Growing and sewing the seeds of the Tree of Life project at UCLH

In 2017 we discussed the development of Tree of Life groups for young people with type 1 diabetes (Casdagli et al, 2017). The Tree of Life is a 1-day group session based on narrative therapy principles that enables young people to tell their stories in ways that make them feel stronger (Portnoy et al, 2016). In this comment, we will share and reflect on our experiences of growing the Tree of Life project and the ‘seeds that have been sewn’ since 2017. 

Background and qualitative data
The group, which we adapted for young people living with type 1 diabetes, has a number of objectives, see Box 1. In summary, attendees are invited to draw a tree and use different branches to represent different aspects of their life. Young people are interviewed by facilitators about their trees and encouraged to share stories of their lives through the use of narrative questions with the intention of strengthening their preferred identity stories (White, 1995). The young people in the group are invited to ‘witness’ each other’s stories and share what they were struck by or connected with, again reinforcing their preferred identity (White, 2000). Young people then ‘plant’ their trees in a ‘forest’, creating sense of community and connection, and a ‘safe place to stand’ (Ncube, 2006). The group collectively think about the ‘storms of life’ (challenges) facing young people generally and the additional storms that living with diabetes can bring. The group members are encouraged to reflect on how they have responded to these storms with strength. Certificates are created detailing the young people’s strengths, skills and important people. These certificates are presented in a ‘ceremony’ that their parents, families and medical team are invited to attend, creating a further opportunity to strengthen the preferred identify story and spread the news.

Qualitative data highlight how the Tree of Life groups have helped young people to:

• Develop positive views of themselves.
• Connect with others
• Respond to negative attitudes about diabetes
• Improve diabetes management

Attendees on average rated enjoyment of the day at 9.56 out of 10. They rated the likelihood of recommending a friend take part in a group at 9.16, and the usefulness of sharing of experiences at 9.19.

How the project has grown
A total of 122 young people with diabetes aged 8–19 years have attended 23 Tree of Life groups since 2014. All attendees are invited to come back to train as ‘peer trainers’ who help facilitate the groups, in addition to supporting the UCLH team at conferences and other events (Casdagli et al, 2017). We run a peer training event annually and 34 young people have been trained to date. 

In the past 3 years we have expanded the event to include a half-day activity that all peer trainers are invited to, with the intention of creating a sense of community and connection. These activities have included an art therapist helping participants to create a group ‘Tree of Life’ representing what the group means to them and their hopes for its future, see Figure 1. 

In 2018 the peer trainers created a video about the groups in collaboration with the organisation DigiBete. This video will soon be posted on the UCLH Paediatric Diabetes and Digibete websites. Our peer trainers have reported the positive benefits of feeling like they have helped others and growing confidence. A fuller description of the experience of peer trainers is in currently being prepared. 

Sewing seeds
Training
Since 2014 we have run training events for professionals on delivering the Tree of Life groups for young people living with type 1 diabetes and other health conditions. In response to demand for the training, we now run two events in London each year and at least one external training session. We have run events in Liverpool, Glasgow and Dublin and hope to take the approach to Switzerland later this year. Over 150 multidisciplinary professionals have attended 11 training days, which introduce the principles of narrative theory that underpin the project alongside experiential learning of the four aspects of delivering the Tree of Life programme. The main objectives are that professionals will: 

• Have a clear understanding of narrative principles
• Have the confidence and skills to run a Tree of Life group in their service.

The impact of the training workshop has been positive. A recent survey found that 50% of respondents had run between one and seven Tree of Life groups in their services, with positive results. A third of professionals running groups had also used peer trainers and reported that they ‘put young people at ease, encouraged them to share experiences and added to the power of the day’. A further quarter had adapted the training and used the Tree of Life individually with clients, which had helped the young people ‘separate diabetes from their identity’.

New branches
Principles from the Tree of Life have been used in the development of our transition to secondary school programme for young people with diabetes. The Getting Ready for Transition (GReaT) programme includes a summer group where young people create ‘school bags of life’ where they think about the different skills, resources, values, important people and hopes that they will be taking to secondary school with them (Christie et al, 2017). The GReaT programme was highly commended in the 2018 Quality in Care in diabetes awards.

Our narrative training workshops also offer the opportunity to learn more about the Beads of Life or ‘just Bead It’ approach (Portnoy et al, 2016), which is based upon the same narrative therapy principles. While this group was originally developed to support young people living with cancer, we have found it a very useful approach in our work with young people with diabetes. Colleagues have also adapted the Tree of Life protocol to include self-compassion and mindfulness exercises for young people with chronic fatigue syndrome and chronic pain.

Reflections and hopes for the future
Reflecting on the growth of the Tree of Life project over the past 2 years leaves us excited for its future. With each group run, our commitment and passion for the approach are re-ignited. Our peer trainers are an incredible group of young people and we hope to be able to continue collaborating with them to grow our community. 

Recruitment and resources for groups remains a challenge, and we often hear about the struggles diabetes teams are facing in getting new groups up and running. We too have tried to find ways to navigate some of these challenges, such as recruiting online and via email, and we hope our new video will help us to reach more young people. We have found that the biggest facilitator for the growth of the project has been the commitment of the whole UCLH paediatric diabetes service, who passionately encourage young people to give it a try, particularly since experiencing the project at our team away day. 

Our next hopes for growth are to create a group for parents and to think about how the ideas might improve the transition to adult services. We also plan to consider how we might reach more young men and how we can support young people living with type 2 diabetes.