Volunteering as a Meaningful Occupation in the Process of Recovery From Serious Mental Illness: A Qualitative Study

Abstract

Importance: Volunteering is an activity that facilitates social welfare, a sense of connection to others, and the construction of links with other people and the community.

Objective: To describe the experience of a group of people with serious mental illness (SMI) who engaged in community volunteer work.

Design: Qualitative, phenomenological study using purposeful sampling and an inductive thematic analysis.

Setting: Several mental health community centers in Madrid and Catalonia, Spain.

Participants: People with SMI engaged in community volunteer work.

Outcomes and Measures: In-depth interviews were used to collect data.

Results: Two themes, with four subthemes each, emerged from the data: (1) engaging in a meaningful occupation enhances the recovery process (subthemes: undergoing positive experiences, performing or resuming a meaningful occupation, living in the present moment, and relating with one’s social and family environment) and (2) a process of mutual support (subthemes: in helping others, you help yourself; helping others on the basis of one’s first-person experience; recover before you can help others; and role of professionals in volunteering).

Conclusions and Relevance: Volunteering is perceived as a meaningful occupation. Helping others generates a reciprocal benefit that favors the recovery process and contributes to the establishment of personal and social bonds.

What This Article Adds: This study provides a basis for understanding the potential of volunteering to be a meaningful occupation in the recovery process of people with SMI. It can help occupational therapy practitioners develop volunteer-based intervention programs that support the recovery process.

A qualitative, phenomenological study of people living with SMI in Spain highlights the potential of volunteering to be a meaningful occupation in the SMI recovery process.

Mental health is not merely the absence of a mental disorder; the term also implies that people who are mentally healthy can fulfill their potential, enjoy a meaningful life, and contribute to their community (World Health Organization [WHO] & Calouste Gulbenkian Foundation, 2014). Helping people with serious mental illness (SMI) involves applying strategies that encompass personal, social, structural, and community dimensions (Addington et al., 2017; Norman et al., 2017). People with SMI must also address the social stigma attached to mental health struggles, which limits opportunities for recovery (Thornicroft et al., 2016; Wang et al., 2018). Mental health paradigms are geared toward person-centered interventions (recovery model; Stuart et al., 2017) and the development of structural changes that create an inclusive society (citizenship; Ponce & Rowe, 2018). The act of volunteering facilitates social welfare, a sense of connection to others, and the construction of links with other people and the community (United Nations, 2018). However, research showing the positive effects of volunteering on people with SMI is limited (Held & Lee, 2020). To increase the knowledge base about recovery in people with SMI, we conducted a qualitative phenomenological study that examined their experiences with volunteering.

Method

Research Team

The research team consisted of four occupational therapists, one nurse researcher, and one physiotherapist. Four researchers had clinical and research experience with people with SMI, and four had experience in conducting qualitative studies in the fields of health sciences and mental health. None of the researchers had previous contact with any of the study participants. The theoretical framework used was the recovery paradigm, also known as the recovery model or recovery approach (Stuart et al., 2017), which conceptualizes the recovery of people with SMI as a dynamic process supporting the ability to (1) regain control over their lives and their own decisions (empowerment), (2) assign meaning to their lives, and (3) develop a new identity as opposed to the “mentally ill” identity. The goal is to help people with SMI face the future with hope while strengthening their connection to others (Stuart et al., 2017).

Participants and Sampling Strategies

We selected the participants using purposeful sampling, not clinical representativeness (Creswell & Poth, 2018), because the former was more relevant to our research question, “What is the lived experience of people with SMI who perform volunteering?” Sampling continued until redundant information from the data analysis was achieved (Creswell & Poth, 2018). We reached this point after the inclusion of 23 participants. There were no dropouts. The six selection criteria were (1) age 18 to 65 yr with an SMI (diagnosis of nonorganic psychotic disorder [F20.x, F21, F22, F24, F25, F28, F29, F31.x, F32.3 and F33, according to the International Classification of Diseases, 10th Revision [WHO, 2016]); (2) ≥2 yr since the onset of the SMI; (3) a moderate to severe level of dysfunction of global functioning (score ≤70 on the Global Assessment of Functioning Scale; Ruggeri et al., 2000); (4) participation in a volunteer program that complied with the regulations for volunteering activities in Spain (Spanish Official Government, 2015); (5) ability to maintain all legal rights and autonomy; and (6) willingness and capability to sign the informed consent document. The three exclusion criteria were (1) age <18 yr, (2) acute psychopathological imbalance, and (3) diagnosis with a disorder that affects language or understanding. Local community public mental health services facilities were contacted for participant recruitment, and once approval had been obtained from the centers and the university ethics committee, the participants were contacted.

Data Collection

Data were collected between September 2016 and April 2017. The first stage of data collection consisted of unstructured interviews (Participants 1–11), using the following open-ended question: “What is the experience of volunteering like for you?” The second stage consisted of semistructured interviews (Participants 12–23) based on a question guide (Table 1), to obtain information regarding specific topics of interest (Creswell & Poth, 2018).

Table 1.

Semistructured Interview Guide

Research Area	Questions
Volunteer process	How is the experience of volunteering for you? How do you feel when you volunteer? What are your motivations for volunteering? and for doing this type of volunteering in particular? What does volunteering do for you?
Recovery process and sense of life	How does volunteering influence your daily life? How does volunteering influence your mental health? Is volunteering a goal to reach when one is recovered, a way to recover, or both? How does volunteering influence the meaning you give to your life?
Concentration, being in the present moment	When you are doing volunteering, are you focused on what you are doing in the present moment, or are you thinking of other things, or distracted? How is this for you?
Social and interpersonal relationships	How is your relationship with the recipients of the volunteering? How is your relationship with other volunteers? How has volunteering influenced your relationship with others, such as your family?
Role of professionals and the organization	What is the role of health professionals in your volunteer activity, and/or what have health professionals done to support your volunteer activity?

The question guide was developed on the basis of participants’ accounts of their experiences volunteering. Twenty-three researcher field notes also were collected. Twenty-three interviews were conducted and audio recorded; the average duration of interviews was 66 min for the unstructured interviews and 61 min for the semistructured interviews.

Data Analysis and Rigor

Each interview and corresponding researcher field notes were transcribed verbatim. The texts were collated to allow for qualitative analysis (Creswell & Poth, 2018). An inductive thematic analysis was performed (Braun & Clarke, 2006). This process began with the most descriptive content to obtain the meaningful units and then went into further detail and data reduction to produce thematic code groups (i.e., by grouping meaningful units that referred to the same aspect or content until the main topics emerged). Thus, the level of abstraction and complexity of the analysis increased from meaningful units to thematic code groups and, finally, themes (Braun & Clarke, 2006). The final outcome was the identification of themes that represented the participants’ experiences of volunteering. The themes were obtained on the basis of the participants’ narratives by means of a process of coding and analysis. Each researcher subsequently listed the emerging themes and negotiated confluent and diverging issues. Finally, in the event of differences of opinion, theme identification was decided by a consensus.

No software was used to conduct a qualitative analysis of the data. The APA Publications and Communications Board Task Force on Journal Article Reporting Standards for Qualitative Research (Levitt et al., 2018) and the Consolidated Criteria for Reporting Qualitative Research (Tong et al., 2007) guidelines were followed. Moreover, we used criteria put forth by Lincoln and Guba (1985) to establish the trustworthiness of the data by reviewing issues concerning data credibility, transferability, dependability, and confirmability. The following techniques were used: triangulation of data collection instruments and researcher triangulation during the analysis, participant validation, a comprehensive description of the study, records of the reflexivity process during the study, tree coding on the basis of narratives to the final themes, and an external audit.

Results

Participant Characteristics

Twenty-three people with SMI (16 men and 7 women) from the Autonomous Communities of Madrid and Catalonia, Spain, participated in this study. Participants’ illness had a mean duration of 18 yr (SD = 9.2) since diagnosis, and their mean age was 47 yr (SD = 8.2). The remaining sociodemographic data are shown in Table 2.

Table 2.

Participants’ Demographic and Clinical Characteristics

Participant No.	Age, yr	Sex	Marital Status	Living Situation	Level of Education	Work and Social Situation	Duration of Volunteering	Frequency	Type of Volunteering	Diagnosis	Yr Since Diagnosis
1	42	M	Single	Mother	Professional training	APD	1 yr, 3 mo	1 day/wk	Food delivery	F20.0, paranoid schizophrenia	7
2	52	F	Single	Alone	Professional training	APD	5 yr	1 day/wk	Care for older adults	F20.5, residual schizophrenia	31
3	43	M	Single	Parents	Primary school	APD	3 yr	1 day/wk	PSPSMI; guitar teacher	F20.0, paranoid schizophrenia	8
4	43	M	Single	Parents and brother	Primary school	APD	3 yr	1 day/wk	Chess teacher	F25, schizoaffective disorder	20
5	36	M	Single	Parents and grandmother	Primary school	APD	3 yr, 2 mo	1 day/wk	Volunteering with animals	F20.0, paranoid schizophrenia	12
6	56	F	Single	Mother and brother	University	APD	1 yr, 2 mo	1 day/wk	Care for older adults	F20.0, paranoid schizophrenia	34
7	46	F	Single	Sister	Primary school	APD	4 yr, 2 mo	1 day/wk	Care for older adults	F20.6, simple schizophrenia	29
8	44	M	Single	Parents	Primary school	APD	2 yr	1 day/wk	Chess teacher	F20.0, paranoid schizophrenia	15
9	51	F	Single	Parents and brother	Primary school	APD	5 yr	1 day/wk	Care for older adults	F31, bipolar disorder	24
10	63	M	Divorced	Alone	University	APD	4 yr	1 day/wk	PSPSMI, social activities	F33, recurrent depressive disorder	30
11	54	M	Single	Parents	High school	APD	2 yr	1 day/wk	Volunteering with animals	F20.0, paranoid schizophrenia	36
12	62	M	Single	Hospital unit	Professional training	TPD	1 yr, 4 mo	5 day/wk	PSPSMI, artistic activities	F20.0, paranoid schizophrenia	16
13	30	M	Single	Brothers	High school	APD	5 mo	1 day/wk	Soccer coach	F20.9, unspecified schizophrenia	11
14	40	F	Single	Hospital unit	Professional training	APD	9 mo	1 day/wk	PSPSMI; aerobics teacher	F20.0, paranoid schizophrenia	24
15	46	M	Single	Alone	Professional training	APD	2 yr, 4 mo	2 day/wk	PSPSMI; urban garden	F31, bipolar disorder	18
16	47	F	Separated	Sons	Primary school	APD	4 yr	1 day/wk	PSPSMI; flamenco teacher	F31, bipolar disorder	10
17	47	M	Single	Parents	Professional training	APD	4 mo	2 day/wk	Library assistant	F20.9, unspecified schizophrenia	11
18	48	M	Single	Parents	High school	APD	4 mo	2 day/wk	Library assistant	F20.0, paranoid schizophrenia	13
19	39	M	Single	Father, partner, and son’s partner	Professional training	APD	7 yr	2 day/wk	Soccer coach	F20.0, paranoid schizophrenia	13
20	37	M	Married	Wife and sons	Professional training	APD	5 mo	3 day/wk	PSPSMI	F28, other psychotic disorder	2
21	59	F	Married	Husband and sons	University	TPD	1 yr, 3 mo	1 day/wk	Volunteering with animals	F25, schizoaffective disorder	20
22	48	M	Single	CMHR	Primary school	APD	1 yr, 6 mo	1 day/wk	Volunteering with animals	F20.5, residual schizophrenia	15
23	48	M	Single	CMHR	Professional training	APD	2 yr, 6 mo	1 day/wk	Volunteering with animals	F20.0, paranoid schizophrenia	13

Note. Diagnosis and diagnosis codes are from the International Classification of Diseases, 10th Revision (World Health Organization, 2016). APD = absolute permanent disability for all jobs; CMHR = community mental health residence; F = female; M = male; PSPSMI = peer support for people with serious mental illness; TPD = total permanent disability for usual profession.

Thematic Analysis

Two specific themes, each with four subthemes, emerged: (1) engaging in a meaningful occupation enhances the recovery process (subthemes: undergoing positive experiences, performing or resuming a meaningful occupation, living in the present moment, and relating with one’s social and family environment) and (2) a process of mutual support (subthemes: in helping others, you help yourself; helping others on the basis of one’s first-person experience; recover before you can help others; and role of professionals in volunteering).

Theme: Engaging in a Meaningful Occupation Enhances the Recovery Process

All participants described volunteering with a sense of satisfaction, indicating that they experienced it as a highly meaningful occupation for their recovery.

Subtheme: Undergoing positive experiences

All participants described positive experiences such as happiness, joy, and enthusiasm. In addition, they felt relaxed and at peace and perceived themselves as being stronger to face life. Volunteering was experienced as a tool to keep moving forward, giving meaning to their lives, and helping them to feel fulfilled as people: “You face life with greater courage, joy, and satisfaction. You feel free, [like] a positive person; you feel better because when you no longer feel ill, you feel like you have wings” (Participant [P]11). “It helps me feel stronger in [my ability] to fight the disease. Volunteering is an important part of my life” (P20).

Subtheme: Performing or resuming a meaningful occupation

Volunteer work is selected on the basis of individual interests (music, dance, computers, care of animals) and is a means to regain meaningful occupations. The participants experienced the satisfaction of resuming an occupation that had played an important role in their lives, which they could then share and use to help others: “The only thing I know how to do is music; it is what I spend the most time doing, and being able to offer it to someone who is eager to learn is great. I like it a lot” (P3). “For me, volunteering in flamenco is giving me something to live for. Being able to dance again is like being reborn; it’s like a new beginning” (P16).

Subtheme: Living in the present moment

Participants related the importance of being focused on the present moment during volunteering. This counteracted uncomfortable feelings, stress, and anxiety as well as recurring thoughts about the illness: “You’re stuck in your head, you don’t quite understand what you’re thinking, you’re isolated, and volunteering thwarts the isolation. When I am in the present moment, I feel very good” (P2). “When you are busy, you don’t think about the past or the future; you think about the present. To think about the present is to move forward with everything that needs to be done” (P18).

Some participants described how being focused on volunteering decreased psychotic symptoms during their performance: “Over there, I don’t have hallucinations; I am focused on work. If I am doing something, I am not thinking about the illness or strange things; I am focused on what I am doing” (P23).

Volunteering is real, because it’s an activity that you know is happening, you’re not imagining it . . . there is no anxiety, no bad thoughts, no worrying about voices. That is what volunteering is, knowing that you are in the truth. (P6)

Subtheme: Relating with one’s social and family environment

All participants described how volunteering had helped them relate with others and share their experiences with fellow volunteers. During their illness they lived in isolation; interacting with other people made them feel connected to their social environment: “When you volunteer, you meet people, you talk to them, you ask questions; it makes you open up” (P10). It even improved their family relationships:

It’s been good for me to socialize again. I’ve been locked up at home for 15 years, and the volunteering has made it easier for me to get back in touch with society. You start communicating with people again, making friends . . . you have [a] family that supports you, and you feel good. You notice the improvement in your relationship with others, with your family. (P20)

Theme: A Process of Mutual Support

All participants acknowledged that volunteering had a positive effect on both sides. They described their recovery, and the support of professionals, as factors necessary to their capability to help others.

Subtheme: In helping others, you help yourself

Participants noted that helping others also helped themselves. Some moments, like providing affection, experiencing joy, or teaching something to others, deliver mutual gains: “The help you provide comes back to you, dignifies you as a person, and enriches you in all aspects of life” (P10). “While I teach, they teach me, too” (P13).

Subtheme: Helping others on the basis of one’s first-person experience

Participants who volunteered by supporting other people with mental illnesses reported how satisfying it was to help others with the same condition; it was easier for them to help, accompany, and advise people on the basis of their own experience. They became a model to follow: “Everyone sees me as a reference because I help others, and they see me as the big brother. I give them good advice; I tell them what to do and what not to do” (P20).

I identify with them, I see them and I know what happens to them, I understand them. There are times when they have gone through a rough spell, their medication has been increased, and I can tell. I don’t know whether a teacher who hasn’t experienced this would be able to actually understand it. (P3)

Subtheme: Recover before you can help others

After the participants had been stabilized for a while, starting to volunteer became a goal to reach. Once a person had traveled part of the way through the recovery process, volunteering offered the chance to prove they had the ability to help others: “You have to be a little stable. You can’t do this when you start with the disease; it’s impossible. But we have been given a path” (P4).

Volunteering is like a master’s degree, where you go to help and show that you are already available. You have achieved your goals and now you try to devote part of yourself to others—that’s what volunteering is for me. (P10)

Subtheme: Role of professionals in volunteering

The “professionals” in this subtheme are those who proposed volunteering and encouraged the participants to try it. Participants said they relied on professionals to determine when to start volunteering:

The professionals enabled us to participate in a very beautiful project. When I was offered [the opportunity] to volunteer, I didn’t see that I had the skills to volunteer. [The professionals] have been on the ball with everything and have been able to give us wise advice. (P4)

Discussion

Participants in this study described volunteering as a meaningful occupation that helped their recovery from SMI. Previous studies (Kaite et al., 2015; Stuart et al., 2017) have shown that meaningful occupations are essential to the recovery process. Volunteering has been identified as a valuable occupation in the treatment of SMI (Gunnarsson & Eklund, 2017; Thomas et al., 2020). Other reports have shown that people with SMI who engaged in volunteer work scored higher on measures of personal growth, indicating improvement in their mental well-being (Cabezas Sánchez et al., 2016), and obtained a better perception of their overall health (Held & Lee, 2020). Conversely, volunteering may also generate feelings of vulnerability, stress, or discrimination or a fear of being stigmatized (Farrell & Bryant, 2009; Read & Rickwood, 2009).

Our results coincide with those of Ørjasæter et al. (2018), who described how people with SMI who participate in other meaningful occupations (music and theater) live in the present moment, thus helping them avoid recurring thoughts, anxiety, and stress. Ørjasæter et al. reported that people with SMI often lose control of their lives over the years; however, engaging in meaningful occupations creates a “free zone” that is unfettered by negative thoughts. Concentrating on an activity in the absence of negative thoughts can be conceptualized as the person entering into a “flow” experience, which is characterized by intense concentration on a task at a particular time, when the person becomes absorbed in the activity and pays no attention to external events or conditions (Nakamura & Csikzentmihalyi, 2014).

Participants in this study created new bonds, developed friendships, and decreased their sense of isolation. Previous studies have reported that connectedness with others is a key element in the recovery process (Leamy et al., 2011; Stuart et al., 2017). In addition, volunteering is a tool for maintaining a social network for people who experience social isolation (Tabassum et al., 2016), helping people with SMI interact with others, and giving them a sense of belonging to the community (Jun & Choi, 2020).

Our results also demonstrate how volunteering is experienced as offering a mutual benefit. The reciprocity inherent to interpersonal relationships, whereby there is an opportunity to give and receive help, is beneficial to people with SMI (Terry & Townley, 2019) because it allows them to establish relationships between people (Myers et al., 2016) and find meaning (Stuart et al., 2017).

Some of our participants supported and taught different activities to other people with SMI, which they experienced as being very fulfilling. Previous studies have shown that people with psychiatric disorders can accompany and help others on the basis of their own experience through peer support (Chien et al., 2019) and have demonstrated that peer support is a key element during recovery (Stuart et al., 2017). In addition, people who accompany and guide others through peer support experience a reduction in self-stigma, thus helping them increase their sense of usefulness, acquire greater competence, and gain the opportunity to feel normal and experience a transformation of their identity (Watson, 2019).

Our participants told us that to begin volunteering, they had to be at an advanced and stable stage in their recovery process. The evolution of people with SMI during recovery is a personal journey that involves stages such as regaining control of their lives and being able to help others (Stuart et al., 2017), the absence of symptoms, and the ability to commit to the volunteer work (Bejerholm & Areberg, 2014). Lloyd et al. (2017) described how recovery is related to having a productive life; feeling independent, effective, and that one has a vital purpose; and being able to assume responsibility.

In this study, the professionals had offered our participants the possibility of volunteering and had served as a source of support and supervision as they volunteered. Previous studies have identified professional support as an essential part of the recovery process (Oborn et al., 2019; Stuart et al., 2017). Clinicians need to empower people with SMIs and help them recognize the resources at their disposal for developing their full potential instead of focusing on the losses associated with the disorder (Pańczak & Pietkiewicz, 2016).

Limitations

This study is not without limitations. First, the method we used does not allow for generalization of our findings to other populations and settings. However, we believe that it enabled us to delve into a poorly known aspect of the recovery process of people with SMI. Also, the inclusion criteria did not include the length of time the participants had been engaging in volunteer work.

Implications for Occupational Therapy Practice

The results of our study have the following implications for occupational therapy practice:

This study provides a basis for understanding the potential of volunteering as a meaningful occupation in the recovery process for people with SMI.

These findings may help occupational therapy practitioners consider the use of meaningful occupations for people with SMI as a way to gain empowerment and help others.

Our results may broaden occupational therapy practitioners’ knowledge of volunteerism, contributing to its implementation in community mental health services.

Conclusion

People with SMI experienced volunteering as a meaningful occupation that enhanced their recovery process and allowed them to gain a sense of connection with other people and the community at large. In addition, participants who supported others with SMI became role models. A possible future course of action would be for mental health service professionals to work with groups and organizations that allow people with SMI to volunteer. Future lines of research should further explore the perspectives of people with SMI who volunteer and should consider the different areas of volunteer services (e.g., animal care, peer support, teaching activities).

Footnotes

Acknowledgments

We are grateful to the participants for their cooperation and to the entities that collaborated in the study: Fundación El Buen Samaritano (http://fundacionbuensamaritano.es/), Grupo Exter S.A. (https://www.grupoexter.eu/), Instituto de Neuropsiquiatría y Adicciones del Parc de Salut Mar (https://www.parcdesalutmar.cat/es/), and Hermanas Hospitalarias ().

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