Beyond consultation theatre

About the author

Dr Frank Reilly is an Independent Adviser to the Scottish Association of Social Workers (SASW), where he coordinates frontline social worker voices in national policy development. He is a council member of the Scottish Social Services Council (SSSC). Frank began his career as a home maker and addiction counsellor in 1989 and has over 25 years of senior management experience across health, social care, and the third sector, including roles with the Simon Community, the Scottish Recovery Network, and the State Hospital. He recently completed his PhD at the University of Strathclyde on co-production in secure forensic mental health settings across Scotland and Ireland.

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Introduction

Co-production has become a central ambition in Scotland’s social care landscape. It appears in legislation, national standards, and reform programmes with a confidence that suggests consensus. Yet the settings where co-production is most needed, and most difficult, remain largely absent from the conversation: secure forensic mental health services. These are environments defined by compulsion, restricted liberty, and profound power asymmetry. They are also places where the stakes of getting collaboration right are exceptionally high.

This article draws on multi-site qualitative research across secure forensic hospitals in Scotland and Ireland. Through interviews and focus groups with staff working at different security levels, the study examined how co-production is understood, enacted, constrained, and sometimes enabled in settings where risk, rights, and recovery intersect. Although patient voices could not be included due to ethical and security restrictions, the staff accounts offer a rare window into how collaborative practice is shaped by institutional rules, culture, and environment.

The findings challenge the idea that co-production is simply absent in secure care. Instead, they reveal a continuum of collaborative practice: ranging from compelled compliance to genuine shared decision-making; and show how physical spaces, staff orientations, and organisational histories shape what is possible. Game theory (Von Neumann and Morgenstern 2007, Leonard 2010) and ecological psychology help illuminate these dynamics, showing how staff and patients navigate incentives, uncertainty, and trust in a system where both parties must continually assess each other’s intentions.

The behavioural gateway: progress as a strategic interaction

Across all sites, staff described a central mechanism that governs patient progression: the behavioural gateway. This threshold represents the level of behavioural stability and symptom management required before a patient can access off-ward activities. As one nurse put it:

Passing through the gateway changes the entire relational landscape. On the ward, security is dominated by physical and procedural controls. Off the ward, whether in a sports hall, garden project, or escorted community leave, security is managed through relationships. These spaces afford different possibilities: more trust, more reciprocity, more conversation, and more opportunities for patients to take on meaningful roles.

Staff consistently reported that patients disclosed more, relaxed more, and contributed more in these environments. As one manager in Ireland noted:

“They actually discuss more with me just in a conversation — ‘how’s your day?’ — and it turns out there’s all sorts of issues going on.” (Bert, high secure Ireland)

Game theory and the gateway

The gateway functions as a strategic game in which:

• Patients signal stability through behaviour
• Staff interpret those signals under uncertainty
• Both parties adjust their strategies based on past interactions

Staff repeatedly described the difficulty of distinguishing genuine therapeutic progress from strategic accommodation: behaviour that looks compliant but is motivated by access to valued activities. One psychiatrist warned:

“There lies the danger… sometimes you don’t actually realise what they are doing.” (Pete, State Hospital)

This is a classic problem of imperfect information: staff cannot directly observe internal states, only outward behaviour. Patients, meanwhile, must decide whether to invest in genuine cooperation or adopt short-term strategies that maximise immediate payoffs.

Over time, as evidenced from repeated games demonstrate, stable relational patterns emerge. Staff who spend more time with patients off the ward described being better able to detect authentic change because repeated interactions generate trust, reduce uncertainty, and create shared expectations.

The gateway as an affordance

Drawing on Gibson’s (1979) ecological psychology, the gateway can also be understood as an affordance – a structure that offers different possibilities for action depending on the individual’s capabilities and the environment.

For patients, the gateway affords:

• Hope
• Progression
• Access to meaningful activity
• Opportunities for relational engagement

For staff, it affords:

• A clearer basis for dynamic risk assessment
• Opportunities to observe decision-making
• A shift from procedural to relational security

The gateway is therefore not simply a rule. It is a relational and environmental structure that shapes behaviour on both sides.

Staff archetypes: custodians and relationally close practitioners

The research identified two broad staff orientations that shape how co-production is understood and enacted.

The custodian

Custodians prioritise procedural and physical security. This is essential during admissions or periods of instability, but when it becomes entrenched it can crowd out relational work. Staff described a “ward busyness cycle” where constant containment leaves no capacity for the relational engagement that might reduce risk over time.

A small subset of custodians engaged in what staff called “gunslinging” — provoking patients to justify restrictive responses. As one charge nurse reflected:

“They would get into a situation with a patient and then expect someone else to come and dig them out of it.” (Bob, medium secure 1)

Custodians often work in environments that afford vigilance and rule enforcement: high-security wards with locked doors, observation windows, and unpredictable admissions.

The relationally close practitioner

Relationally close practitioners use dynamic risk assessment, shared interests, and everyday conversation to build therapeutic relationships. They are more common in off-ward environments, where the psychological load of constant monitoring is reduced. Their approach is grounded in shared humanity. One nurse described connecting with a patient through horse racing:

“I never won, and he never hit me.” (Jim, high secure Scotland)

These practitioners often create conditions for reciprocity. Patients apologise after restraints, take on voluntary responsibilities, or protect staff during incidents. These behaviours reflect what Elinor Ostrom (1990,2011) would call the co-production of a “commons” of peace and security.

Game theory and staff orientations

These orientations reflect different assumptions about the “game” being played:

• Custodians assume a zero-sum game: safety is maintained by control; patient gain is staff risk
• Relationally close practitioners assume a positive-sum game: cooperation increases safety for both parties

The orientation a staff member adopts shapes the strategies available to patients. In a zero-sum environment, strategic accommodation becomes rational. In a positive-sum environment, cooperation becomes rational (Von Neumann and Morgenstern 2007.

Environment as affordance: why space changes the game

Drawing on Gibson’s 1979 ecological psychology, the study found that environments afford different kinds of relationships. High-security wards: with locked doors, observation windows, and unpredictable admissions; afford vigilance, rule enforcement, and distance. Off-ward spaces afford connection, conversation, and shared activity.

Staff in Ireland also described a phenomenon unique to their environment, “garden privilege”: a tacit understanding that certain informal interactions were acceptable in the garden project but not on the ward.

“You are allowed to say some things that won’t be taken against you.” (Tom, high secure Ireland)

Environmental affordances and relational security

Off-ward environments afford:

• More natural conversation
• Shared tasks that reduce social pressure
• Opportunities for patients to take responsibility
• Space for emotional regulation
• A sense of normality

These affordances shape not only behaviour but identity. Off-ward staff are often seen as “outsiders” or “safety nets”, able to hear things patients would not share with ward staff. Conversely, ward staff are seen as the final arbiters of rules and risk.

Game theory and environmental affordances

The environment changes the payoff structure of interactions:

• On the ward, the cost of relational risk is high; the payoff is uncertain
• Off the ward, the cost is lower; the payoff (trust, disclosure, cooperation) is higher

This shift explains why patients often disclose bullying, distress, or fears only in off-ward settings. The “game” becomes safer to play.

Co-producing safety: a high-stakes cooperative game

The clearest example of co-production came from a medium secure site, where staff involved patients in designing their own de-escalation and restraint plans. Patients identified triggers, preferences, and early warning signs. This approach prevented harm and strengthened trust. One nurse described a patient who self-harmed on leave after staff ignored her own warning signs. On return she said:

“You said it yourself, but you still let me go.” (Martha, medium secure 2)

This moment captured the cost of excluding patient knowledge. Where co-produced plans were used, post-incident recovery was markedly different.

“After 99.9% of restraints they will come up and apologise… ‘Did I hurt you? I’m really sorry.’” (Liz, medium secure 2)

Game theory and co-produced safety

This is a classic iterated cooperation game:

• Both parties benefit from cooperation (reduced harm, increased trust)
• Both lose from defection (injury, mistrust, increased restriction)
• Repeated interactions allow trust to accumulate
• Co-produced plans reduce uncertainty and align incentives

In this sense, co-production is not a “nice-to-have”, it is a rational strategy for maintaining safety in a high-risk environment.

Culture, history, and the weight of the past

Institutional history profoundly shaped what was possible. At the Scottish high secure site, a notorious escape and subsequent murders functioned as a cultural anchor. Staff repeatedly invoked it as evidence that relational approaches were dangerous. This historical memory reinforced a risk-averse culture that prioritised physical security over relational engagement.

In contrast, the Irish high secure site experienced a cultural shift when community-trained nurses joined after the 2008 financial crisis. Their relational orientation challenged existing norms and reshaped off-ward practice.

Across all sites, “teamness” (the solidarity forged through managing violence) was both protective and restrictive. It created trust within teams but could exclude staff who worked differently, particularly those adopting relational approaches.

Game theory and culture

Culture shapes the “rules of the game”:

• What behaviours are rewarded or punished
• What counts as safe or unsafe
• What strategies are seen as legitimate

Changing the game requires changing the rules, not just the players.

Co-production as a continuum, not a binary

The study found that co-production in secure care is best understood as a continuum:

• Compliance — following rules to avoid consequences
• Strategic accommodation — selective compliance to gain privileges
• Cooperation — recognising shared interest in maintaining safety
• Co-production — trust, reciprocity, and conditional autonomy

Movement along this continuum depends on environment, staff orientation, and institutional culture — not only patient motivation.

Game theory helps explain why: cooperation emerges when incentives align, information is shared, and interactions are repeated in stable conditions (Von Neuman and Morgenstern 20076, Leonard 2010).

Implications for policy and practice

Four implications stand out for Scotland’s secure accommodation:

1. Rethink admission pathways
   High-secure sites without dedicated admission wards inadvertently reinforce custodian cultures. Structured rotation across admission, continuing care, and off-ward roles would broaden staff experience and support relational capacity.
2. Manage teamness, don’t dismantle it
   Team cohesion is essential for safety, but when it becomes a mechanism for enforcing conformity it suppresses relational practice. Leadership must hold both safety and relational security in view.
3. Involve patients in risk assessment
   Tools like the HCR-20 during data collection were completed about patients, not with them. The model described in the medium secure 2 site shows that incorporating patient self-knowledge improves safety and strengthens therapeutic relationships.
4. Resource reflective practice
   Relationally close practitioners sustain their approach through reflective supervision, not administrative oversight. Staffing levels must allow protected time for reflection if relational security is to be embedded.

Conclusion

Co-production in secure forensic mental health care is not an optional extra. It is a practical mechanism for maintaining safety, supporting recovery, and sustaining staff in one of the most demanding areas of social care. The conditions that enable it: transparent behavioural gateways, environments that afford relational engagement, reflective supervision, and cultures that value relational security; are achievable.

Game theory helps illuminate why co-production works: it aligns incentives, reduces uncertainty, and creates the conditions for cooperation in environments where trust is fragile and risk is ever-present.

As Scotland builds carer reform and the National Social Work Agency, the question is not whether co-production belongs in secure care. The evidence shows it already exists, in fragile and uneven forms. The real question is whether new structures will support the kinds of relationships that make secure care safer, fairer, and more humane.

References

• Gibson JJ (1979) The Ecological Approach to Visual Perception. Houghton Mifflin
• Leonard R (2010) Von Neumann, Morgenstern, and the creation of game theory: From chess to social science, 1900–1960. Cambridge University Press
• Ostrom E (1990) Governing the Commons. Cambridge University Press
• Ostrom E (2011) Design Principles for Robust Institutions. Journal of Institutional Economics
• Vaswani N and Paul S (2019) Trauma and Mental Health in the Criminal Justice System. British Journal of Social Work
• Von Neumann J and Morgenstern O (2007) Theory of games and economic behavior: 60th anniversary commemorative edition. In Theory of games and economic behavior. Princeton university press