The Maytree Respite Centre in London: therapy for people at immediate risk of suicide (2002 - Ongoing)

The initiative

Maytree is a national registered charity providing therapy for people at risk of suicide.[2] Maytree offers therapy through the free provision of a four-night, five-day stay at its residence in North London, which opened in 2002.[9] Maytree employs a non-medical, therapeutic approach which allows its guests to “explore their thoughts and feelings, and feel heard with compassion and without judgement”.[3] The therapeutic approach is “based on three fundamental principles - befriending, limits and risk management”.[9] “Befriending” is a term that relates to the relationship between the Maytree's staff and volunteers and its guests. The staff and volunteers offer a confidential and trusting relationship which aims to treat guests as equals rather than as patients, in order to reduce any power imbalance or stigma around the mental illness. The guests find a sense of self-worth in the willingness of a volunteer to give up their own time, for free, to spend time with them. Maytree clearly defines the limits of its stay and does not allow for repeat guests. In order to manage the inherent risks of its approach, Maytree does not admit people experiencing acute mental health issues, people without a home to return to, or those with drug or alcohol problems.[9] Its services are available for free to UK residents over the age of 18.[3] Maytree considers a five-day stay to be optimal, as it provides enough time for effective therapy while limiting the risk of overdependence.[3]

While spending time in Maytree's peaceful environment, guests are able to reflect on their personal situation and gain empathy. Guests are required to talk to one member of staff and one volunteer each day. Staff try to ensure that guests open up about their suicidal thoughts at some point during these conversations. Guests are also encouraged to take time to rest and reflect.[10] Through this process, Maytree attempts to provide an environment for guests to come to terms with the emotions behind their suicidal thoughts. With guests' permission, Maytree actively communicates with the mental health team associated with the guest, such as the GP, psychiatrist or mental health worker.[10]

Maytree also provides an initial telephone “befriending” service, through which people can discuss their suicidal thoughts. Before any stay, guests typically have four or five calls with Maytree volunteers. If the “befriending reports” from the initial phone contact suggests a stay at Maytree is suitable, staff will then lead an assessment, either in person or on the phone, to confirm that this would be appropriate.[10]

Since it was set up in 2002, Maytree's operating model has relied largely on its volunteers. As of 2015, Maytree employed only four full-time and three part-time members of staff.[8] By contrast, Maytree had 141 volunteers in 2019, each working approximately 3.5 hours per shift.[10] The volunteers bring a diverse range of experiences. They can be guests or people that have experienced mental conditions; people that have lost someone to suicide; people working in the NHS or with a background in healthcare. The permanent staff each have either a qualification in psychotherapy or counselling or lived experience of mental health conditions or suicidal thoughts.[10] Each volunteer is required to undertake an 18-hour training course delivered by a small group of experienced volunteers. The training course is unique to Maytree and covers Maytree's principles of operation, role playing scenarios, and policies and procedures.[10]

During a guest's stay, a member of staff will take the lead with guests and have a one-to-one conversation with them each day of their stay. Staff are also responsible for managing the handover of each shift. Volunteers are responsible for having one-to-one “befriending” time with guests, after which they will submit a report to staff which raises any risks or concerns. Volunteers also help with cooking meals and eat together with guests. Each day, two members of staff and three volunteers are present at the house. At night, two volunteers sleep in the house, one on each floor, and manage any incidents that occur.[10] In the first two weeks after their stay, guests will receive a follow-up call and a reflection letter from a member of staff (with input from volunteers) that validates their strengths and qualities. Since its inception, Maytree has employed a consultant to provide clinical oversight. This is currently a psychotherapist with a background in suicide prevention.[10] This consultant advises members of staff. Members of staff, in turn, lead “reflection groups” each month to discuss challenging incidents or guests with volunteers.[10]

Historically the majority of Maytree's funding has come from trusts and foundations.[10] Maytree currently receives no government funding and sources funds from organisations such as the UK's National Lottery, Comic Relief, The Henry Smith Foundation, Freemasons Charity, and the City Bridge Trust.[2][8] Maytree is governed by a Board of Trustees, which is responsible for the charity's overall strategy and operation.[11]

The challenge

Suicide prevention is a central goal of the UK government's mental health policy.[5] In 2017, there were a total of 5,821 suicides in the UK.[6] While the rate of male suicide is declining over time, suicide remains the single biggest cause of death of men under the age of 45.[1] Within the public health system, there is a shortage of funding for mental health programmes. While it is estimated that mental illness accounts for 28 percent of the burden of disease in the UK, it only receives 13 percent of the total budget of the National Health Service (NHS).[5]

There is a growing recognition of the need to develop community-based initiatives for suicide prevention. There is a movement in the UK, as in other European countries, to deinstitutionalise mental healthcare and develop community-based mental health services in order to reduce the stigma of mental illness and establish a system that is oriented towards recovery and social inclusion.[2] One study suggests while most people who died by suicide had contact with their GP in the months prior to their death, only a third had been in contact with psychiatric services.[7] Furthermore, the long waiting lists for psychiatric and psychological care have created a demand for services that are more responsive to the needs of suicidal people.[8] While there are telephone helplines offering remote support, there is a lack of community-based services that provide care and support for suicidal people.[9]

The public impact

There is evidence that Maytree provides effective short-term relief from stressful and life-threatening situations. According to a 2017 study from Imperial College London, 80% of guests believe themselves to be at less risk of suicide on the day they leave Maytree than the day they arrived, and 77% report this decreased risk remains a week later.[12] A 2012 study of the experiences of 50 guests at Maytree, undertaken by researchers from the University of East London, found that 32 percent of guests reported transformational changes.[4]

Maytree's Report of the Trustees for 2018 stated that Maytree has supported a total of approximately 21,000 people at risk of suicide since opening in 2002, whether by means of a stay or contact with its telephone befriending service. In 2017/18, Maytree provide 127 people with a stay at its house, and supported 2,380 people through its telephone befriending service.[11]

Stakeholder engagement

Maytree's successful operation of a self-contained and independent programme of suicide prevention has depended on its strong reputation, support from charitable funding bodies, the knowledge and skills of its board and permanent staff and sustaining a large team of volunteers with experience of mental illness. However, the contrast between Maytree's approach and conventional psychiatric treatment methods, along with its independent model, limits its broader engagement with public mental health bodies.

Maytree has developed a sustainable operating model that relies exclusively on funding from public donations and charitable bodies. The support from funders reflects Maytree's growing reputation as a well-run and effective programme which fills a void in the network of mental health services available to people suffering from suicidal thoughts. Maytree has found the monitoring and reporting requirements that come with government funding to be onerous, and that these can potentially impact upon the independence of the Maytree model.[10]

As a registered charity, Maytree is governed by a Board of Trustees whose directors possess the broad range of skills necessary to oversee the strategy and operation of the Maytree model. Their experience relates to diverse areas, including psychiatry, charity fundraising, public health and counselling, finance, and law. One external report found that it is “well-organised and well run by gifted and committed directors”.[9]

While Maytree's operations do not depend on the public health system directly, it does provide much of the context for Maytree's operations in the mental health sphere. Maytree employs an outreach worker to deliver suicide awareness training to workers in the public and voluntary sector, to develop links with other community organisations and recruit volunteers.[10] Anecdotal evidence from one of Maytree's patrons suggests that, while public bodies generally support Maytree's service, some in the psychiatric field may have concerns with the safety of Maytree's therapeutic approach for suicidal people compared to that of acute inpatient care, which makes use of psychiatric medication.[8][9]

Political commitment

The UK government has demonstrated a strong political commitment to the objective of reducing the suicide rate. However, this political commitment is directed at the development of public health initiatives more broadly, and somewhat unrelated to the privately funded suicide prevention programme run by Maytree.

Through the independent Mental Health Taskforce, established in March 2015, the government has created a Five Year Forward View for Mental Health for the NHS in England.[13] The Five Year Forward View sets out recommendations on suicide prevention and reduction, with an overall goal of reducing suicides by 10 percent nationally by 2020/21. The government has committed a total of GBP25 million over this time period to the development of suicide prevention and reduction schemes, with particular attention paid to local communities worst affected by suicide.[14] Suicide remains the single greatest cause of death for men aged under 45. In January 2018, then health secretary Jeremy Hunt announced a further goal of achieving “zero suicides” for mental health inpatients.[15]

Political commitment for Maytree's initiative is limited by its small scale and its independence from government funding. An evaluation financed by the City Parochial Foundation suggested that public services are “pleased and grateful that it is available” and that replication of its services is desirable.[9] Political support for another registered charity that has a comparable objective and approach, the Samaritans, is an indication of the potential political support for Maytree's initiative. In 2018, the Samaritans were promised GBP1.8 million by the state for the provision of “immediate” and “lifesaving” support to those suffering from mental health issues, primarily through its telephone helpline services.[15]

Public confidence

Media reports indicate that the public perception of Maytree's initiative is very positive and that there is a high degree of acceptance of its therapeutic approach. However, public confidence is limited by the initiative's small scale and the lack of general public awareness.

Over the years of Maytree's operation, the media have written a number of human-interest stories on the experiences of Maytree's guests and how their lives have changed for the better as a result of their stay at Maytree. The stories reveal that Maytree provides a unique and effective service for people who were overwhelmed by mental health issues, such as depression and anxiety, and were contemplating suicide. In one article, a woman told of her inability to prevent suicidal thoughts through medication or talking therapy, and her frustrations with the long waiting list for specialist support from the NHS.[16] Others identified Maytree's provision of a safe environment as a source of much-needed respite, and the personal nature of its care as an important factor in their recovery.[8][17] Media reports focus on the benefits of Maytree's befriending approach, and how its volunteers were able to connect with those suffering from suicidal thoughts by listening and providing empathy based upon their own experiences.

These stories trace the recovery of the guests after their stay at Maytree and demonstrate the positive impact of the stay on the individual and their families. One GP was so impressed by his patient's recovery that he contacted Maytree to praise the service and ask for further information.[18] Another report mentions that family members often write to Maytree to express their gratitude for helping to improve the lives of their loved ones.[5]

Clarity of objectives

Maytree has maintained its principal objective, namely that of suicide prevention, throughout its operation. Maytree's governing document defines its objectives and activities as the following: “to relieve persons in need who are suffering from suicidal tendencies, primarily but not exclusively, through a befriending support line and the provision of a one-off, short term non-medical residential befriending service”. It targets people in suicidal crisis, particularly those people suffering from problems of isolation, social alienation, or deprivation.[11] This overall objective has remained unchanged since Maytree's establishment. Director Natalie Howarth confirms that the “main aim is to make a significant contribution to the prevention of suicide”.[8]

Maytree appears to have maintained an approach to treatment that is consistent with the objectives of the governing document. An evaluation of Maytree conducted in 2006 found that befriending remained a key principle of its therapeutic approach.[9] Over the course of its operation, Maytree's approach has been subject to a process of evolution. Limits and boundaries of the service, along with risk management practices relating to vulnerable guests, have been developed. Maytree limits guests to one four-night stay and does not admit guests with drug or alcohol problems, without a permanent residence, or currently experiencing acute mental illness. These practices serve to enhance the sustainability of Maytree's approach and further its principal objective of suicide prevention.

Strength of evidence

The founders of Maytree, Michael Knight and Paddy Bazeley, established Maytree because they observed a gap in the services available to people at immediate risk of suicide.[19] Knight and Bazeley both worked at the Samaritans, which provided a telephone service for those at risk of suipital admission” when the Samaritans were unable to open a safe house themselves.[5] According to Kncide.[8] They established Maytree as a means to “fill the void between telephone helplines and hosight, it was felt that while the services provided by psychiatric hospitals, community psychiatry, general practitioners and counsellors may be helpful in some instances, they were often unsuitable for people at immediate risk of suicide.[19] The founders saw a need to provide a humane environment for such people which could address their feeling of isolation, which according to Knight is “the essence of suicide”.[19] While at Samaritans, Bazeley occasionally offered people at risk of suicide an overnight stay at its London branch. Through this, they observed how the provision of a safe environment could make an ‘overwhelming difference' to their mental health.[19]

One core concept of Maytree's approach, “befriending”, is a term that is also used by the Samaritans. The following quote from a caller to the Samaritans, listed on their website, indicates a high degree of similarities in the approach of the two organisations: “the fact that somebody understood, did not criticise, did not palm me off, did not judge or advise... gave me back my confidence in me as a person”.[20]

It is also unclear to what extent evidence from other therapeutic approaches was used to inform Maytree's way of working. Different types of therapeutic approaches have been widely employed in the treatment of mental health issues. These are thought to have been based upon the ideas of Sigmund Freud, the founder of psychoanalysis. Such therapies are used today in the UK mental health system to help the mentally unwell “deal with negative thoughts and feelings and make positive changes”.[21]

Feasibility

Over the past 17 years, Maytree has demonstrated the sustainability of its operational model in delivering a refuge at its house in North London for people at immediate risk of suicide. There are, however, feasibility concerns relating to the replication of the model, given that Maytree has not yet established any further centres despite its intention to do so.[8]

Maytree has gradually developed greater capability for fundraising and managing its relationships with trusts and foundations. According to its director Natalie Howarth, Maytree experienced financial problems in 2011 and 2013 that related to an overreliance on a small group of funders. In 2017, Maytree expanded its management team to include both a finance and resource manager and a fundraising manage. Since this time, staff have focussed on developing relationships with a wider group of funders. Staff use the customer relationship software Salesforce to help manage these relationships.[10]

Despite its reliance on private funders, Maytree has demonstrated its ability to raise sufficient funds to support its operations. According to Maytree's Report of Trustees for 2018, the centre operated at a surplus and has established a healthy operating reserve equivalent to approximately eight months of expenditure. It also has established a secondary reserve for potential replication of the initiative. Another indication of the feasibility of operations is the increase in the number of guests by over 20 percent in 2017/18.[11]

There is a strong weight of responsibility on Maytree's permanent staff to manage the charity's operations, particularly given the large number of volunteers within Maytree's human resource structure. The necessity to operate Maytree's house 24 hours a day, 7 days a week, places great emphasis on its ability to find and train sufficient numbers of volunteers. This model has proved sustainable, although one evaluation found that volunteers “could benefit from more extensive supervision and training”.[9] Maytree has demonstrated that it can recruit and train sufficient numbers of volunteers, with 79 completing the training in 2017/18.[11]

Maytree's attempts to replicate its model in other locations have been delayed by a shortage of funding. Director Natalie Howarth was employed in 2012 to open a second house in south London, “'But then the recession hit,' she says. ‘We had to make some very difficult decisions, and touch wood we're OK now, but we had to strip back to our original model.'”[8] According to Maytree's website, it hopes to open a second house in Manchester this year, and has already set aside funds for this purpose. In a recent newsletter, it announced plans to enter into a shared ownership model with a partner, MSV Housing Association, in order to reduce the financial risk of the proposed replication.[22]

Management

Maytree has demonstrated the ability to develop managerial capability and adapt its model in the financial of financial difficulties and uncertainty.

Since 2017, Maytree has established a management team with the full-time roles of director, service manager, outreach worker, finance and resource manager, and fundraising manager. The service manager works from the house, while other members of the management team work from an office at a separate location. Previously, Maytree's management team was limited to a director, senior coordinator and fundraising manager.[10] As Maytree's reputation grew, the increased demands on staff in areas such as outreach, marketing and communications drove the expansion of its management team.[10] According to Natalie Howarth, Maytree's current director, Maytree suffered financial problems in both 2011 and 2013, which she attributes to a gradual slide towards a less cost-effective, staff-led model.[10] In response to these difficulties, Maytree conducted a review of its model. This review led to a shift in the model back to greater involvement of volunteers in Maytree, which was in keeping with the original vision of its founders.[10]

Maytree's management team announced in 2019 that a qualitative review of Maytree's work, conducted jointly by the British Association for Counselling and Psychotherapy and Chester University, is about to start.[22] This evaluation will examine Maytree's service delivery, policies, procedures, structure, management and care model. The focus of Maytree's previous evaluations has been primarily on establishing that it has a robust model of care.[2][4][12]

Measurement

Maytree has a culture of openness to evaluation, and the organisation has demonstrated a willingness to partner with external institutes and universities to gather data on its effectiveness. Maytree has been evaluated by external researchers, using a variety of qualitative and quantitative methods. There are currently three external studies available which have assessed Maytree's impact. Researchers from the Tavistock Clinic led two studies, published in 2007 and 2012, while a researcher at the Department of Psychiatry at Imperial College London published a further study in 2017. The studies provide a detailed picture of the characteristics of guests, their backgrounds and history of mental illness, the method of referral, and previous contact with psychiatric agencies.

To assess the impact of Maytree, the 2007 study asked guests who had stayed at Maytree during a 5-month period to complete a Clinical Outcomes in Routine Evaluation test on their admission and when leaving Maytree. In addition, interviews were conducted at three months and six months after their stay, followed by qualitative and quantitative analyses of impact.[2] The 2012 study relied on guest case notes and semi-structured interviews of ex-guests.[4] The main limitation of these evaluations was their small sample size. The 2017 study analysed the impact of staying at Maytree using the guests' own assessment of their suicide risk at different points in time, including before and after their stay.[12] A qualitative review of Maytree's practices by researchers at Chester University was announced in 2019.

Maytree's management team provides a financial report, fundraising report and operational report to its Board of Trustees report each quarter as a means of internal evaluation. Its management details any risks and incidents and how management has responded to these risks.[10]

Alignment

Maytree's founders have adopted an operating model that ensures that stakeholders are well-aligned. This allows Maytree to implement its therapeutic approach according to the concept of befriending, without any need for compromise. The decision to fund Maytree through charitable and public donations, and preclude any financial involvement from the state, is an important feature of the model. It is likely that Maytree's founders prefer to be independent because psychiatric care and the use of medication to treat mental illness remain prominent in the public health system. Maytree has chosen to engage with mental health experts, and has previously appointed as trustees psychiatrists who are relatively sympathetic to its initiatives.[23] Where permitted, Maytree maintains contact with the guest's mental health team and will provide an escort for guests that wish to see their psychiatrist.[10] Maytree's main funders also appear to be in full support of its approach and objectives.

Maytree's staff and volunteers have a strong belief in the effectiveness of the therapeutic approach. Many of them have previously suffered from mental illness and relate personally to the effectiveness of such an approach.

There is potentially a conflict between Maytree's approach and any potential expansion of the model. Maytree has a culture that emphasises personal relationships. As such, there is a natural conflict with the adoption of corporatisation processes that may be required for replication of the model. Despite this, Maytree's current plans to develop a second site, and its recent expansion of staff numbers, suggest that it is growing its capability in this area.

Bibliography

[1] Why more men than women die by suicide, Helene Schumacher, 18 March 2019, BBC, http://www.bbc.com/future/story/20190313-why-more-men-kill-themselves-than-women, Accessed 28 August 2019

[2] Maytree: A Respite Center for the Suicidal, Stephen Briggs, Liz Webb, Jonathan Buhagiar and Gaby Braun, February 2007, Tavistock Clinic, London, UK, https://www.researchgate.net/profile/Stephen_Briggs/publication/5853631_Maytree_A_Respite_Center_for_the_Suicidal/links/582d9d8308ae102f072d70df/Maytree-A-Respite-Center-for-the-Suicidal.pdf, Accessed 9 August 2019

[3] About Maytree: We're open to suicidal feelings, 2019, Maytree, 

https://www.maytree.org.uk/were-open-suicidal-feelings-0#block-views-block-header-image-block-1, Accessed 9 August 2019

[4] GUESTS EXPERIENCES OF MAYTREE DURING AND AFTER THEIR STAY: Final Report, Stephen Briggs, Hannah Linford and Anna Harvey, 31 October 2012, University of East London and Tavistock Clinic, 

http://repository.tavistockandportman.ac.uk/1497/1/Briggs percent20- percent20Guests.pdf, Accessed 30 August 2019

[5] Inside Maytree: The Sanctuary That Has Prevented More Than One Thousand Suicides, 20 May 2016, Huffington Post, 

https://www.huffingtonpost.co.uk/entry/maytree-suicide-sanctuary-london_uk_573b2cace4b01359f687833f, Accessed 9 August 2019

[6] Mental health statistics: suicide, 2019, Mental Health Foundation, https://www.mentalhealth.org.uk/statistics/mental-health-statistics-suicide, Accessed 30 August 2019

[7] Suicide prevention: The contribution of psychoanalysis, Stephen Briggs, in Off the couch: Contemporary psychoanalytic applications, 2010, Taylor & Francis, London, pp. 46-66 http://repository.tavistockandportman.ac.uk/323/1/Briggs_Contribution_of_psychoanalysis_to_suicide.pdf, Accessed 28 August 2019

[8] Under the Maytree, Dara Mohammadi, June 2015, 

https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00244-8/fulltext, Accessed 9 August 2019

[9] The Maytree Approach - Suicide Prevention, June 2006, City Parochial Foundation, https://www.trustforlondon.org.uk/publications/maytree-approach-suicide-prevention/, Accessed 9 August 2019

[10] Interview with Natalie Howarth, Direct of Maytree respite centre, 9 September 2019

[11] Financial Statements for the year ended 30 September 2018, The Maytree Respite Centre, 

http://apps.charitycommission.gov.uk/Accounts/Ends68/0001087668_AC_20180930_E_C.PDF, Accessed 28 August 2019

[12] Characteristics and Outcomes of People Contacting and Staying at the Maytree, Dr Kirsten Barnicot, August 2017, Imperial College London

[13] Mental Health Taskforce, 2016, NHS England,

https://www.england.nhs.uk/mental-health/taskforce/, Accessed 28 August 2019

[14] News: Suicide prevention and reduction, 16 May 2018, NHS England,

https://www.england.nhs.uk/2018/05/suicide-prevention-and-reduction/, Accessed 28 August 2019

[15] Government unveils plans to 'tackle tragedy of suicide', Aubrey Allegretti and Alan McGuinness, 10 October 2018, Sky News

https://news.sky.com/story/government-unveils-plans-to-tackle-tragedy-of-suicide-11522391, Accessed 28 August 2018

[16] “What happened when I checked myself into the UK's only suicide sanctuary”, Rachel Barber, 2018, Stylist, 

https://www.stylist.co.uk/long-reads/suicide-uk-anxiety-depression-mental-health-the-maytree-suicide-sanctuary-therapy-anti-depressants-advice/226212, Accessed 28 August 2019

[17] From teaching suicide prevention to being on suicide watch, Pam Rutherford, 5 December 2015, BBC News, 

https://www.bbc.co.uk/news/health-34808355, Accessed 28 August 2019

[18] Guardian Christmas appeal 2006: Maytree - London, 2 December 2006, The Guardian, https://www.theguardian.com/uk/2006/dec/02/christmasappeal20062, Accessed 28 August 2019

[19] Interview with Michael Knight, Co-founder of Maytree respite centre, 10 September 2019

[20] Samaritans: What we do, Samaritans, 

https://www.samaritans.org/about-samaritans/our-organisation/what-we-do/, Accessed 28 August 2019

[21] Talking therapies, Mental Health Foundation, 

https://www.mentalhealth.org.uk/a-to-z/t/talking-therapies, Accessed 28 August 2019

[22] Maytree Newsletter Spring 2019, Maytree, 2019, https://www.maytree.org.uk/sites/default/files/Maytree_Summer_19.pdf, Accessed 28 August 2019

[23] About Maytree: Staff, Maytree

https://maytree.org.uk/about-maytree/trustees-and-patrons#block-views-block-header-image-block-1, Accessed 30 August 2019