Lessons from the Maytree
Natalie Howarth, Anja Murphy, Angela Rodriguez, Ben Scanlan
Suicidal crises: the importance of space to talk, rest and reflect
Since 2002, Maytree has been offering support for adults who are in suicidal crisis in (what we think is) a unique way through befriending on the phone followed by a residential stay if appropriate. Throughout our lifespan to date, we have grown and refined our service based on experience of what does and doesn’t work and we now want to share some lessons learned with colleagues from the world of psychotherapy and counselling, as well as flag ourselves up as a service that can be referred to.
Maytree: background and history
Maytree itself is a terraced house in Finsbury Park, north London, and as a house is pretty unremarkable with four guest bedrooms, three offices, a large kitchen etc. You get the picture – just an everyday terraced house. We currently operate with one senior co-ordinator, three full time co-ordinators, eight part time assistant co-ordinators and 120 volunteers who keep the house running 365 days a year, 24 hours a day. We have guests who self-refer and guests who are referred by other services and health professionals. This happens via both email and phone with an emphasis on talking and phone calls as this is more indicative of how a potential guest may experience being in the house. This is important to try and ensure that a stay is the right thing for a guest and that now is the right time.
In a typical year we deal with around two and a half thousand individual callers (not counting referrals) who are looking for support, with around 100 guests staying with us every year. During their stay in their own private room, the guest has the freedom to go out for a walk during the day, is encouraged to speak to volunteers when in the house and will have 1:1 time with a co-ordinator throughout their stay to give some consistency. Chats last around an hour naturally, but can be significantly longer if it feels right. This is driven by the guest and what they want; it is caveated by us not wanting to foster any dependency nor place a volunteer or guest under too much stress or weight of expectation – Maytree is about giving space to talk, rest and reflect.
Maytree came into existence after a couple of long term Samaritans felt that some callers needed more support. We are deliberately non-clinical in nature, but have benefited from the involvement on the board of Trustees of people such as Keith Hawton, a world renowned expert in suicide and professor of psychiatry at Oxford University. The University of East London did a study in 2012 talking to 50 ex-guests, in-depth with 12 of them. Of the larger population, 86% reported reduced suicidal feelings at the end of their stay with us, and of these, 32% described transformational changes. These results were termed a success by Stephen Briggs, Professor of Social Work who oversaw the investigation.
Suicide as a topic is hot right now. The worldwide trend, that mirrors evidence in the UK, is that suicide is becoming more and more frequent (although measuring this trend accurately is difficult given cultural sensitivities and the propensity of coroners not to want to rule suicide). Roughly 13 people will kill themselves in the UK everyday, the majority of whom are men. Traditional gender stereotypes suggest that whilst women have more attempts, they aren’t successful due to choice of method and they also tend to seek help with suicidal feelings before they reach that stage. Maytree has been involved in national television programmes on the BBC to try and highlight different aspects of those who kill themselves, including targeting young men via Professor Green: Suicide and Me, whilst also hosting the Duke and Duchess of Cambridge.
Through conversations with volunteers, guests, ex-guests and professionals who refer, we believe there are a number of lessons that are potentially useful for therapists of any background, especially those who are near the start of their own journey.
Lessons we have learnt
1 Be honest about everything from the first contact
We have a way of working that we explain in the first call. We keep notes that allow us to provide continuity for a potential guest, but we will not breach that confidentiality unless there is potential harm to children or a guest tries to kill themselves whilst in the house. We are unable to help anybody who is street homeless. This is not a judgment on their circumstances, but in our experience giving somebody five days of care and warmth can exacerbate suicidal urges on leaving us to go back onto streets. We have a no drugs or alcohol policy, therefore any potential guest needs to be able to safely come and stay. Again, this is not a judgement, but people can struggle to engage with difficult feelings if they’re withdrawing, and we’re not specialists in helping and managing withdrawal so we signpost on to specialist treatment services. We do not offer ongoing support and once a guest has stayed they can’t use our phone service or come and stay again or have contact with any staff or volunteers for at least a year. This may seem slightly harsh, but we feel it serves two purposes. Firstly, we want to empower guests and fostering a dependency runs counter to that so we want to limit the potential as much as possible. Additionally, we are a relatively small charity and, practically, providing on-going support would potentially increase the demands on us to an unsustainable level.
We have heard it said a number of times that guests have gone to other health professionals, shared things under the impression that it was confidential and then had that trust broken. For us the relationship really is at the heart of everything and having that discussion with a guest is key. One story in particular told to us was that a male guest was placed on the waiting list for therapy and told if he was struggling he was to go to A&E. He did this, then at his first therapy appointment was told he was too risky and not ready for therapy due to his A&E visit when suicidal – which was ironic as it was the carrot of therapy that helped him through.
Ultimately, are you, as therapists, explicit about everything from the beginning, or are some things obvious to you, but maybe not to your clients?
2 Asking frankly about plans for suicide opens the door
Asking the really obvious, but potentially scary, questions can help ease the pressure on a guest. “How suicidal do you feel?” and “Do you have any plans to kill yourself at the moment?” Almost every guest comments on the relief they experience that their suicidal feelings are accepted and the sense they are not alone. This works on several levels. It illustrates that we can hold their suicidal thoughts, and if we can hold those, we are perceived as probably able to hold whatever else they’ve got to say (which isn’t to say that they then pour out everything). We ask, not because we think we know what the answers are, nor because we can offer solutions, but because having the dialogue means that together we can begin to disentangle what has lead them to feeling like this. We accept that we really do not have the answers.
Although some of our volunteers are trainee counsellors and therapists, at the beginning of Maytree training almost everybody struggles to ask “how suicidal are you feeling?” in role play, or even to use the term suicide. There’s a fear that by mentioning suicide, it can make somebody suicidal or more suicidal than they were. The opposite is true. It can act as a pressure valve for the acutely suicidal. Just through this one conversation, their feelings can be alleviated, or perspective found. If the only place you can be suicidal is within yourself, it’s easy to see how pressure can build.
Just as an indicator, have you ever experienced saying “I’m suicidal. I really do want to kill myself”, even just as part of a role play? Ben ran a workshop at a conference in 2015, aimed at Existential therapists and of the twenty five people in the room, the vast majority UKCP accredited, 90% hadn’t had this experience. The discussion from that point revealed an alteration in perspective just through framing the experience from the ‘I’ position, something that we would argue is very difficult to replicate just through listening, irrespective of the attentiveness of the listening.
3 Theory really needs to be a secondary consideration
All of us have training and experience as counsellors and therapists. Angela is more person-centred, similar to Nat, while Anja tends to lean more towards psychodynamic perspectives. Sixty per cent of our volunteers are trainee therapists from all sorts of theoretical stances – existential, psychoanalytic, cognitive-behavioural, transpersonal. Additionally we have one psychiatrist and two lecturers, as well as a lot of volunteers who have a personal rather than professional interest in mental health.
What is apparent is that those who are earlier in their own psychotherapy training journey tend to draw on theory or use phrases like “Oh, I know how to work with people like him” in reference to a diagnosis. There is an inherent danger in using labels as a foundation for working with somebody. As indicators they can be useful, but more than that, they can take you away from who is sat opposite you. As an example, if somebody is autistic, and identifies themselves as such, then you can assume and run with the ‘fact’ that they struggle relating to people and are unable to convey emotions, allowing you to miss that actually they convey things with subtlety.
As with our view about being frank, so much of psychotherapy training seems to be about theoretical considerations rather than working on skills in a real and practical way. Skills like holding silence and working on different levels between process and narrative are important but so is working out how you feel when faced with somebody who could be crossing a very big ethical boundary for you. Training does need to equip trainees with the theory, but does this too often come at the expense of experiential learning about sitting with difficult feelings such as suicide and seeing what that brings up for the therapist?
4 Self-care is imperative
Every so often, we have a new volunteer start, pull double shifts (so six and a half hours) twice a week, begin helping with outreach and then disappear towards the end of their first year. Their disappearance can be for any number of reasons – more than likely it’s burn-out.
The work can be tiring and challenging and difficult to hold, even more difficult if you end up carrying it around.
That’s not a potential. It’s a definite. It doesn’t matter if it’s your full time job, or whether you’ve racked up ten thousand hours and are the most experienced person on the planet. We’re fortunate in that we have each other, and the volunteers, to talk to freely and pretty much instantaneously and there’s a supervisor for us to utilise. Volunteers can take time out, have monthly reflection sessions, and a designated assistant co-coordinator to call on.
How much support do you have? In private practice, it’s probably fair to assume a supervisor and not much else, although if you’re in partnership with peers, you may have more. Do you maintain relationships built during training that are more professional and like peer support/supervision in their nature? Even if you’re working in an organisation, the support may not be readily available. Recently one of our volunteers shared that they had supervision in the morning of their one day placement, before seeing their clients and then having to wait until the next week for supervision. Do you have a plan of how you’re going to process heavy material outside of your more formal structure?
5 One size does not fit all
Within a boundaried frame and limited resources, what we try to offer is something flexible and unique to each guest. The boundaries are provided by our limitations – no ongoing relationship after a stay, and a stay limited to five days.
When a potential guest first makes contact, inevitably they ask about how long it takes to get a stay. And pretty universally the answer they receive is “we like to have a number of calls, with a few days between calls”…. vague in the sense that each potential guest will require something different. This gives us the opportunity to get to know them, but it also gives them a chance to use the space and think about what a stay at Maytree involves, and whether we’re the right place for them. Some callers find that one call alleviates the intensity of their suicidality, others three or four calls. Of those who come to stay, the majority are about 2-4 weeks after that first contact, but some stretch into years.
So how can this flexibility be adopted by therapists? Evidence suggests there’s no real difference in terms of outcome about frequency of therapy, yet once-weekly sessions seems the most common. Do you offer more support to clients who are suicidal, or going through a traumatic experience? How would you feel about your client seeing another therapist, or accessing alternative services, to supplement your own work? Long-term therapy rests on boundaries, and what we offer does too in a far shorter intervention, but could a suicidal client need more support and care from the therapist or through giving space to the client to consider other services such as Maytree?
Ultimately our experience suggests that statutory services aren’t serving a significant proportion of the population – sad but unsurprising news. However, in addition to this, a significant proportion of our guests have suggested their previous therapy experiences haven’t helped them as the societal fear that surrounds suicide also enters the therapy room. We are conscious that we work with a niche clientele in some respects, but actually our guests are drawn from all walks of life, and as the suicide rate increases, giving people space to talk, rest and reflect is more of an imperative.