strong attachment to his mother and likes to
have frequent visits. Unfortunately, these visits are often
cancelled unexpectedly, and this would usually trigger
aggressive and unsafe behaviours. CB’s preferred future is
to settle close to home on discharge.
He reacts to setbacks by deliberate-self harm, which
invariably affects his observation levels and reinforces his
feeling of inadequacy, and this feeds into low self-
esteem and alienation.
CB’s mother suffers from depression, and he rates his
mother’s needs higher than his. 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.
Preferred future
This should be something that CB wants, not
something imposed on him. In this vignette it
would include his desire to leave hospital and move
closer home. In order to achieve this, CB will be
expected to achieve successfully smaller goals such
as maintaining safe behaviours, attending his
sessions and engaging with his treatment
programme.
Noticing suggestions
Staff should comment on positive changes by CB,
no matter how small. He should be given regular
feedback and praised for his achievements. This
may have the effect of reinforcing desirable
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behaviours which cumulatively could herald the
onset of larger ones.
CB is clearly not going to provide his mother
with high levels of care. It would be unrealistic to
expect large changes, but there is a need always to
look for evidence of small improvements. A
guiding comment could be ‘You have been safe
since…’ or ‘You are coping with things really well’.
Such guidance should be aimed at eliciting
positives from CB himself. It is important to make
guiding comments on maintaining and sustaining
the achievement he has listed. It is also important
not to ignore and wait for unsafe behaviour. As CB
is currently safe, one could ask him ‘What has been
helping you get by?’ or ‘How have you been
stopping things getting worse?’.
Problem-free talk
When using the solution-focused approach it is
essential to approach DC initially with problem-
free talk – to engage in conversation or discussion,
for example on a shared interest, that is not related
to the problem. 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.
Exceptions
DC’s attention is drawn to exceptions, since he will
not be able to resolve his problem by emphasising
deficits. DC is invited to think about or discuss the
times when he has behaved or reacted appropriately
and engaged in solutions; he needs to be reminded
of these times and to reflect on the resources that
• When are the times it does not happen to you?
he already has. Exception questions include:
• When do you resist the urge to?
• When are the times it bothers you least?
Conclusion
The last five years have seen a significant expansion
in secure psychiatric services. These services posed
particular challenges in rehabilitating a group of
complex and difficult patients. Solution-focused
ideas deserve consideration in relation to the
development of the underlying philosophy or
models of these services.

Address for correspondence
Dr Ernest Gralton, St Andrew’s Group of
Hospitals, Malcolm Arnold House, Northampton
NN1 5DG. E-mail: EGralton@standrew.co.uk
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