Transcript Using Solution-Focused Therapy in Forensic Settings

Using Solution-Focused
Therapy in Forensic Settings
Laura Freeman
Clinical Psychologist
Wathwood Hospital
July 18, 2015
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Rationale for presentation
Simple techniques
No complicated theory
Don’t have to be therapist to use
techniques
Useful in forensic settings
Future focused direction in offending work
recommended
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Plan for presentation
 What is Solution-focused therapy?
 Brief History
 Overview of techniques
 Practise exercise
 Evidence base including forensic
 Why is SFT useful in forensic settings?
 Potential caveats
 Brief case example
 References
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What is ‘Solution-Focused Therapy’?
 Type of talking therapy based upon social constructionist
philosophy
 Clients are helped to construct a concrete preferred
future
 Questions about strengths, resources and exceptions
 Client already possesses solution to their problems
 By bringing small successes to awareness and repeating
them the client can move towards their preferred future
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Brief History of SFT
Developed from practice and research
findings about what works
Began at Milwaukee Family Therapy
Centre
Key people: Milton Erickson, Steve de
Shazer, Insoo Kim Berg
Approach to working not just set of
techniques
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Overview of techniques
 Pre-session change
E.g. tell me about something that’s changed for the better since coming into hospital
 Problem free talk (identifying strengths)
E.g. I know a little bit about you from… but I know there is more to you than the problems that brought
you here. Tell me about something you enjoy/are good at / tell me about a time in your life when
things were ok
 Exceptions
E.g. Tell me about a time when the problem didn’t happen/happened less
 Goal setting
E.g. what are your best hopes for meeting with me? How will you know when you have achieved that
(define in behavioural terms)? What might be one small step towards that?
 Miracle question
E.g. when you go to bed tonight something wonderful happens and your problems disappear, you don’t
know that this happened as you are asleep. What is the first thing you notice when you wake up
that tells you your problems are gone? What else? Who else notices and what do they notice? Are
there any time when any of these things already happen, even a little bit?
 Praise & compliments
E.g. I think it’s really great that you’ve achieved that, I think you do well to cope considering how difficult
things are for you
 Scaling
E.g. on a scale of 0-10 with 0 being the worst ever and 10 being the best you could imagine – where
are you at now? What tells you that? How have you managed not to be at 0? Where would you be
satisfied with? How will you know when you have moved one step up?
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Scaling exercise
 In groups of 2 or 3 imagine a problem or difficulty that you have that you
would like to improve (it may be giving up smoking, getting more exercise,
getting reports finished or problems leaving work on time!)
 If 0 was the worst it’s ever been and 10 is the best it could be, where are
you at now?
 What tells you you are here rather than 0 (if at 0, how are you managing to
cope despite it being at 0)
 Where would you be satisfied with being? What will tell you that you’ve
reached this number, what things will you be doing differently
 What would one point up look like – one small step towards your goal
 How could you achieve this?
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Evidence base
 Effective (64-80% success rate)
 Useful for a range of cases (depression, suicidal thoughts, sleep
problems, sexual abuse, eating disorders, family violence, personality disorders, self-esteem,
addictions, schizophrenia, self-harm, inpatients)
 Improvements maintained at follow-up
 As effective as other therapies (e.g. CBT, interpersonal
psychotherapy, short-term psychodynamic psychotherapy)
 Briefer than other therapies
 Low dropout rates
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Evidence in Forensic Settings
 Decreased recidivism & reduced length of sentence in prisoners
 Improved self-esteem& solution-finding skills in domestic violence offenders
 Specific & agreed goals predict reduced recidivism in domestic violence
offenders
 Increased optimism, empathy, concentration levels, fewer anti-social
tendencies, chemical abuse, less recidivism in young offenders
 Attribution of positive life events to personal qualities found to be more
common in group that desisted from crime
 Active vs. desisting offenders differentiated by future orientation, taking over
own future vs. dwelling on past mistakes (no difference in whether they
accepted responsibility for past mistakes)
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Why is it useful in forensic settings? a.
 Problem-free talk helps with engagement
 Future focus enables movement towards goals even
without ‘insight’ into mental health problem
 Future focus can help break cycle of shame found to
lead to withdrawal (Gilbert, 1998)
 Identifying strengths and resources builds self-esteem
 Identifying and working towards own goals increases
sense of self-efficacy
 Identifying exceptions creates expectation of change,
hope and optimism
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Why is it useful in forensic settings? b.
 Scaling enables changes to be broken down into
manageable chunks
 Miracle questions helps create clear picture of future
goals
 Effective across all education levels and social classes
 Can be used to undertake offence work from a relapse
prevention/staying well angle
 Can be useful ‘way in’ if someone is in pre-contemplation
stage
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Potential caveats of SFT
 Doesn‘t explore childhood experiences (although can be used as
adjunct to other therapies e.g. CAT)
 Can be seen as overly positive and ‘naïve’ (negatives can still be
acknowledged, just not focus of work)
 Are important things being missed by not focusing on the past? (but
initial assessment and formulation)
 Doesn’t address lack of remorse (but is this necessary?)
 Doesn’t develop insight into mental health diagnosis per se (but
insight into factors necessary to stay well and avoid re-offending are
addressed)
 Can collude with avoidance of difficult experiences (best judgement
used)
 However, therapist skill, experience and good supervision can help
avoid these traps
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Case example - background
‘Nigel’* 48 years old
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Diagnosis probable drug-induced paranoid schizophrenia
Index offence ABH (work on offending requested by team)
Disagrees with diagnosis
Supportive family but often conflict due to opposing view points
Previous attempts at engagement of limited success
Decision to offer SFT
- appeared at pre-contemplation stage of behaviour change
- engaged well with sft questions
- gave clear no-go response to more exploratory questions
* Not a real person, based on an amalgamation of different examples to preserve confidentiality
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Case example – initial interview
 Began with problem-free talk; (identified strengths &
resources e.g. sociability and relationship with wife)
 Pre-session change: feeling ‘less stressed’ in hospital;
attributes to feeling safe here
 Miracle question (day included waking up in own home,
listening to music, working on the garden, spending time
with girlfriend)
 Praise and compliments: I think you’ve done really well
to give up gambling in the past, that must have been
really hard/you must be a determined person. How can
you apply what you learned to giving up drugs/staying
well?
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Case example – use of techniques
 Goal setting: what can we do to convince service that you have a plan of action to
ensure you and others will be safe in future?
- How to stay well/stay off drugs in the future
- How will others be able to tell are well and sticking to the plan
- What impact might specific drugs have on future coping and the
implementation of the plan
 Scaling: stated currently 5/10 would be satisfied with 7/10 – one step forward (6/10)
would be getting to next service
 Identifying exceptions: Discussed ‘near misses’ to offending behaviour and how
managed to prevent incarceration prior to index offence
- What’s worked in the past that can do again (what helped feel safe, times felt
less persecuted etc;)
- What didn’t work and need to avoid doing again
- What might obstacles to implementing these be and how to overcome them
e.g. unable to go walking in the countryside regularly as no car: arrange to go with friend
 Identifying Strengths & resources: What strengths and resources helped cope in past
and will in future
- How can other people help
 Incorporated motivational interviewing techniques used to explore ambivalence by
looking at pros and cons of change and elicit self-motivational strategies
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Case example – process & outcome
 Finding common ground / avoiding arguments!
 Action plan created including fitting safety devices, getting a dog, getting a mobile
phone so can call wife if worried
 Difficult to assess how much internalized (but has encouraged process of
thinking around future)
 If plan not adhered to signal for others to get involved
 Support of wife will be crucial so couple therapy sessions:
- shared preferred future and how to move towards it
- what are signs ‘Nigel’ is well/not using drugs
- what have you tried in past that works in supporting him
- what can others most helpfully do if feel he’s not sticking to plan
- how to promote and build on positives already present
- pre-session task to notice what is already happening in your
relationship that you would like to continue happening
 Will depend on motivation not to return (positive statements have increased
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2015 time)
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over
References - General
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Beyebach, M., et al., Research on the process of solution-focused brief therapy. In Miller S., et al., (Eds) (1996) Handbook of
Solution-Focused Brief Therapy. Jossey-Bass: San Francisco (pp. 299-334).
DeJong, P.,& Hopwood, L., (1992-1993). Outcome research on treatment conducted at the Brief Family Therapy Center. In
Miller S., et al,. (Eds) (1996) Handbook of Solution-Focused Brief Therapy. Jossey-Bass: San Francisco (pp. 272-298).
de Shazer, S., & Isebaert, L. (2003). The Bruges Model: a solution-focused approach to problem drinking. Journal of Family
Psychotherapy, 14: 43-52.
Eakes G, et al., (1997). Family-centred brief solution-focused therapy with chronic schizophrenia: a pilot study. Journal of
Family Therapy, 19: 145-158
Iveson, C. (2002). Solution-focused brief therapy: Advances in Psychiatric Treatment. The Royal College of Psychiatrists,
8: 149-156
Johnson L., & Shaha, S. (1996). Improving quality in psychotherapy. Psychotherapy, 33: 225-236
Kim, (2007). Examining the Effectiveness of Solution-Focused Brief Therapy: A Meta-Analysis. Research on Social Work
Practice
Kiser, D. (1988). A follow-up study conducted at the Brief Family Therapy Center. Unpublished manuscript.
Knekta, P. Et al. (2007). Randomized trial on the effectiveness of long-and short-term psychodynamic psychotherapy and
solution-focused therapy on psychiatric symptoms during a 3-year follow-up. Psychological Medicine, 1-15.
Knekt, P., & Lindfors, O. (2004). A randomized trial of the effect of four forms of psychotherapy on depressive and anxiety
disorders: design, methods and results on the effectiveness of short-term psychodynamic psychotherapy and solutionfocused therapy during a one-year follow-up. Studies in social security and health, no. 77. The Social Insurance Institution,
Helsinki, Finland
Macdonald, A. (1997). Brief therapy in adult psychiatry: Further outcomes. Journal of Family Therapy, 19, 213-222.
Sharry J., et al. (2002). A solution-focused approach to working with clients who are suicidal British Journal of Guidance
and Counselling, 30, 4, 383-399
Stams, G., et al, (2006) Effectiviteit van oplossingsgerichte korte therapie: een meta-analyse (Efficacy of solution focused
brief therapy: a meta-analysis). Gedragstherapie, 39(2): 81-95. (Dutch; abstract in English)
Wallace, J., et al, (2000). Solution-Focused Brief Therapy: A Review of the Outcome Research Family Process 39 (4), 477–
498.
Wiseman, S. (2003). Brief intervention: reducing the repetition of deliberate self-harm. Nursing Times, 99: 34-36.
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References - Forensic
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Corcoran, J. (1997). A Solution-Oriented Approach to Working with Juvenile Offenders. Child &
Adolescent Social Work Journal. 14(4):277-288.
 Henggeler, S. et al, (1992). Family preservation using multisystemic therapy: An effective
alternative to incarcerating serious juvenile offenders. Journal of Consulting and Clinical
Psychology, 60, 953-961
 Henggeler, S., et al, (1993). Family preservation using multisystemic treatment: Long-term followup to a clinical trial with serious juvenile offenders. Journal of Child and Family Studies, 2, 283-293.
 Lee M. Et al, (1997). Solution-focused brief group treatment: a viable modality for domestic
violence offenders? Journal of Collaborative Therapies, IV: 10-17 Maruna, S. (2004). A New
Direction in the Psychology of Reform. Journal of Contemporary Criminal Justice, Vol. 20 No. 2,
May 2004 184-200th
 Lee M. Et al,(2003) Solution-focused treatment of domestic violence offenders. Oxford: New York.
 Lee M. Et al, (2007) Roles of self determined goals in predicting recidivism in domestic violence
offenders. Research on Social Work Practice, 17:30-41.
 Lindforss L, Magnusson D (1997) Solution-focused therapy in prison. Contemporary Family
Therapy, 19: 89-104.
 Seagram B.C. (1998) The efficacy of solution-focused therapy with young offenders. Dissertation
Abstracts International Section B: The Sciences and Engineering 58 (10)-b, 5656.
 Springer DW, Lynch C, Rubin A (2000) Effects of a solution-focused mutual aid group for Hispanic
children of incarcerated parents. Child and Adolescent Social Work, 17: 431-442
 Stith S. Et al, (2004) Treating intimate partner violence within intact couple relationships: outcomes
of multi-couple versus individual couple therapy. Journal of Marital and Family Therapy, 30: 305318
 Ward, T. & Mann, R. (2004). Good Lives and the Rehabilitation of Offenders: A Positive Approach
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To Treatement. In Alex Linley & Solution-focused
Stephen Joseph
(Eds), Positive psychology in practice (pp 598- 18
616). John Wiley & Sons
Final questions
Should we focus on the future or attempt
to resolve the past?
What message do we send to patients if
we treat them ‘positively’?
Does this approach have a place in our
service?
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