Innovation summary

In a psychiatric inpatient setting, mental health problems are defined within the physical constructs of an ‘illness’ leading to a system that focuses on problems and lacks messages of recovery1. National reviews of inpatient mental health wards routinely criticise services for a lack of meaningful approach to services, engagement, and empathy from staff1-3.

In response to the concerns associated with psychiatric inpatient acute care, the South London and Maudsley Trust implemented Tree of Life groups across all adult acute mental health wards throughout their in-patient service. Based on narrative therapy, the Tree of Life approach focuses on facilitating collaborative recovery in a multicultural and multi-ethnic group4-5. This was part of an innovative charity funded project with three main aims:

  1. Promote a recovery-based approach to treatment
  2. Build positive therapeutic relationships between staff and service users 
  3. Provide a multicultural therapy that addresses the needs of an ethnically diverse population

Impact summary

  • 10 service users underwent training to become Tree of Life workshop facilitators
  • Over 650 service users attended 200 workshops and approximately 300 members of staff engaged in workshop-related activities
  • Approximately 80% of all participants were from Black and Minority Ethnic (BME) groups 

"We can forget stuff in our memories, be preoccupied with life now, like when you're in a bad space, but when you start to talk about culture and heritage, [it] reminds you that you can pull back on those certain strengths.. it's uplifting"

- Acute Ward Nurse following a Tree of Life group

Innovation details

Background of the Tree of Life

‘Tree of Life’ is a psychosocial support tool based on Narrative Therapy for facilitating personal recovery5. It was developed in Zimbabwe to support high-risk children affected by HIV/AIDS, poverty, war and conflict in Eastern Africa5-6. The approach seeks to minimize stigmatizing narratives by focusing on strengths and resources first before addressing problems.

In UK acute mental health wards staff is often viewed as being too busy to talk to patients, under-resourced and rely on medication as the only intervention on wards1. The custodial nature of the wards in the absence of positive therapeutic interactions leads to cycles of conflict within staff and service user relationships7. Negative perceptions of staff and service users’ views reported from people following discharge who did not find their inpatient care helpful in addressing their mental health problems; are well documented8-10. There have also been concerns cited by The Equality and Human Rights Commission11 regarding equality and diversity disparities for Black and Minority Ethnic groups within mental health services.

The Tree of Life innovation aims to offer a multi-cultural talking treatment that addresses the needs of an ethnically diverse population while building positive and collaborative relationships between staff and service users. Ultimately helping to promote collaborative recovery approaches to mental health care.

Tree of Life Components

1. Methodology

Tree of Life workshops embody participative activities that involve drawing trees in a group setting with the aim of building a forest of trees together. Each part of the tree is a metaphor for specific components of an individual’s life that define their identity (relationships, strengths, values and hopes for the future).

2. Multicultural therapy

Within the tree of life model, culture and heritage are recognized as resources, thus making the tree of life a practice that can be valued by diverse communities and services. It has proven successful in its flexible approach and adaptability and is now used internationally in a variety of contexts12-14.

​3. Narrative Therapy and promoting recovery in mental health services  

In mental health services, the dominant story can often be the stigmatizing mental health diagnosis. Through narrative therapy:

  • The diagnosis is separated from the person and people are encouraged to first appreciate their resources
  • Service users are able to stand on a firmer foundation to begin talking about their difficult experiences
  • The intention of drawing a tree is to enable individuals to describe a preferred version of themselves (the person they would like others to see) rather than adopting a description imposed on them by others (mental health diagnosis)

4. Building positive therapeutic relationships between staff and service users 

This model enables staff and service users to see each on equal terms as both groups participate in the Tree of Life workshop together. This allows service users to engage from a position of strength, choosing what to disclose and highlighting their strengths

The collaborative approach and reciprocal sharing in a Tree of Life group can help to build positive relationships on inpatient wards by addressing the power imbalances between staff and services users.These power relationships are often exaggerated due to the legal context of sections and other mental health law restrictions placed on a service user in a mental health system

Key drivers

Positive Feedback

  • Following the Tree of Life Project in 2013-2016, an extensive mixed-methods evaluation demonstrated the interest and benefit that staff and service users gained from the Tree of Life groups on inpatient wards.
  • The positive feedback serves as a key driver of the implementation and sustainability of the groups going forward. 

Successful approaches to implementation

  • A previous version of the ToL group within the SLaM wards (2013-2016) was implemented using a successful method
  • This involved rolling groups out across the Trust Acute Wards, with 1 group running on each ward every 6 weeks
  • The approach allowed the group to be available to new and existing service users each time

Co-Production Model

  • Every aspect of the Tree of Life workshops involved a psychologist and service user collaborative approach.
  • The commitment and investment in adhering to this way of work opened up new possibilities for challenging traditional views of therapeutic relationships on the wards and supported the engagement of staff and service users in the groups.  


Staff engagement and attendance

  • Due to staff responsibilities and tasks requiring staff attention on the ward, staff members found it difficult to allocate the time to attend Tree of Life groups.
  • Additionally, staff may find the concept of attending the group with service users as novel, and may be reluctant to attend as a result of it being different to what they are used to

Consistent and flexible payment methods for service user involvement

  • Consistent funding is a key requirement in order to attain service user facilitators who will be running the groups.
  • Uncertainty regarding funding and flexible payment methods make it difficult to predict and/or reassure service user facilitators of their position in the project.  


The Tree of Life workshops are implemented within the South London and Maudsley (SLAM) NHS Trust through over 15 different teams and services and have been running with the SLAM Recovery College since 2013.

Due to the success of the project on the wards, the SLAM Executive Board have recommended that Tree of Life groups run across all 20 adult mental health acute wards and be considered a priority for the psychosocial model of care on inpatient and patient intensive care unit wards in 2018.  



Evaluation methods

The Tree of Life groups were evaluated through both quantitative and qualitative methods. 

  • 250 self-report questionnaires were administered to service users post workshops
  • 150 self-report pre- and post- questionnaires were administered to staff members working on the acute adult in-patient wards
  • 16 ward staff members took part in 4 focus groups
  • 5 staff members were interviewed for an MSc Family Therapy research project (currently unpublished) 

Cost of implementation

The Maudsley Charity provided a total of £150,000 to the SLAM Recovery College for two years of programme implementation.

Impact details

Promoting Recovery and Building Relationships

  • Post-workshop questionnaires: Service users scored the highest average for questions related to improved service-user and staff engagement, personal development and the feeling of being respected
  • Pre- and Post- questionnaires: The greatest changes in scores for staff members were noted on questions relating to improved relationships between staff and service user, sharing of information and valuing service users' identities
  • The following major themes emerged from a qualitative analysis of focus groups and in-depth interviews with staff and service users:
    • Talking about culture helped participants to relate and connect with each other as people
    • Staff reported in qualitative interviews that the new narrative was integrated well into ward rounds, staff handovers and risk management discussions.
    • The Tree of Life groups had a positive impact on ward environment through the challenging of mistrust by sharing 
  • The involvement of service users as workshop facilitators promoted personal recovery stories through their experiences on the ward
  • Improved awareness for the strengths and resources of service users that had an overall positive impact on the ward
  • The project was also mentioned and discussed on a BBC Radio 4 feature on Recovery in Mental Health in the ‘All in the Mind’ programme.

Increased Accessibility to Talking Treatments and Engagement with Black and Minority Ethnic (BME) groups:  

  • This is demonstrated by a high rate of group attendance (75%) of service users from BME groups, which is higher than the average ward figures for BME service users accounting for typically 64% of the inpatient population 
  • In 2015 the Tree of Life project won a national mental health award for ‘promoting equality and diversity in service provision’ and was highly commended for ‘patient experience’


  1. Crisp N, Smith G & Nicholson K (2016) Old Problems, New Solutions – Improving Acute Psychiatric Care for Adults in England. The Commission on Acute Adult Psychiatric Care.
  2. The Sainsbury Centre for Mental Health (2005) The Neglected Majority: Developing intermediate mental health care in primary care. London: SCM.
  3. Schizophrenia Commission (2012) The abandoned illness: a report from the Schizophrenia Commission. London: Rethink Mental Illness.
  4. Brown R et al. (2016) Creating ripples: towards practice-based evidence for narrative therapy within NHS contexts. Clinical Psychology Forum, 284: 48-52.
  5. Ncube N (2006) The tree of life project. International Journal of Narrative Therapy & Community Work, 1(3): 16.
  6. Ncube-Milo N & Denborough D (2007) The Tree of Life Manual, REPPSI.
  7. Flynn S, Bartholomew D (2003) Personality disorders: The challenge of acute in-patient management. Clinical Psychology, 22: 17–21
  8. Bonsack C & Borgeat F (2005) Perceived coercion and need for hospitalization related to psychiatric admission. International journal of law and psychiatry, 28(4): 342-7.
  9. Rain D et al. (2003) Perceived Coercion at Hospital Admission and Adherence to Mental Health Treatment After Discharge. Psychiatric Services, 54(1): 103-105
  10. Thornihill H, Clare L, & May R (2004) Escape, enlightenment and endurance. Anthropology and Medicine, 11: 181-200.
  11. EHRC (2015) Is Britain fairer? The state of equality and human rights. Equality and Human Rights Commission.
  12. Byrne A et al. (2011). A powerful piece of work: African and Caribbean men talking about the ‘tree of life’. Context, 117: 40 – 45.
  13. Hughes G (2014) Finding a voice through ‘The Tree of Life’: A strength-based approach to mental health for refugee children and families in schools. Clinical child psychology and psychiatry, 19(1): 139-153.
  14. Jamieson A (2012) A case study exploring the use of the tree of life as a narrative intervention tool with a black adolescent girl who was sexually abused in South Africa. Unpublished dissertation.
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