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The Solihull approach: pros and cons

Research that explored the experiences of two professions using the Solihull approach revealed benefits and challenges. Eleni Vasilopoulou, Ayesha Afzal, Kirsty Murphy and Clea Thompson explain more.

The Solihull approach: pros and cons

The experiences of professionals using the Solihull approach: A Fife-wide focus group study

  • Eleni Vasilopoulou - Clinical Associate in Applied Psychology, NHS Fife
  • Ayesha Afzal - Specialty Trainer 6 CAMHS, NHS Lothian
  • Kirsty Murphy - Clinical Associate in Applied Psychology, NHS Fife Dr Clea Thompson Clinical Psychologist NHS Fife

Abstract

The Solihull Approach (SA) has been developed and cascaded to many different professions. This study aimed to explore professionals’ experiences of being trained in and using the SA. A qualitative service evaluation was conducted using two focus groups to explore health visitors’ (HVs) and child and adolescent mental health service (CAMHS) professionals’ experiences of the SA training and implementation.

Thematic analysis was used to identify common threads emerging from the data. Four key themes and their subthemes emerged:

1) impact on practice

2) challenges when using the SA

3) training improvements

4) post training support.

This study is one of the first to explore health visitors’ and CAMHS professionals’ experiences of the SA training and its professional application. Several benefits and challenges have been highlighted when incorporating SA into HV and CAMHS professionals’ practice. Suggestions have been made around future training and implementation to enhance the effectiveness of the SA foundation training.

KEY WORDS: Solihull Approach, Service Evaluation, Practitioners’ experiences, Family support


Background

The Solihull approach (SA) was originally developed to provide health visitors (HVs) with a theoretical framework in order to conceptualise and manage preschool children’s sleeping feeding, toileting and behavioural difficulties. Since its development, the SA has been applied in a range of different professional contexts, focussing upon practitioners’ interaction with families and engagement in interagency work. Training has been widened to include a variety of different professional groups such as nursery staff, family support workers, child and adolescent mental health service (CAMHS) staff and social workers (Solihull NHS Care Trust, 2006). As more professionals become involved in the SA, it is important to evaluate their experiences for two main reasons: (a) to understand how the SA becomes conceptualised in different contexts and (b) to explore the ways in which we can improve training, consultation and support, specific to the needs of each discipline.

A limited number of studies have examined the impact of the SA on professionals’ practice. Whitehead and Douglas (2005) explored the experiences of HVs implementing the SA. Participants in this study reported having a better understanding of children’s emotional and behavioural development after the training. According to the participants, SA training allowed them to conduct more holistic assessments and made them more reflective. The SA was also associated with increased job satisfaction as well as improved team work and professional relationships.

Ottman (2010) examined the impact of SA on professionals within a multi-disciplinary team. Professionals reported positive effects including increased confidence, better understanding of parent-child relationships and enhanced team closeness. Based on these findings, Moore et al. (2013) designed a questionnaire to address the impact of the training on the practice of different professional groups, including HVs, family support workers, therapists, managers, teachers and social workers. Results from this study showed that the SA training was beneficial to team work by providing a shared framework in which to conceptualise child development. Nevertheless, the questionnaire used in the study was based solely on one qualitative study with a small sample size (n=5). Further studies are therefore needed in order to gain an in-depth and more up-to-date understanding of the experiences of professionals using the SA.

AIMS: We conducted a service evaluation in order to explore the experiences of professionals using the SA.


Method

DESIGN

This study employed a qualitative design in order to obtain an in-depth understanding of the experiences of practitioners using the SA. Focus groups were chosen due to their interactive nature, and their ability to provide a broad range of perspectives (Smith, 2008).

PARTICIPANTS

The following two professional groups were included in the research:

• CAMHS staff

• HVs

The choice of these groups was influenced by the large number of staff in each discipline trained in the SA, but also by the differences in their roles and training that might lead to different experiences of implementing the approach.

RECRUITMENT

An email was sent out via the NHS Fife SA database to all CAMHS staff and HVs who participated in the SA training between 2007 and 2016. The email included an information sheet as well as a consent form. Information about the study was also distributed during SA conferences, forums and training events in order to identify additional participants. Professionals wishing to participate in the research project were asked to contact the researchers within 21 days. Potential participants were then contacted to discuss any questions and to arrange a suitable date and venue for the two focus groups.

FOCUS GROUPS

Two focus groups were conducted in March 2016, one for each professional group. Three HVs and five CAMHS practitioners agreed to participate in each group. The groups were conducted at an NHS Fife setting and lasted around 60 minutes. Two of the researchers led the focus groups, which aimed at providing a safe environment wherein participants could freely express their views.

Upon meeting with the focus group facilitators, practitioners were provided with the opportunity to ask further questions. It was anticipated that practitioners may be reluctant to share negative information regarding the SA, because of the dual role of the facilitators as researchers and as SA trainers. Participants were offered reassurance on this matter and facilitators emphasised that both positive and negative feedback was welcomed. Issues regarding confidentiality and dissemination of findings were discussed. Participants were then asked to complete a consent form to participate in the study. Following this, participants granted permission for the focus groups to be recorded.

Facilitator A administered the semi-structured focus group questions while Facilitator B took notes and asked questions for clarification when necessary. The focus group questions were developed by the authors based on previous research on the SA. These addressed the following areas: feelings around work; impact of the SA on team relationships and functioning; advantages and disadvantages of using the SA; thoughts on training improvements and thoughts on consultation and post-training support.

Participant anonymity was not possible due to the localised setting of the evaluation. However, we believe that familiarity among practitioners helped create a more supportive and informal group environment, thereby enhancing participant disclosure.

ETHICS

As this project was a service evaluation being conducted with members of staff, it did not need ethical review via the research ethics service. The Research and Development Department in Fife involves a process of internal peer ethical review to ensure high ethical standards. A senior colleague in clinical psychology, unconnected to our project, assessed our study protocol to ensure that it adhered to NHS guidelines.

ANALYSIS

Focus group data were transcribed by an independent transcriber. Transcriptions were then checked for accuracy by the authors. Thematic analysis was chosen to identify, analyse, and report patterns (themes) within data. The coding analysis followed the process outlined by Braun and Clarke (2006). First, each transcript was read carefully and notes on key ideas or observations were marked. Initial codes from the data were then produced. Coded data were then collated into potential themes. Each potential theme was examined in more detail, identifying over-arching themes and sub-themes. The data were then reviewed to contextualise themes and modify if appropriate. A final analysis was implemented to refine the themes.

PARTICIPANT CHARACTERISTICS

Three HVs and five CAMHS practitioners (three clinical associates in applied psychology, one clinical psychologist, one occupational therapist and one psychotherapist) participated in the service evaluation. Participants’ level and time of training can be seen in Table 1.

Table 1: Participant characteristics
Time of training 8 
Over two years ago 3  
In the last two years 5
Level of SA training 8
2-day Foundation Training 2
Training to deliver Foster Carer groups
Training to Train Others 3

 

Results

Four main themes emerged from the data. Themes and their subthemes can be seen in
Figure 1.

1. IMPACT ON PRACTICE

More collaborative approach

Both HVs and CAMHS practitioners mentioned that the SA training influenced a more facilitative and collaborative approach in which practitioners were supporting families in making sense of their own experience.

Participant 2: "One of the aspects of the process [...] of using SA is to take the family through making sense and trying to understand, using their understanding […]. You (are) facilitating that rather than being the expert model.”

Participant 7: “I used to be an instant giver of advice whereas now I will sit back and I’m a far better listener. Active listener. And really trying to hear what is being said and read behind what is being said and I think the Solihull model has allowed me to just take that little step back and wait and think about where the mum wants to go or what it is that she is wanting to achieve rather than me saying, well, I think you should be doing this or I think you need to achieve this […] It’s a more collaborative approach.”

Enhanced awareness of clients’ readiness

Practitioners stated that the SA highlighted the importance of exploring families’ needs and their readiness for an intervention as part of an in-depth assessment.

Participant 2: “Being aware of what’s possible at that particular time […] Understanding the context before applying strategies.”

Participant 6: “I think really it comes back to where the parents are at […] it’s really finding out where they really are at that present time.”

Enhanced reflection

CAMHS and HV practitioners mentioned that the SA influenced a more reflective stance, and enhanced their capacity to notice reciprocity in the therapeutic relationship. HVs reported that this enabled them to build stronger therapeutic alliances.

Participant 2: “Conceptual thinking, personal grounding and looking for your own professional supports around you […], what this means to you, it’s really good reflecting. You are conscious of your reciprocity or lack of.”

Participant 7: “It has made a difference. […] Because I feel I’m a more reflective practitioner, I think it makes you more approachable […] Folk know that I will listen to them. I feel on the whole you don’t have a perfect relationship with all your clients but […] with most of them (I have) a good working relationship.”

Focus on parents’ and children’s feelings

HVs reported that Solihull training allowed them to pay more attention to parents’ and children’s feelings in the room.

Participant 6: “How are they actually feeling when the child […] has a huge tantrum.”

Linked theory and practice

HVs reported that the SA has provided a structure and a theoretical model in which their practice could be conceptualised.

Participant 7: “I think it gives us a model that we can really relate some of what we are saying to our mums and it gives us structure to what we are saying […] It just gives that theoretical underpinning to things that we do […] I think it gives some robustness as well to what we do as HVs.”

Shared language among professionals

Participants in the CAMHS and HV groups agreed that the SA offered a shared language and understanding among professionals. This led to better communication and problem-solving within multi-disciplinary teams and when engaging in interagency work.

Participant 2: “As a practitioner, it’s a very positive thing […] I think it has been very helpful even when you are in a school meeting or something […] and the educational psychologist uses the term and concept containment [...] it really turns the meeting round.”

2. CHALLENGES WHEN USING THE APPROACH

When asked about the challenges using the approach, practitioners’ answers focused both on managing the emotional impact of sessions as well as on implementation challenges.

Emotional impact

CAMHS participants mentioned finding it difficult to keep a balance between containing the patients’ emotions and delivering session content, especially during group work.

Participant 3: “Trying to get the balance between, the processes the carers are going through but at the same time you are offering a containing session […] that’s quite tricky at times.”

In addition, three of the CAMHS participants who had been involved in delivering SA groups for families and carers discussed that containing people’s emotions can be difficult and can give rise to very intense emotions within themselves.

Participant 4: “(Clients) bring to groups some really harrowing stories about the children’s background. Things like that can be really very intense to hear […] because their emotions about these stories are so complex.”

Implementation challenges

Two CAMHS participants felt that the SA concepts were hard to apply within certain high-risk contexts. Although participants recognised the importance of containment, they mentioned that, in some situations, when following child or adult protection guidelines, other procedures need to be taken into consideration, which could appear in contrast with the SA principles.

Participant 4: “You know it’s really necessary to do a certain list of things first, which maybe don’t really fit with the SA […] frame of mind cause they might be a bit sort of strategic and a bit maybe mistimed.”

HVs spoke about the recent changes in their role and the fact that they are currently working within a reduced function environment. When asked how easy it is to apply the SA principles in this setting, HVs reported that they find it stressful and challenging.

Participant 8: “I think that’s quite hard, actually. I think you almost have to be very choosy about what you do. I mean, I’ve had to turn things down which before I wouldn’t have had to […] you’ve got to think very long and hard about what training you can do, what meetings you go to and it is actually influencing quite a lot of our practice. And I felt like I was getting quite stressed and I’m not a stressful person.”

3. TRAINING

Positive aspects of training

When asked about the positive aspects of the SA foundation training, practitioners in both groups mentioned enjoying the information on early years, particularly brain development and attachment.

Participant 7: “The one thing that I think for HVs is so useful is the baby brain development and getting more of that and more about attachment […] that’s what we’re really concerned about. How our babies grow into adulthood.”

Negative aspects of training

When practitioners were asked about the negative aspects of training and how this could be improved, their answers revolved around training pace and delivery. For example, professionals stated that the training included a lot of input, which they found difficult to consolidate.

Participant 5: “I did feel it was one thing after another and another you know and feeling […] you know this is a lot coming my way.”

Practitioners also said that at times the training felt ‘a bit dry’ and wondered whether changes in training delivery and presentation could make it more engaging in the future. For example, one CAMHS participant wondered whether it would have been useful to include experiential learning in the SA training. HVs also wondered whether introducing ice-breaking activities would have made the training more engaging.

Participant 5: “There was no sort of experiential element […] Perhaps I can understand why, not because if you are working with colleagues and you’re sort of doing experiential exercises […] slightly close to an emotional edge it may not be very helpful.”

Practitioner 6: “I think it’s always challenging when you’ve got a new group […] I think some […] ice breakers, (otherwise) I think that can be quite a hit, kind of, to start with.”

4. POST TRAINING SUPPORT

Participants in both focus groups agreed in the importance of post-training support and discussed ways in which this could be achieved.

Structured discussions of SA

Both CAMHS professionals and HVs agreed that it would be beneficial to set some time aside in order to support each other and help with the implementation of the model.

Participant 1: “To have time set aside to as a group to simply focus on SA and have dedicated time to view things from one way.”

Participant 6: “Sticking to the model even in our own office, we can do some containment of really how we are feeling [...] it’s peer support that gets us through and always has done.”

Consultation and supervision

CAMHS participants discussed that it might be difficult to obtain SA group supervision with a wide professional group because practitioners may have different views of supervision. HVs said it had been difficult due to time and workload constraints.

Participant 3: “At the training I went on there were home visitors and education staff and 16+ groups so there was a wide professional group. I think it would be tricky to get these people together regularly for groups supervision.”

Participant 6: “Well, when I first did the training we had very good consultation […] but like everything it’s difficult to keep it all going […] As soon as work demands increase, things like supervision or consultation tend to be the first thing to go.”

Online resource development

Finally, HVs discussed that it might be beneficial to develop more robust online or electronic resources in order to help practitioners update their SA knowledge and skills.

Participant 6: “I don’t know if you should come out with, like, an e-learning package [...] just to keep up your skills [...] But also offer [...] new and current information.”


Discussion

HVs and CAMHS professionals participated in focus groups regarding their experiences of using the SA. Practitioners identified a number of benefits of the SA such as enhanced practitioner reflection, greater focus on parents’ and children’s feelings as well as an increased awareness of the family’s readiness in therapy. These elements are essential in forming and maintaining therapeutic alliances and in establishing positive therapeutic outcomes (Martin et al, 2000). Practitioners also mentioned that the SA positively influenced team relationships and communication by offering a shared language among professionals. This is consistent with previous work in this area (Whitehead and Douglas, 2005).

HVs and CAMHS professionals identified a number of challenges when using the SA. CAMHS practitioners discussed challenges around the emotional aspects of sessions, such as managing clients’ emotions during group sessions. Time, stress and workload constraints were the main barriers in implementing the approach mentioned by HVs. Incorporating restorative supervision approaches (Wallbank, 2013) to support both CAMHS and HV practitioners in debriefing, reflecting and managing stressors in their work environment might, therefore, be beneficial.

The lack of additional sessions to help implement the approach in practice was the main identified gap in post-training support. This has been a recurrent theme in SA evaluations (Basset, 2015). A recent development of the SA was the implementation of theory-to-practice sessions to support practitioners in embedding the approach (Basset, 2015). Evaluating these sessions would therefore be beneficial to see if they meet practitioners’ post-training needs. In addition, HVs wondered whether further development of SA online resources would support the implementation of the approach and provide a time-efficient alternative to group sessions.

Finally, practitioners identified a number of opportunities for training improvement such as providing different presentation modes and reducing the content of sessions. These themes could be taken into account when designing and delivering future training in order to increase engagement and participation.

There are a number of limitations that need to be borne in mind when considering the results of this study. This study is a service evaluation with a small sample size, which makes it difficult to generalise to other settings. It may be helpful to create a questionnaire based on the aforementioned themes as well as on themes from previous research in order to increase the generalisability of the findings. Nevertheless, results from this study can offer some preliminary evidence on the impact of the Solihull approach on clinical practice and can help improve future training and post-training support.


Key points

We conducted a qualitative service evaluation in order to obtain an in-depth understanding of the experiences of practitioners using the Solihull Approach.

Two focus groups which comprised of four CAMHS staff and three health visitors were included in the study.

A number of themes and subthemes emerged including impact on practice, challenges when using the approach, training improvements and post-training support.

Implications for future training development and clinical practice are discussed.


References

Basset, A. (2015) Solihull Approach trainers practice session toolkit. N.Ireland: Clinical Education Centre. See: averil.bassett@cec.hscni.net

Braun, V., Clarke, V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2): 77-101.

Martin, D. J., Garske, J. P. and Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of consulting and clinical psychology, 68(3): 438-450.

Moore, T., Adams, M., and Pratt, R. (2013). A service evaluation of the Solihull Approach training and practice. Community Practitioner, 86(5): 26-29.

Ottmann, J. (2010). Service research project: The experiences of a multi-disciplinary team in using the Solihull Approach: Exploring whether training in the Solihull approach changes practice. Unpublished manuscript, Department of Psychological Sciences, University of East Anglia, Norwich, UK.

Smith, J. A. (2008). Qualitative psychology: A practical guide to research methods. London: Sage.

Solihull NHS Primary Care Trust (2006) Solihull Approach Trainers Pack: For Training Care Professionals Working with Infants, Children and Young People. Cambridge: Jill Rogers Associates Ltd.

Wallbank, S. (2013) Maintaining professional resilience through group restorative supervision. Community Practitioner, 86(8): 26-28.

Whitehead, R. E., Douglas, H. (2005). Health Visitors' experiences of using the Solihull approach. Community Practitioner, 78(1): 20-23.

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