With People with Learning Disabilities Tree of Life Group With People with Learning Disabilities Dr Myro Themistocleous Lead Clinical Psychologist Newham Community Learning Disabilities Team

Overview Key assumptions of Narrative Therapy (NT) Introduction to what tree of life is & for who What does it look like? 4 part structure What we did- the story of our tree of life day Outcomes References & further reading

Narrative Therapy: Key Assumptions To maximize effectiveness knowledge of NT is needed The problem is the problem the problem not the person. But, problem saturated stories are often the dominant story. They can be experienced as oppressive as they limit the perception of available choices for life and identity They obscure peoples hopes, dreams, skills, achievements “Life is multi-storied not single storied- there is usually a stock of lived experiences that is un-storied” (Baum, 2014) Identity is seen as a project that can be created & recreated in relationship with others

Narrative Therapy: How ? (1) By reducing the power of the dominant problem saturated stories. By brining forth the sub-ordinate & preferred stories of people's lives Facilitating connections to others Facilitating connections to values & what & is important to enable preferred ways of living

Narrative Therapy: How? (1) Externalising Mapping personal histories, focusing on action & identity Deconstructing language & cultural discourses Authenticity & Communities of acknowledgement Thickening the alternative story using definitional ceremonies, therapeutic documents etc

Tree of Life: What is it & Who is it For? "it is a tool that uses different parts of a tree as metaphors to represent the different aspects of our lives" (Ncube & Denborough, 2007) Developed for children who have experienced losses & traumas. Used in many contexts. Only used for people with LD’s in a group by Lynggaard et al (2010) Helps to give language to people who may otherwise struggle Creates strength & hope for future around shared values Creates a safe place to stand by bringing forth preferred aspects of identity which helps to change their relationship to the problem

What Does it Look Like? 1. Trees of life: creation of a preferred identity by bringing forth the subordinate stories. These encompass skills, abilities, hopes, dreams, and the histories of them. 2. Forest of life: the re-telling of preferred identities and connecting with others. 3. Storms: enable participants to talk about their problems & how they are responding 4. Certificates: to ensure that people leave with a rich acknowledgment of their skills and abilities. As well as links with significant people in their lives. 4 part structure (Denborough, 2008)

The Story of Our Tree of Life Invitations & Participants Colleagues asked to refer clients who would benefit from a workshop to improve confidence and self-esteem. 22 clients referred, 10 were invited, 6 attended. Most have experienced physical or sexual abuse. 3 facilitators. From Individuals to Group Introductions & co-created rules. Warm up exercise. Images of trees around the room for inspiration.

Part 1: Tree of Life   Draw trees: Participants were invited to draw trees that included ground, roots, trunk, branches, leaves fruit and flowers. Not about artistic skill. The ground: Where they are now, activities enjoy, where they live. The roots: Heritage, family, culture, country/place of origin/ significance, religion, favourite childhood songs and games, important teachers etc.  

Part 1: Tree of Life The trunk: Use of stories to identify skills & abilities. Stands in direct contrast to the totalising label of ‘learning disability’ Adapted Post it Note exercise (Maggie Carey, 2013) Clients invited to tell a story whilst others listened out for skills Variety of stories shared from ‘breaking up a table’ to ‘passing a piano exam’ Phun’s story- ‘doing voluntary work in a shoe shop’ Excerpt illustrating questions used to thicken the alternative story Powerful exercise- All participants surprised they had so many skills

Part 1: Tree of Life Natasha is brave. The branches: Hopes, dreams and wishes for their life. E.g. wanting to live independently, to have a partner and children, get a job, do more sport, to travel, learn to drive The leaves: Significant people from now or the past, real or fictional. The fruits: Gifts they have been given. Adapted using pictures of apples with space for writing & asking them to give each other gifts. We began with an example: Natasha is brave. Participants were generous with their gifts: e.g. “caring person and friendly too” , “good at dealing with things” & “thoughtful” The flowers: Gifts they have given others. Needs adapting.

Part 2: Forest of Life Created ‘the forest’ by sticking up each persons tree Sharing of the trees They seemed proud

Part 3:When the Storms Come Invited to name dangers for trees “storms, fire, wind, floods..” Linked dangers to what hurts people in general sense. Keen to avoid rehearsed single problem saturated stories. They were all nodding, some making comments such as ‘yes’ and others seeming pensive.

Tree of Life certificate Part 4: Certificates, Songs & Photos Reading & presenting of certificates Silence as they listened intensively. Celebration honouring participants’ skills, hopes and dreams and special connections Collaboratively completed certificates to ensure focus remains on clients priorities (de centred practice) Talk of who they would share these with to recruit an audience outside of therapy room Tree of Life certificate Awarded to: ____________________ For proving to herself and to others that she has many skills and abilities that help to give her strength in her life. She also has special dreams and hopes for the future. ____ skills and abilities include ____________ ___________________________________ Her hopes and dreams are _______________________________________She would like to appreciate the following special people in her life: _______________________________________Date: ____________ Signature: By Lynggaard et al (2010)

Part 4: Certificates, Songs & Photos serve many functions Join people around shared themes in ways that thicken the alternative stories of their lives (White, 2007) Just as Myerhoff (1986) talks about how definitional ceremonies serve to combat the sense of isolation and invisibility that is often experienced by people who are socially marginisalied. The reading of the certificates provides opportunities for people to be seen in their preferred ways and the presence of an audience serves to authenticate these alternative identity claims. They can be used later to share the alternative stories with others in their lives to further authenticate them. Therapeutic documents act as a reminder to them of the day and to stay connected to their commitments (Morgan, 2000). To serve as counter-documents to the problem saturated reports that have often been written about people (Morgan, 2000)

Part 4: Photos Tree of Life Day Consent was obtained to photograph each tree for our clinical records. Request for a group photograph. Chorus of voices ‘that’s a good idea.’ Important bonding ceremony as they all stood together in front of their trees. Created cards thanking them for attending and reminding them to look at their trees or certificates if any storms come.

Outcomes- Quantitative A short questionnaire was designed despite epistemological tensions. 0-10 point likert scale where zero represented ‘not at all’ and 10 ‘totally’. Group run twice with different people. Results for both are presented below. Group 1 (August 2013) Group 2 (February 2014) Chart 1: How confident do you feel about yourself? Chart 2: How much do you like yourself?

Outcomes- Qualitative What did you like about the day? Themes Frequenc y Making friends & the people “meeting new people”/ “I like to help other people as well. Because they are caring and helpful.”/ “The staff were lovely” / “People treating me with respect. Friendly people.” 7 Talking “ talking about myself made me feel better/ talking about girlfriend/boyfriend/future” 6 Learning, Skills & Life “I learnt about myself.” / “..I learnt my skills. I gained some skills today.” / “I came on time.” 5 General positive & other “Everything, all good” / “Listening” Making Trees, drawing and writing “creating trees in group” / “I liked doing the pictures, drawing and writing.” 3 Fun & enjoying day “Having fun” / “I really enjoyed myself today. And I realty liked it so much.”

What did you dislike about the day? Outcomes- Qualitative All comments on what participants disliked Frequency “…I dislike where you have to make up a story because I found it hard to hear.” 1 “it was a bit long but we managed to fit it in ok” “I would like it to be longer, maybe for 2 days” “disliked drawing”   “Coming late I missed a lot.”

Ad hoc: growing trees!? (1) Clients and families 4 requests for the photo weeks later 2 mothers said their daughters ‘really enjoyed it’ and were ‘excited’ ‘I was surprised I could speak in front of the group’ ‘seeing people like me who have jobs and their own flat makes me think maybe I could too!’ 5 months later a client said he looks at his tree ‘to cheer him up when he feels down’ which he has put up inside his wardrobe! Friendship? 2 requests for phone numbers “try to be her friend” 3 clients who DNA’d have since contacted to apologise and request another group.

Ad hoc: growing trees!? (2) Facilitators “That’s exactly the kind of thing I want to do more of” “a special memory” she will take with her to her new job “life affirming & inspiring day” Both clients and facilitators felt inspired and hopeful

References & further reading Baum, S. (2014). Presentation on Using the tree of life with people with learning disabilities. Oxleas: Oxleas NHS Trust. Denborough, D. (2008). Chapter 4, The tree of life: a collective narrative approach to working with vulnerable children. In Collective Narrative Practice, responding to individuals groups and committed who have experience trauma. Adelaide: Dulwich centre publications. Lynggaard, H. et al (2010) unpublished resources for a tree of life group with people with learning disabilities. Islington. Maggie Carey in H.Fox, C. Goney and P. Ord (2013). Exercise on Level 3 Narrative Therapy module Linking Lives, working with groups and communities. Institute of Narrative Therapy. Morgan, A. (2000). What is Narrative Therapy? An easy-to-read introduction. Adelaide: Dulwich centre publications. Myerhooff (1986) In White, M. (2007). Maps of narrative practice. New York: W.V Norton & Company Ltd. Ncube-Millo, N., & Denborough, D., (2007). Tree of Life, mainstreaming psychosocial care And support: a manual for facilitators, Randburg, South Africa: REPSSI. White, M. (2007). Maps of narrative practice. New York: W.V Norton & Company Ltd. Example of contexts in which tree of life has been used e.g. International adoption (Ames, 2006), African & Caribbean men with mental health problems in the UK (Carlin, 2009), Vietnamese men in Melbourne (Read, 2010). Contact me for full referenceces.

My contact details Dr Myro Themistocleous Lead Clinical Psychologist Newham Community Learning Disabilities Team Myro.themistocleous@eastlondon.nhs.uk 0208 250 7500