The therapeutic power of volunteering

Summary

There is growing evidence from smaller evaluative studies in the USA and anecdotal papers in the UK that supported volunteering can help recovery and can be a pathway into paid work for people with serious and fluctuating mental health conditions. It allows the person to take risks and test out a working environment. This opportunity can integrate their experience of mental illness into a valued identity and provides opportunities to engage with a world of work. We recommend that mental health professionals consider ways of providing volunteering opportunities as part of a recovery-oriented service within their organisations.

LEARNING OBJECTIVES

1. Appreciate the benefits patients gain from volunteering.

2. Understand the principles of a supported volunteering scheme.

3. Appreciate the potential value to the patient of volunteering within health and social care settings.

It is well documented that people with mental health conditions experience high levels of unemployment as well as disadvantage and discrimination associated with their illness. Depression, for example, can affect a person’s social position and financial circumstances (Butterworth 2009). Various factors have been identified that contribute to the difficulties that people with mental health problems face in finding and keeping employment in the UK. These include the low expectations of healthcare professionals and a poorly developed vocational rehabilitation service (Rinaldi 2008). People also face structural barriers (such as potential loss of welfare benefits), stigma and stress in the workplace and fear of disclosure of mental ill health to employers (Bevan 2013).

Changes to the welfare system require individuals to be actively looking for paid work. This is a concern for those who do not feel ready or able to engage in open employment. The risk and anxiety associated with a move away from benefits should not be underestimated. Paid open employment can lead to an initial financial loss. Discrimination against employees with mental health conditions can mean that access to paid employment is restricted and so individuals continue to be marginalised and excluded.

A decade ago, the government’s Social Exclusion Unit (2004) reported that only 24% of people with long-term mental health problems in England were in employment. However, more recently Marwaha et al (2007) reported employment rates in the UK of 12.9% for this client group compared with 71.0% for the general population. A 2008 survey by the Healthcare Commission established that only 22% of people using specialist mental health services were in paid work or full-time education. Berthoud (2009) studied the impact of the current recession on patterns of unemployment of people who report themselves as having a ‘limiting longstanding illness’. This definition does not detail the exact nature (physical or mental) or severity of impairments and Berthoud (2009) believes that it exaggerates estimates of the number of disabled people in the working-age population and underestimates the extent of their disadvantage in the labour market. In 2011, 1.18 million people were in contact with secondary mental health services. It was estimated that 136 000 of these would need support to find and keep some form of work (Borton 2011).

Establishing a work role

Work is important for social inclusion and has health benefits (Waddell 2007). The opportunity to work allows individuals to socialise, contribute, and retain an identity and role that complements and balances other social roles. Involvement in meaningful work, whether paid or not, has been recognised not just on the basis of economics: it also has social benefits, including raised social status and better use of time (Wilkinson 2005; Wilcock 2006). Rinaldi et al (2008) explored the evidence base for interventions that have been aimed at supporting people back into work, although volunteering as a pathway was not acknowledged.

Individual placement and support

Current research credits individual placement and support (IPS) as the best model to help psychiatric patients who feel they are ready for paid employment (Crowther 2001; Rinaldi 2008; Kinoshita 2013). A European randomised controlled trial demonstrated that IPS was successful at getting 55% of people back into open employment (Burns 2008). This is a great improvement in the employment prospects of people with mental health problems, but for many a meaningful work role still remains elusive. A substantial number of people with severe and enduring mental health conditions remain excluded from any mainstream paid work and are unable to fulfil a socially valued role linked to work activities. For these individuals, alternative approaches such as volunteering are worth considering.

Volunteering as an alternative

There have been very few rigorous research studies on the outcome of volunteering, but the occupational therapy literature has a number of peer-reviewed papers that address volunteering as a meaningful and productive occupation and explore the value of volunteering for people with severe and enduring mental health conditions (Young 2007; Farrell 2009). Research suggests that volunteering can be a meaningful occupation for some, enabling them to participate in the social life of their communities (Rebeiro 1998; Clark 2003) and having a self-reported positive effect on their mental health. There is still a significant gap in current research concerning the potential effect volunteering may have on employment prospects for those with mental health problems. However, an evaluation of the Volunteering for Stronger Communities programme (Bashir 2013) targeted those disadvantaged in the labour market, including people with mental health problems and others who are marginalised. The evaluation found that the programme resulted in positive changes in the health and well-being of the volunteers and reported that 22% were helped into paid work, 69% were actively seeking employment and 80% now felt more confident about finding paid employment.

The social and cultural implications of mental ill health, including unemployment and worklessness, mean that individuals may be excluded from activities that provide meaning and purpose. Finding meaning and appropriate challenge from work is as important for those who volunteer as it is for those who are in paid work (Leufstadius 2009). Worthwhile social and economic contributions can be made by people outside paid employment, in a volunteer role or as unpaid carers (Holmes 2007). There is a need for other substantial studies to add weight to the many smaller evaluative studies and anecdotal papers on this topic.

What is volunteering?

Defining volunteering is not without its challenges. It has been viewed as a mutually beneficial exchange, as social participation and as unpaid but productive work.

Mutually beneficial exchange

Formal volunteering is ‘an activity that involves spending time, unpaid, doing something that aims to benefit the environment or individuals or groups’ (Zimmeck 2009: p. 3). The notion that volunteering is essentially altruistic is not universal (Ellis 2010). It has been noted that there can be a mutually beneficial exchange relationship and that volunteering ‘provides benefits to the individual, be it enjoyment, skills, or the sense of having given something back’ (Institute for Volunteering Research 2004: p. 25).

Social participation

Historically, volunteering has rarely been conceptualised as a field in isolation. More often it is taken from the perspective of a broader phenomenon such as work, leisure or participation (Ellis 2010). The concept of volunteering as participation underpins the current government’s policies that support volunteering, seeing it as an overtly prosocial activity. Volunteering is a way of getting more people involved and engaged with their community, allowing them to participate in projects that are meaningful for them. Theories of social participation, social capital and political engagement support these ideas.

Hill (2009) and Bashir et al (2013) provide evidence that volunteering can lead to an increased sense of belonging and involvement for individuals excluded from other social spheres. It can be a form of positive social engagement. However, there is evidence that volunteering can also replicate exclusionary features that can be found in the workplace.

Unpaid but productive work

Volunteering can also be viewed through the lens of work (Rochester 2010) that people do for free for the benefit of a community (Stebbins 2004). They work alongside paid employees, but without the latter’s contractual obligations (Restall 2005). Conceptually, volunteering can substitute for, compensate or complement paid work (Rochester 2010). This has several implications, not least that motivations are extrinsically motivated (Ryan 2000), that is they may be driven by a reward (such as praise or pleasing someone else) or they may be self-endorsed because the activity has an accepted value, for example as a way of using time more productively.

Musick & Wilson (2008) suggest that when volunteering is viewed not as a gift but as unpaid labour, the emphasis in terms of motivation shifts to an act of productivity. The role and nature of motivation is questioned empirically rather than being a defining principle of volunteering. Volunteering is one of a number of productive behaviours that an individual may or may not pursue, depending on the context. Context is particularly relevant to patients whose motivation is to find employment.

Viewing volunteering primarily as a productive activity focuses attention on the value of that productivity and on strategies to increase it. This has had the advantage of increasing the focus on volunteer management, but it can reduce the value of volunteering purely to productivity and output, ignoring its wider holistic benefits. It has been argued that the place of volunteering in society has rarely been more prominent and the weight of expectation about the contribution it can make to an individual’s development, to social cohesion and to addressing social needs has never been greater (Rochester 2010).

Volunteering and mental health

Schon et al (2009) propose that people with serious mental health conditions can be active agents in shaping and choosing occupational opportunities to maintain and enhance their health. A British survey of volunteers with mental ill health reported that ‘formal’ volunteering can protect role identity and psychological well-being (National Centre for Volunteering 2003). Studies conducted in the USA (Musick 2003) highlight the benefits of volunteering based on long-standing sociological arguments that social integration and subjective well-being are linked. Volunteering may also add roles and promote social ties (Musick 1999; Pancer 1999). Furthermore, volunteering is thought to provide altruistic and egotistic motivations.

Black & Living (2004) reported benefits to mental health and well-being of volunteers, which translated into improved social functioning. Volunteering has also been shown to have a beneficial effect on depression in people over 65 years of age (Li 2005). Benefits of volunteering are also experienced differently and at different times across the lifespan (Musick 2003).

Despite growing interest in the effect of volunteering on mental health, Howlett’s (2004) literature review found that most studies relating to the topic came from the USA. He noted the ‘remarkable’ paucity of research from the UK and the difficulty of identifying UK experts in this field.

Volunteering as a testing ground for work

Self-stigma, whereby people judge themselves negatively, can affect recovery from mental illness as well as confidence to take part in mainstream social interactions (Perlick 2001). These judgements can be related to societal norms of mental illness and the baggage that comes with them. The individual’s self-esteem and self-efficacy are decreased and impeded. The opportunity to do voluntary work can challenge this stigma, allowing the volunteers to experience feelings of value and self-worth and recognise the skills they either once had or want to develop (Holmes 2007). It is an opportunity to bring skills and experience to volunteering and this can replace a lost role (Omoto 2000). Conceptually, volunteering can substitute for, compensate or complement paid work (Rochester 2010).

Blank & Hayward (2009) propose that it is possible to assist an individual’s recovery journey by using a broader definition of employment that encompasses volunteering and stressing that volunteering can be a meaningful, occupationally focused goal. It is by developing a sense of self through doing that people with mental health problems can begin to develop the capacity to consider a possible future as a worker. However, McGilloway & Donnelly (2000) were cautious about the advantages of volunteering as a way of supporting people back into work. They felt that volunteering can become a ‘substitute for work’ and therefore have negative long-term effects on motivation. However, they had no evidence to substantiate this. Musick & Wilson (2008) point out that volunteering as unpaid labour can shift motivation to engage in more productive use of time.

For an unemployed person receiving welfare benefits related to mental illness, volunteering can feel like a less financially risky opportunity to engage in a work environment that nevertheless places demands and responsibilities on them (Fegan 2012). It allows them to practise self-management of their fluctuating symptoms, to recognise how these affect them at work and how they can cope in a work environment. Volunteering therefore provides a testing ground for work. It provides opportunities for exposure to and negotiation of new relationships. It also gives evidence of work experience to put in a curriculum vitae (CV) and it provides the opportunity to demonstrate work skills that can inform a reference for paid work based on performance in a real-world work context (Box 1).

BOX 1 Volunteering as a preparation for paid employment

Sam is in his late 20s. Despite a severe and enduring mental illness and a number of hospital admissions, he completed a degree. He did not feel able to look for paid work at that time, but he was motivated to volunteer by a close relative who thought that it would help him to fill the days. Despite persistent low mood and anxiety, Sam has maintained a regular and consistent link with volunteering. He has volunteered for a number of mental health-related agencies and has received feedback about his skills and attributes, which helps to validate who he is.

During his time as a volunteer, Sam has been able to help train mental health staff and this enhances his CV. Sam has recognised that volunteering provides personal meaning and an opportunity to develop relationships – he has been able to identify with other patients he has met, which he has found to be beneficial. He feels that his role as someone who has experienced personal difficulties can be a positive thing for others to see. Volunteering has provided structure and routine to his week. His fluctuating symptoms continue to challenge him, but he has never wavered in taking responsibility as a volunteer. Sam’s longer-term goal is to study to work in the health and social care sector. Volunteering is giving him the experience to pursue this goal.

Work is an important yardstick of recovery (Shepherd 1989) and should not be deterred by the low expectations of mental health professionals who hold to a model of illness that emphasises symptoms (Lauber 2006). The skills and abilities of patients are often underestimated and volunteering may provide a less risky re-entering or exposure to a work environment.

Volunteering as an aid to recovery

It has been suggested that volunteering can be an agent for recovery involving a journey towards a new and valued sense of identity, role and purpose (Lloyd 2007). Mancini (2007) suggests that transformation is at the heart of the recovery process. The patient moves from an illness-dominated identity to one where the self is valued, has competence and strengths. Finding that one has ‘something to give’ is central to building positive self-esteem. Developing a sense of identity beyond illness is key to recovery (Gewurtz 2007) and this can be achieved through opportunities to work, as well as through engagement in other meaningful and socially valued roles. In becoming a ‘volunteer’, patients are able to see beyond a label that reflects a psychiatric diagnosis to one that suggests someone who contributes and is socially valued. The self-concept of volunteers is also enhanced through interactions with coworkers (Michalos 2010). When identities and roles have been constructed and connected to being in hospital, to diagnosis and to risk, then volunteering allows some rebalance of those identities and a new, more socially valued role is adopted.

Slade (2012) asserted that the idea of promoting citizenship among individuals in recovery ‘has been the least investigated and yet is the most influential’. Improving social inclusion and community integration requires professionals to pay more attention to supporting the person to make connections. Having responsibility appears to be a central component to the recovery process. Self-determination and self-direction are the foundations for recovery as individuals define their own life goals and optimise their independence and autonomy by leading, controlling and exercising choice, including vocational aspirations.

Supported volunteering schemes within mental health services

Supported volunteering refers to schemes where the volunteer receives additional support to carry out their volunteering roles (e.g. Volunteering England, www.volunteering.org.uk/component/gpb/supported-volunteering) (Box 2). A number of mental health trusts in England have already established integrated employment services within their organisations and there is a commitment to supporting patients to access work or volunteering. Examples include Sheffield Health and Social Care NHS Foundation Trust’s User Support & Employment Service (www.shsc.nhs.uk/working_for_the_trust/service_user_employment) (which we discuss below) and South West London and St George’s Mental Health NHS Trust’s User Employment Programme (www.swlstg-tr.nhs.uk/work-for-us/service_user_employment_programme).

BOX 2 Principles of a supported volunteering service

1. • A dedicated coordinator, ideally an ‘expert by experience’ who is leading by example

2. • Volunteering is part of the individual’s vocational goal

3. • Standard employment processes are used (e.g. application process, human resources, Disclosure and Barring Service processes)

4. • A dedicated mentor in the workplace with time for supervision

5. • An honorary agreement is drawn up which outlines expectations of the volunteer’s role, conduct, confidentiality, sickness absence and handling grievances, as for any paid worker

6. • Access to appropriate training relevant to the role and also standard induction into the organisation

7. • Regular review and appraisal with the volunteer to ensure progress

Supported volunteer placements within a mental health service can be very varied, for instance in a clerical department, an arts project, on a ward as an advocate or in training other patients or staff. Supported volunteering should provide an appropriate challenge to the volunteer and, as voluntary work can be graded, the individual can be exposed to increasingly challenging tasks and responsibilities that will support self-efficacy and growth in confidence. Rebeiro & Polgar (1999) argue that, for any occupation to be meaningful, certain factors need to be at the right level to provide the optimal conditions for the individual to benefit. These include choice, control, stress, boredom, challenge and skill. These factors therefore require consideration when matching an individual to a volunteering opportunity.

The Sheffield User Support and Employment Service

Sheffield Health and Social Care NHS Foundation Trust’s User Volunteer Service uses the locally developed WORKS framework to help patients into employment and maintain support once in work (Cassinello 2012). This recognises that volunteering within the trust can be a helpful pathway. The framework focuses and builds on three elements:

1. • getting started

2. • keeping going

3. • moving forward and growing.

Individuals who would like to work but do not feel ready to look for employment in the open market can join the programme. They receive a contract that outlines clearly the work they will be doing. Each volunteer has a mentor who is a member of staff. Both are supported by the trust’s User Support & Employment Service. The current coordinator of the scheme is an ‘expert by experience’. In the paper by Cassinello & Bramley (2012) it is demonstrated how the WORKS framework was used to support someone to become a mental health worker following an episode of significant mental illness. The paper shows how a patient can travel along a pathway from volunteering into paid work.

Volunteers as experts by experience

Peer support as a reciprocal relationship can offer encouragement and hope (Davidson 2006). Hope is central to recovery and if an individual can see how others are moving forward as a result of the support they get to be active and take control over their lives then that too can inspire hope. Patients working as volunteers in health and social care settings bring a unique perspective. The experience of mental illness and the ‘expertise’ it affords opens up new options in the world of work, for example as a peer support worker, support, time and recovery (STR) worker or healthcare assistant. The option to volunteer allows these motivations to be tested out first.

Moran et al (2014) used self-determination theory to examine the intrinsic and extrinsic motivation of peer support workers. They found that their extrinsic motivation for the role was to do something different from previous work experiences. Their intrinsic motivation included the freedom to disclose and use personal experience to help others.

Some of the benefits of supported volunteering are listed in Box 3.

BOX 3 Benefits of supported volunteering for patients

1. • A bridge to participation (Hill 2009)

2. • Provides personally meaningful occupation that has purpose, challenge and pacing (Black 2004; Leufstadius 2009)

3. • Provides a socially valued role and a new identity (Michalos 2010)

4. • Provides stepping stones to work and other opportunities (Fegan 2012)

5. • Enables the volunteer to take positive risks related to a worker role (Lauber 2006)

6. • Validates new skills (Black 2004)

7. • Integrates mental health experience in a positive way (Mancini 2007)

8. • Enhances and provides opportunities for hope-inspiring relationships (Perkins 2006)

Implications for the professions working with patient volunteers

Recovery from mental illness is a social process (Schon 2009) in which the quality of social relationships plays a key role. Volunteering in a mental health organisation offers an opportunity to be exposed to and develop new relationships beyond that of the patient–professional and this process can be empowering. In any work environment we learn to manage and negotiate relationships with a range of people. For a volunteer, the opportunity to be a co-worker with mental health professionals can reduce power or paternalistic relationships. The concept of recovery goes beyond the individual and for it to be effective, professionals need to be sensitive and ‘not take over’. Roberts & Wolfson (2004) suggest that professionals should offer their skill and knowledge, but they also need to learn from and value the patient, who is an expert by experience.

When individuals volunteer in a mental health service that is familiar to them, the power in relationships can be shared and clinicians are ‘on tap’, not ‘on top’ (Repper 2003; Shepherd 2008). This helps individuals move through the transition from patient to volunteer. Borg & Kristiansen (2004) identified key relationship skills required of health professionals working alongside patients, including empathy, caring, acceptance, mutual affirmation, encouragement of responsible risk-taking, and a positive expectation for the future. Perkins (2006) also identified ‘hope inspiring relationships’ at the heart of her prescription for recovery-oriented practice.

Implications for services that provide a supported volunteering scheme

There are a number of benefits to a recovery-focused mental health service that provides a volunteer scheme (Fegan 2012). Much can be gained from the instillation of hope, role modelling and exposure to alternative world-views that patients who volunteer can provide. There are gains for both professionals and other patients by the very presence of volunteers in the mental health workforce. Benefits specific to other patients are that volunteers can help them navigate through an often frightening and complex system, and provide an ‘expertise’ that they can learn from and identify with. In these ways, volunteers complement the roles of health and social care professionals.

A service that values patient volunteers alongside those in paid positions will promote a culture focused on recovery. It can help change mindsets by focusing on what people can do and achieve rather than on their symptoms. Our research revealed that supported volunteering can enhance the individual’s recovery because it encourages them to take positive risks, is a stepping stone to work-focused activity and gives them a valued identity that integrates their mental health experience (Fegan 2012). Volunteers experienced recognition of their achievement and a new sense of hope as they emerged as workers. Mental health services are in a unique position to build partnerships with patients to support their recovery and journeys towards employment by providing opportunities for volunteering.

Challenges to supported volunteering in mental health organisations

There is some controversy about whether it benefits individuals to volunteer within health and social care services, including the service they have been attending. There is evidence to suggest that patients prefer to volunteer in a service sensitive to their mental health needs (National Centre for Volunteering 2003) and that there is a barrier to progression from this to other volunteering opportunities owing to perceived discrimination and stigmatisation (Yanos 2001). Thus, patients can be ‘ghettoised’ into like-minded organisations and then find it difficult to move out of them (Farrell 2009), so that volunteering is no longer a stepping stone to other things.

Mundle et al (2012), in a literature review on volunteering in health and care settings in England, found evidence that volunteers can become demotivated if: they cannot meet other patients’ expectations; opportunities for volunteering are of poor quality; or they experience ‘burnout’. Problems also arise when there is a lack of clarity among professionals about the role of the volunteer (Cook 2011). In services where the workforce is often stretched there may be a danger that volunteers are used to plug a gap in service provision. Hotchkiss et al (2009) say it is important to recognise the financial value of volunteers and suggest avoiding the potential for exploitation by monitoring the number of hours they provide. Volunteering should not take the place of paid workers or provide cover for what should be a paid professional role (Buckingham 2012). However, where volunteering is offered and is supported, then the volunteer workforce is able to reach its full potential.

It is important to view volunteering in mental health organisations as part of a broader vocational experience. Volunteers should be able to apply for paid posts in mental health services – or indeed in any field – in the expectation that their mental health history and experience will be positively viewed by prospective employers. The current economic downturn may prove even more challenging for vocational rehabilitation interventions including individual placement and support. Perkins et al (2009) talk about time-limited internships and time-limited voluntary work. Such opportunities are particularly important when there is limited open and competitive paid work.

Although this article has put forward a view that is in favour of supported volunteering, it has not focused on the financial costs of setting up such a service or the objective vocational outcomes that it would be expected to provide. Obviously, adequate resources are required to maintain the support networks needed in supported volunteering.

Conclusions

Mental illness can have a disruptive and even catastrophic impact on an individual’s life course. It can dislocate their sense of who they are and how others perceive them. Rebuilding personal and social identities is integral to recovery. There is strong evidence to suggest that people who experience mental health difficulties are subject to widespread social stigmatisation, particularly with respect to employment. Interventions that rely solely on an outcome of paid employment can exclude many patients. However, a personally meaningful occupation such as volunteering can offer a pathway to recovery for all, and to paid employment for a good many. More importantly, volunteering provides opportunities for individual journeys of recovery that bring a sense of fulfilment and meaning from a socially valued, work-related role.

MCQs

Select the single best option for each question stem

1. 1 Volunteering in health and social care:

   1. a should be an alternative to paid work for some patients

   2. b should be supported and have a clearly defined role

   3. c is better than paid work

   4. d should be available for as long as it is needed

   5. e should be supported by in-patient units only.

2. 2 Supported volunteering:

   1. a leads to a conflict of roles

   2. b provides financial gains for an organization

   3. c provides meaningful occupation

   4. d helps mental health professionals

   5. e is less stressful than paid work.

3. 3 An important feature of recovery-promoting relationships is:

   1. a clear boundaries

   2. b paternalism

   3. c confidentiality

   4. d professionals ‘on tap’ not ‘on top’

   5. e role reversal.

4. 4 Supported volunteering schemes:

   1. a always provide altruistic activity

   2. b offer a way to participate with charities

   3. c provide an alternative vocational pathway

   4. d are available for everyone who wants to join one

   5. e should be separate from individual placement and support.

5. 5 Factors that can affect the success of any occupation and can benefit well-being include:

   1. a repetitive work

   2. b the individual’s diagnosis

   3. c the individual’s medication

   4. d the environment

   5. e the level of challenge.

MCQ answers

1

b

2

c

3

d

4

c

5

e