The Use of Volunteers to Promote Community Integration for Persons with Serious Mental Illness

Introduction
Social isolation is one of the greatest problems that people with a severe mental illness (SMI) encounter. Individuals with SMI have great difficulty building and sustaining social networks and are likely to have limited social networks (Brown, 1996). Isolation, poor social functioning and poor quality of life are among the consequences experienced by those with SMI (Oliver et al., 1996). This group of people frequently has no friends, spouse, nor family with whom they are in contact. Although mental health service providers are committed to providing quality services to consumers with SMI, most consumers are frustrated and struggle with problems related to inadequate resources and a service system that does not always facilitate their recovery.

Prompted by the recognition that natural social networks for individuals with SMI are limited (Jablensky et al., 2000) and that traditional service delivery is deficient in providing appropriate support and social services (Senate of Canada, 2004), interest in volunteer programs has increased considerably during the past decade. Volunteers from the community can play a significant role in working with individuals with SMI. Evidence suggests that they are particularly cost-effective as they can supplement and extend the work of mental health professionals through individualized support for consumers and/or resource development. (Canadian Centre for Philanthropy, 2004)

The purpose of this article is to present the findings of an evaluation of a newly implemented volunteer program for persons with a serious mental illness, The Quality of Life Program, which was developed at the Douglas Hospital; a university affiliated psychiatric hospital in southwest Montreal, Canada. The Quality of Life Program was designed to operate within a network of 150 supervised residential settings (foster homes) which served over 800 persons with serious mental illness. Seventy percent of the resident population had a diagnosis of schizophrenia and their ages ranged from twenty to eighty with the average age being in the mid-forties. Length of stay in the foster home network ranged from 2 months to over 20 years with the average being 5 to 7 years.

Context
Emerging evidence suggests that social support is associated with greater life satisfaction, recovery from chronic mental illness, and enhanced ability to cope with life difficulties (Rogers et al., 2004). Previous studies on social interaction among individuals with SMI reveal that consumers demonstrate poorer social adjustment, fewer social skills, less elaborated social networks, poorer overall social competence (Mueser et al., 1990; Mueser et al., 1991; and Bellack et al., 1990) and increased social withdrawal. These difficulties often force persons with SMI into small, traditional social groupings which fail to provide the feedback necessary to build self-esteem and self-confidence (Hjorten, 1982).

In order to improve social interactions and support for persons with serious mental illness, volunteer networks may be created and mobilized to provide intervention services. Increasingly volunteers are playing an important function alongside paid labour. Despite the recognition that most public institutions involve volunteer programs and that volunteers can significantly contribute by enhancing the quality of programs (Hall et al., 2001) little is known about the impact of these volunteer programs on individuals with SMI.

Through contact with consumers, volunteers can acquire first-hand knowledge about the challenges and barriers facing individuals with SMI. They are also in a position to identify and build upon the individual’s strengths, while promoting independence. Ultimately volunteers can assist consumers in their process of recovery and provide hope for a better quality of life as consumers learn how to help themselves.

Program Description
Implemented in 2003, the goal of the Quality of Life Program was to facilitate the integration of foster home residents into the community by promoting the development of their social skills, interpersonal interactions and physical and mental health, through activities and outings with volunteers. The primary focus of the program was the development of a relationship between the resident and the volunteer with the expectation that residents would participate in decision making and improve their self-confidence. Fundamental to the program was the belief that by becoming involved in meaningful social, cultural and recreational activities, foster home residents would develop new skills and experience less isolation.

Priority was given to those residents who were not enrolled in any day or vocational programs. This targeted population included those residents who, after many years of SMI had lost most social skills and suffered the effects of diminished social interaction and had an impoverished quality of life. In many cases the residents did not venture from the home by themselves, were not able (or refused) to attend day programs, had no involved family or friends, and had little opportunity to meet others. A full time coordinator recruited, trained and supervised volunteers. At the time of the study there were 45 volunteers involved in the program.

Purpose of the Evaluation
The purpose of the evaluation was to determine to what extent the program met its stated goals and objectives, as well as to identify which aspects of the program should be maintained or discontinued. An Advisory Committee composed of mental health consumers, service providers, foster home caregivers, and family members oversaw the evaluation.

Sample
The sampling frame for this study involved two stakeholder groups: (1) individuals with serious mental illness residing in the foster home network and participating in the program and (2) program volunteers. Participants were randomly selected among 96 residents and 45 volunteers involved in the program

Research assistants contacted residents and volunteers by telephone to explain the evaluation objectives and the nature and extent of their participation. Participation was voluntary. In the case where a resident or volunteer refused or was unable to participate, another participant was randomly selected until the sample size of 30 residents, and seven volunteers was attained. In all, 12 residents refused to participate and 15 volunteers were unavailable to attend a focus group. Typical reasons for not participating included: previous commitments, and finding it difficult to get to the hospital site during the winter.

Seventeen (57%) women and thirteen (43%) men participated in the study. Language shows the exact same distribution with 17 residents coming from an English speaking background, and 13 from a French speaking background. Four male and three female volunteers participated.

Research Instruments
Two questionnaires were administered: 1) The Resident Interview Questionnaire adapted from Taylor & Botschner (1998) and (2) The Focus Group Interview Guide. The Resident Interview Questionnaire consists of 53 items (27 close-ended and 26 open-ended) reflecting satisfaction with program objectives, including the following dimensions: 1) Relationships developed between volunteers and peers (19 items); 2) Skills learned (3 items); 3) Knowledge of services and participation in community activities (2 items); 4) Program activities (8 items); 5) Loneliness, isolation, and autonomy (7 items); 6) Quality of life (6 items); 7) General perceptions and suggested improvements (8 items). The questionnaire was administered in person by a research assistant and was approximately 30 minutes in duration.

The volunteer’s perspective was elicited through a focus-group lasting two hours. Seven volunteers, randomly selected, participated. The researcher and research assistant conducted the focus-group. The focus group interview guide consists of 16 open-ended items and was designed to address common topics and specific issues as they arose. Dimensions explored included: 1) Relationships developed between volunteers and peers (1 item); 2) Skills learned (1 item); 3) Knowledge of services and participation in community activities (1 item); 4) Program activities (1 item); 5) Loneliness, isolation, and autonomy (2 items); 6) Quality of life (1 item); 7) General perceptions and suggested improvements (9 items).

Data Analysis
Completed questionnaires were returned to the research assistant for coding, data entry and analysis, using the Statistical Package for Social Sciences (SPSS 11.5 for Windows). The focus group was audio recorded and transcribed verbatim. Content analysis methods (Krippendorf, 2004) were used to analyse the data emerging from the focus group. Major themes were identified and findings were presented formally to volunteers, consumers and foster caregivers for validation.

Results

The relationship between residents and volunteers
The relationship between residents and volunteers was an important evaluation dimension. Nearly all respondents indicated that the program enabled friendships to develop between residents and volunteers. The majority of residents (86.7%) indicated that they were very or extremely happy with the volunteer assigned to them, and 28 (93.33%) stated that they became friends with their volunteer. They also felt that volunteers were good listeners (96.7%), and trustworthy (86.7%) and most residents (more than 73 %) rated volunteers as being very or extremely friendly, supportive and respectful.

General comments elicited from residents about the relationship with their volunteer included: “She believes in me, I feel more comfortable with her”; “I feel good about having a volunteer, it makes me look forward to the outing”; “She is a friend”; “She is made for me, responds to my needs, my ideologies, has good values, is funny, a good listener, and straight forward”.

Volunteers also reported a positive relationship with residents. Two stated that although residents never contacted them at the beginning of the relationship they now have developed the confidence, trust and comfort to do so. One volunteer who works with a resident with a short-term memory deficit indicated that while the person with whom she is paired does not remember most people, she remembers her.

Skills learned
Over half (56.67%) the residents stated that they had learned new skills since becoming involved with their volunteer. Specific comments highlighted the uniqueness of the skills learned eg.: “I have learned to speak more, I communicate more”; “I learned to participate in a group”; “I learned to like sports”; “Cooking”.

Volunteers also identified a number of skills that the residents learned. These included: repairing a television, reading, doing puzzles, writing, crafts and painting, and a resident teaching the volunteer a foreign language.

Knowledge of services and participation in community activities
Only 3 residents (10%) were more knowledgeable about community services since meeting with their volunteer, and 11 (33%) viewed themselves as being more involved in their community. Volunteers offered a different perspective on this issue. They stated that the program encouraged participation in community activities. Activities cited included: driving the resident to various places, going to church, the shopping mall and restaurants, and playing pool. One volunteer specified that while her role allows her to act as a liaison between the community and the individual, the resident was not yet ready to participate.

Program activities
Close to half the residents indicated that they had a role in determining what they did with volunteers and a majority (83.3%) stated that they always enjoyed the activities. One resident stated “My volunteer never forced me to do things, she presents a situation and if I don’t want to we choose something else”. Another resident stated “My volunteer is a fun person, tries to please us, and she makes us choose what we want to do and where we want to go.”

Almost three quarters of the residents (73.3%) stated that they did activities that they had never done before. The most common type of activities described included in-house leisure activities, such as socializing, listening to music, exercising, playing cards and board games, and learning how to cook. Many residents referred to various outings such as visiting seniors, going to a restaurant, museums, shopping, and fishing.

Over half the volunteers described implementing a number of new “in-house” activities, which were the same as those mentioned by the residents. Twelve (40.0%) residents reported doing sports, such as a team sport, or walking, dancing, running, and cycling with their volunteers. Ten of these residents (83.3%) said that they felt healthier since doing sports and/or physical activities and seven (58.3%) stated that doing a sport with their volunteers had encouraged them to do it on their own. Typical benefits described included: “I have a better appetite, more energy” “I am more active, energetic and alert.”

Loneliness, isolation, and autonomy
Most residents confirmed that the program was successful in reducing their feelings of loneliness and isolation. Typical statements included: “I can talk more easily to people; communicate better what I mean to say”; “The presence of someone helps me and encourages me to do things outside”; “I was too isolated before, it wasn’t good”; “Because I know there is going to be someone who puts life into me, they make me forget about my illness.”

Most volunteers identified ways in which the program reduced the sense of isolation among residents. Emerging themes included: improved communication, residents talking more, increasing personal disclosure, and reaching out to the volunteers when needed. One volunteer indicated that the resident has begun to understand that she is not excluded from society and that there are numerous opportunities to socialize.

Fifty percent (50%) of the residents indicated that since having a volunteer they now go out on their own. Volunteers who observed autonomous behaviours noted changes such as residents going shopping and for walks on their own, residents taking more personal decisions, increased assertiveness, and being more capable of expressing personal needs.

Quality of life
Twenty-six (86.7%) residents indicated that they were happier since becoming involved with a volunteer. Their comments included : “The thought of being with a volunteer gives me positive thoughts about myself; I have a more positive attitude”; “Because when she is there I am happy, but when she is not I feel sad”; “I am not as lonely, more satisfied”, “I am happier, I know someone”.

Volunteers were also asked to identify successes they experienced with the residents and several comments relating to quality of life emerged. These included: residents being more hopeful, trustful, confident, assertive and caring. Others stated that residents went out more often on their own. One proudly stated that the resident had better self-esteem, was now more capable of making choices and taking control over certain aspects of her life.

General perceptions and suggested improvements
Ninety percent of the residents thought that the program was worthwhile. Although most (80.0%) would encourage other residents to have a volunteer five stated that it would depend on the individual. Typical comments about the program included: “It increases the strength to go on in life, to go ahead”; “Makes you come out of your shell, brings everybody together”; “It is truly worthwhile, it provides new training”, “It makes me active, I examine what my volunteer does; gives me a good example of what I have to do to be happy”, “It’s a good achievement it helps people, it makes them happier.”

Most residents (67.0%) noticed changes in themselves since their involvement with a volunteer. For the most part, additional comments related to increased sociability: “Helps me to socialize with the other residents”; “I am more outgoing”; “I understand people around me better”; “As a person, I can relate to people more effectively”; “I am friendlier around people I live with, my volunteer gives me good tips on how to react. I am open to do more outings, I have blossomed.” Other comments related to having a friend, being happier, less anxious, more autonomous, and feeling less isolated and lonely.

Volunteers consistently observed changes in residents and described them as: being more open, being a better person, having more confidence, being in a better state of mind, being more comfortable socially, being more assertive and determined, and going out more often to visit friends on their own.

Volunteers also identified the need for more support for themselves. Suggestions included more supervision, input and feedback from program staff, mutual support among volunteers such as talking over the phone, and a regular support group where ideas could be exchanged. Some suggested that formal training and/or workshops would be very helpful in clarifying their role within the program and helping them to be more effective. Topics suggested included how to communicate with their residents and how to empower them.

Discussion
The majority of respondents confirmed that the program was successful in providing the opportunity for foster home residents to participate in social, cultural and recreational activities both in and outside the foster home. Volunteers have made a positive contribution to the residents’ quality of life. Findings revealed that volunteers have enhanced the well-being of residents in a multi-faceted way; by helping to regain their self-confidence and emotional balance, by enhancing their existing skills, and increasing their optimism. Volunteers have successfully provided a high level of support to a vulnerable group thus helping them alleviate some of the loneliness, isolation and life difficulties experienced by the majority of residents.

Evaluation results indicated that residents had no difficulty socializing with their volunteers. In fact, the majority of respondents reported that residents and volunteers had developed a positive relationship. Results also indicated that the program was successful in reducing feelings of loneliness and isolation and both residents and volunteers identified greater self sufficiency and autonomy among the residents. Residents and caregivers were “very” or “extremely” satisfied with the volunteers, and most volunteers felt that they had a good relationship with their residents and respective caregivers.

The program was also successful in exposing residents to new activities. Those involved in physical activities reported feeling healthier and were encouraged to exercise on their own. Most residents reported being happier and experiencing positive changes in themselves since their involvement with the program. Ultimately, residents and volunteers all agreed that the program contributed to the improved quality of life of the residents.

The evaluation also indicated that there were some challenges to overcome. Results demonstrated that while most residents “always” enjoyed activities with their volunteer, only about half were involved in choosing their activities. This was consistent with the issue raised by volunteers where they questioned whether they should “stimulate” the residents regardless of their desire to remain “ inactive” and stay at home.

Another issue which emerged from the evaluation was the socialization and involvement of residents in the community. The majority of respondents indicated that residents did not make new friends or meet new people besides their volunteer. In addition, respondents indicated that residents were not more knowledgeable or involved in their community. This was consistent with the statements of many volunteers who explained that despite considerable effort they had not yet succeeded in doing more outings with their residents.

Conclusion
The evaluation determined that the program met most of its stated goals and objectives. Although the program is still relatively new it was decided to maintain its original objectives but place more emphasis on community integration and socialization of this population. Developing a trusting relationship with a volunteer is an important first step in integrating foster home residents into the community.

Several limitations to this evaluation should be noted. First, residents were not asked their age nor their specific diagnosis. This missing information could partially explain the reasons for fewer reported outings and a limited exposure to the wider community. This may also explain why some residents were hesitant to socialize or be involved in the community. In order to measure the specific outcomes, such as getting out of the house, meeting new people and becoming involved in the community, a longer term evaluation is required.

The evaluation has demonstrated that volunteers can be extremely useful in helping persons with an SMI to broaden their social network, to develop new skills and become more involved in a variety of activities both at home and in the community. It also showed that based on their experiences with volunteers, residents can learn to become more independent. The concept of using volunteers as partners in the provision of services to persons with an SMI should be considered when developing programs for this population.