Comparing the views of mental health professionals and volunteers on volunteering in mental health care in the UK

Voluntary schemes can serve to address reduced social functioning experienced by people with mental illness. However, the views of the key stakeholders in such provision remains under-researched. This article aimed to compare the views of mental health professionals and volunteers on volunteering in mental health care in the UK through a qualitative study analysing the data of six focus groups with n = 27 participants using thematic analysis. Six overarching themes were identified: (i) An act of friendship but not a true friendship, (ii) Addressing a social agenda, (iii) Structure and responsibility of volunteering schemes, (iv) Challenges of volunteering (v) Role of technology in volunteering and (vi) Impact on wider mental health care. Whilst various commonalities were identified, nuances in participants views suggest stakeholders may place differing levels of importance on the volunteering framework. Volunteering as a social intervention for people with mental illness was deemed to hold significant importance in wider mental health care. The divergent views expressed between stakeholders can be attributed to their own direct experiences with patients in practice and suggests there is a need for flexibility in the design and delivery of voluntary programmes.


Introduction
Volunteering has been defined as an unpaid activity undertaken out of free will for the benefit of others [1,2].Within mental health care, there are varying models of volunteering programmes including befriending, and unpaid peer support [3], all aiming to support patients in building social connections and engage with their communities [4,5].The exact nature of these relationships can vary, ranging from more structured interactions to friendships [6].
Mental health professionals and volunteers represent two key stakeholders in the provision of voluntary support.Professionals are well-positioned to identify recovery needs, make recommendations, and refer their patients to voluntary programmes.The volunteers themselves play a central role in the delivery of these programmes [7].Previous research on volunteering has often focused on the motivations and characteristics of volunteers [8][9][10] while investigating the 2 Methods

Study design
A secondary qualitative analysis of a subset of data derived from an international focus group study exploring the perspectives of two key stakeholders (i.e., mental health professionals and volunteers) on volunteering in mental health [7].Separate focus groups for each stakeholder group were conducted between March 2017 and September 2017 in London, which was the focus of this current investigation.

Study participants
For the London sample, mental health staff were recruited from the East London NHS Foundation Trust (ELFT), a mental health trust.Volunteers were recruited from healthcare organisations, non-governmental organisations and volunteering and community associations across the UK.Information about the study was disseminated via emails to ELFT staff and volunteering organisations; snowball sampling was used, allowing recipients to share the information with their contacts.All focus groups took place at various locations part of the NHS Trust, facilitated by the primary researcher and a co-facilitator.Each lasted between 60 and 90 min and followed a topic guide comprising four overarching questions that explored the purpose of volunteers in the volunteering schemes, the character of the relationships between volunteers and people with mental disorders, the potential for the use of technology and the benefits and challenges.Focus groups were audio recorded and transcribed verbatim.

Data analysis
The research team for this secondary qualitative analysis comprised two researchers (PA, a female MSc student in clinical psychology and MPC, a female clinical academic psychiatrist).MPC was the main researcher and lead facilitator of the focus groups in the primary study.Data analysis for this study was conducted by PA and MPC.
Reflexive thematic analysis was conducted following Braun and Clarke [18,19] six phase guidelines, employing a mixed deductive and inductive approach.All transcripts, along with the coding frameworks, were uploaded onto NVivo qualitative analysis software, V.12.Initial coding was guided but not confined to, the preliminary coding frameworks, and throughout this process additions and adjustments were made.Subsequently, codes from both stakeholder groups were integrated into a distinct framework to initiate a comparative analysis of thematic commonalities and differences.From this point, the iterative process of revisiting coding, searching, reviewing, and defining themes was undertaken.Themes were then organised into main themes and subthemes, so that each theme was clearly defined and that there was coherence within each theme.Illustrative quotes were identified and compiled for all subthemes to support analytical claims.

Ethical approval
This study received ethical approval from the Queen Mary University of London (Reference number: QMREC1665a) and written informed consent was obtained from all participating prior to the start of the group's discussions.

An act of friendship but not a true friendship
Across all focus groups, discussions revolved around the exact nature of the volunteering relationship, with debates arising over whether these relationships could be likened to friendships or whether the presence of a volunteering scheme introduced an element of professionalism (Table 2).Overall, both volunteers and mental health professionals indicated that the relationship falls somewhere in between.Volunteers are present to offer patients social support, but it cannot be considered a true friendship due to the artificial nature through which these connections are established.
"…it is prescribed if you like, or it is contracted and so it cannot be a…it can't be a naturally forming relationshipbecause it's a contractive relationship…" (Mental Health Professional Focus Group 1, Participant 2) "I mean, it says 'befriending' but it doesn't mean that we are bosom friends; you know, I have my own life as well."As volunteers are not practitioners, the relationship does not need to explicitly address the patients' disorders or symptoms, as reflected in the subtheme "without a therapeutic agenda", denoting a more informal relationship.
Views diverged when discussing boundaries.Professionals emphasised the need to establish a clear definition of the volunteer's role, ensuring volunteers are aware of their limitations, and setting realistic expectations for patients.In contrast, volunteers conveyed a more flexible perspective on boundaries, perceiving that each individual relationship required a unique approach to navigating these boundaries.

"I think it's important to have boundaries even in those roles and relationships. And I think it's important to have the boundaries for both and understanding of the role and the expectations of the befriender." (Mental Health Professional Focus Group 1, Participant 2) "it's the boundaries and management of those boundaries; what you see as the boundaries, but what the charity thinks the boundaries are can be different and it's you need to work that out yourself for the good of your friendship." (Volunteer Focus Group 2, Participant 4)
Professionals also underlined the role of organisational schemes in mediating these relationships, as these schemes facilitate initial contact and ensure safeguarding.Conversely, volunteers attributed greater significance to the quality of the relationship built with their patients.Professionals felt that the focus of the relationship should be addressing the individual needs of the patient.Whilst volunteers shared similar sentiments, highlighting the importance of a personcentred approach, they also expressed that a degree of reciprocity was necessary for volunteering to be meaningful.

Addressing a social agenda
The role of the volunteer was perceived as providing social support in various ways (Table 3).Both groups mentioned the sense of normality that volunteers can bring to patients by engaging with them on a human level, rather than focusing on their 'patient' status.Empowering and giving motivation were also deemed important facets of the relationship.It was discussed how patients often lack the drive or competencies to address their own social needs, thus making volunteers valuable facilitators in forming and maintaining social connections.Views diverged, however, on how to achieve this.Mental health professionals focused more on the practical aspects, such as participating in social activities together, accompanying the patient outside the home, and offering advice and guidance.Volunteers emphasised their role in providing companionship and emotional support to the patients.
"…social inclusion, supporting people, fighting against isolation, promoting engagement or general physical health even, just having a walk or doing something together."(Mental Health Professional Focus Group 4, Participant 1) "I think it is important, just as a friend would listen to another friend, it is important I believe for a befriender to be able to listen to their concerns."(Volunteer Focus Group 1, Participant 2)

Structure and responsibilities of volunteering schemes
The structure and responsibilities of volunteering schemes were thoroughly discussed (Table 4).There was consensus regarding the recruitment of volunteers, with recognition that selecting the 'right volunteers' is crucial.What qualified as a 'right volunteer' generally revolved around personal attributes such as patience, empathy and personability.There were suggestions of explicit exclusion criteria and the incorporation of an interviewing process.Matching was also deemed a vital responsibility which in practice may involve a certain degree of trial and error as both gauge their compatibility.Having selection packs in place was suggested as a means to facilitate this.
Safeguarding responsibilities were also emphasised.Recommendations included implementing processes like DBS checks to help identify potentially risky volunteers, risk assessments for patients were deemed necessary to protect volunteers.Various participants suggested volunteer supervision, acknowledging that volunteering can sometimes be challenging and emphasising the need for a supportive system in place to support them.

"you need a clear line of sort of a supervision arrangement, so that there's someone they can go to if there is a problem, you know to discuss how to deal with it and that kind of thing." (Mental Health Professional Focus Group 4, Participant 2) "of course they're giving up their time and you wouldn't want it to be too heavy on themselves; I know at times during my befriending where I did feel like it was a bit too much." (Volunteer Focus Group 2, Participant 3)
In terms of the relationship's duration, while it was acknowledged that many voluntary schemes implement time limits, participants expressed the view that such limits might be arbitrary and there could potentially be room for the relationship to continue if both parties wish.
Both professionals and volunteers mentioned the need for training; however, there was a difference in the extent to which this training should be provided.Professionals mainly discussed the need for initial basic training, while volunteers focused on aspects like the rules, regulations, and some mental health awareness training.Volunteers felt that training should be ongoing, such as refresher training to boost confidence and uphold standards, or personal development opportunities to acquire new knowledge and skills.

Challenges of volunteering
While there was a generally positive attitude towards the potential of voluntary schemes, both professionals and volunteers mentioned the challenges that may arise, particularly within the relationship itself ( Regarding differences, professionals expressed concern about the risk of volunteers crossing boundaries due to their lack of skill sets needed to effectively apply them in practice.On the other hand, volunteers were more focused on the potential risk of patients becoming overly dependent on them.Professionals also discussed the potential impact volunteers might have on their practice, expressing concerns that volunteers could undermine their previous work with patients, either by causing patients to question treatment or interacting with the patient in a way that could be counteractive to their recovery.Some volunteers discussed feeling conflicted between their obligation to safeguard patients by breaking confidentiality when necessary and their desire to maintain trust within the relationship.Some professionals also mentioned the potential risk of relying too heavily on volunteers, which might involve delegating tasks and responsibilities that could strain the volunteers.Conversely, volunteers highlighted that they sometimes felt schemes placed excessive responsibility on them, including tasks like filling out case notes and having access to system emails, often without sufficient support in place. "I think it's very easy to say oh they've got a volunteer that they see every week.And we give the volunteer responsibilities that's not theirs; that they are volunteers, they're not support workers -that we don't dictate to a volunteer, a befriender, that they will take our service user to a group every week -because that's not the role."(Mental Health Professional Focus Group 1, Participant 2) "I almost felt like I had too much responsibility, because I had to be given like a system email, I had to write reports about every meeting that I had with him."(Volunteer Focus Group 2, Participant 3)

Role of technology in volunteering
Overall, technology was identified as being a useful tool to incorporate into the delivery of voluntary schemes (Table 6).It can serve to initiate and maintain contact, allowing patients and volunteers to keep each other updated between inperson meetings.It was also felt that it would serve the benefit of accommodating varying patient needs and also reach more isolated groups, particularly in locations which are underserved.There were however also limitations identified.Primarily, many participants felt it defeated the purpose of providing human contact, feeling it could be impersonal and perhaps creating a barrier to building a strong rapport.

"You're taking away the human touch though. And I think that human touch is very special; you lose that when you introduce technology." (Mental Health Professional Focus Group 3, Participant 3) "…the whole purpose is to beat isolation, you know, and then I wouldn't want to encourage the client to be sitting in their home, because then they are still isolated." (Volunteer Focus Group 1, Participant 5)
Boundaries would be more difficult to maintain, allowing both parties access to unlimited contact.The appropriateness of sharing personal contact details or even using personal social media accounts was questioned.It was viewed that whilst the use of technology may benefit some participants, it could also be inaccessible to others, either due to a lack of technological literacy or financial limitations.
Professionals' and volunteers' views differed on two points.Firstly, professionals felt that the use of technology would need to be monitored or mediated by the organisation in some way.Some participants suggested that organisations could provide mobile phones to volunteers and set up online forums which volunteers and patients could access.Volunteers, however, had a more flexible view on exchanging contact details, feeling this would be appropriate but only after trust is established.

"If they want to Facetime each other that is great and, you know, as long as that contact is somehow maintained and I guess monitored." (Mental Health Professional Focus Group 3, Participant 1) "I would advise the same: don't give out your own telephone number, which I respected right at the very beginning, but as the trust grew between us, then she has my phone number." (Volunteer Focus Group 2, Participant 4)
Whilst professionals viewed technology as supplementary to face-to-face interactions, volunteers spoke more about its potential as an alternative service, providing examples of schemes that operate completely remotely.

Impact on wider mental health care
The presence of volunteering schemes was identified as having an impact on both individual patient care and its role within the broader landscape of care provisions (Table 7).Participants widely viewed voluntary services as integral to a holistic care approach, promoting recovery by addressing social factors.Many participants mentioned how meaningful connections with others could improve mental health and how voluntary schemes helped played a role in this, acting as a supplementary support to mental health services.

"…we wouldn't expect that befriending schemes perhaps would take over the work of clinicians but we might get more information from, from that-that can complement what a patient would tell the clinician when they meet in a formal setting." (Mental Health Professional Focus Group 2, Participant 4) "..it's a supplementary thing, you know, we're just there as a friendship thing." (Volunteer Focus Group 2, Participant 2)
Professionals, however, questioned the extent to which volunteering schemes would be helpful, with some feeling it would have no significant impact on the need or demand for mental health services.On the other hand, some 1 3 volunteers shared their experience of voluntary schemes increasingly receiving more complex referrals, often due to patients' limited access to other services, therefore playing an important role in assisting more disadvantaged patients.
"But I think on a micro level I don't think it's gonna impact any of the services whatsoever because there's a clear difference between what they will be taking from the volunteering scheme and why there's a need for services."(Mental Health Professional Focus Group 3, Participant 3) "…because there's less government funding then they're falling through these cracks and we're picking them up."(Volunteer Focus Groups 2, Participant 1) While voluntary services may not replace primary mental health services, professionals did feel that it could offer a less intensive form of intervention for patients who are further along in their recovery.This potential decrease in workload was further discussed, with some professionals feeling it would have no significant impact, while others believed there could be a risk of it adding to the workload of professionals.Volunteers highlighted the role they could play in aiding patients to access different support services, but they also expressed concern about the burden that volunteering could have on their own wellbeing particularly when it concerned patients who were unwell.

Main findings
The six overarching themes demonstrated varying degrees of commonalities and differences.Notably, the place of technology in volunteering and the structure and responsibilities of schemes had the highest degree of commonalities.Divergent views emerged particularly concerning the impact of volunteering on broader mental health care and the nature of the volunteering relationships.
Professionals emphasised organisational considerations, the need for structure and clear boundaries, while volunteers focused more on the experiences of both volunteers and patients and the impact of the relationship on them as individuals, adopting a more flexible approach to navigating boundaries.Mental health professionals perceived volunteering as supplementary, aiding diverse needs in patients' recovery or acting as a transitionary service post-discharge.Professionals felt that the running of these programmes would be best situated within the third sector, both to avoid overburdening mental health services and to distinguish the intervention targets.
Professionals arguably adopt a more goal-directed and recovery-oriented approach with patients, needing to work within stricter professional boundaries.Consequently, their views on volunteering may have been influenced by their professional practices.Similarly, volunteers drew from their direct volunteering experiences, emphasising what they valued most: building a strong relationship with their match and gaining enjoyment and fulfilment.

Strengths and limitations
This study was the first to compare the views of mental health professionals and volunteers in the UK.The vast scope of the primary study generated a substantial amount of data, which this secondary analysis further employs to delve into this under-researched area [20,21].
To facilitate full immersion in the data, the second researcher familiarised themselves with additional materials used in the original study, accessed relevant literature produced by the primary researcher and received direct supervision from the primary lead researcher, allowing for a deep understanding of the rationale, procedures and perspectives to be developed.
Separate focus groups were organised for each stakeholder group to minimise the potential risk of uneven group dynamics between professionals and volunteers.However, it should be acknowledged that there was overlap in participants' experiences.Mental health professionals held differing job roles, and some had experience of volunteering.Similarly, some volunteers had a professional background in mental health, and not all volunteers had direct experience of volunteering within mental health.This paints a more complex picture and raises the question of how these varying experiences impacted participants' views and their understanding of mental illness and mental health care.
Another limitation concerns the geographical distribution of participants who attended the in-person focus groups organised in London.Mental health professionals were working in London, while volunteers came from different parts of the UK, although most were also based in London.This might restrict the transferability of findings to all UK regions.

Comparison with the literature
Volunteering is deeply ingrained in the UK culture, supported by well-established policies and procedures [22][23][24].This study delves into the nature of these volunteering relationships, sparking substantial debate over the term 'befriending' , commonly used by voluntary schemes, and its reflection of the true relationship's nature.For some participants the structured rules and nature of these services introduce professionalism, while the social support offered felt more akin to a friendship.This spectrum of roles was previously conceptualised in a systematic review on befriending [6].
The purpose of volunteering relationships has been perceived as 'addressing a social agenda' .Volunteers are primarily tasked with addressing the challenges that people with mental health problems face in establishing and maintaining social relationships.Participants categorised the process of helping into active 'doing things' or passive 'being there' .This distinction was previously highlighted in a qualitative study exploring experiences of volunteers and patients in mental health befriending [25].Both mental health professionals and volunteers acknowledged the importance of offering patients opportunities for informal interactions, a key benefit of volunteering schemes in mental health [26].
Examining the organisational structure of volunteering schemes, various practical aspects were discussed, deemed crucial for their effective operation.These encompassed volunteer selection, matching of volunteers and patients, safeguarding responsibilities, training and supervision.Previously it has been emphasised the need for formal procedures and systems in place to address these aspects within voluntary schemes [27,28].Studies have reported that effective organisation and management of voluntary schemes are linked to volunteer satisfaction and the quality of care patients receive [29].Participants also discussed the duration of the relationships, some suggesting an ongoing dynamic.While many schemes adhere to a 12 month timeframe [3], a survey investigating the preferences of patients with severe mental illness regarding befriending schemes reported a majority favouring open-ended relationships [30].This underscores the importance of flexible delivery based on patients' needs and volunteers' motivations and availability.
This study also raises awareness to the potential challenges that volunteers in the UK may encounter, especially in cases where patients exhibit complex symptoms or behaviours, given that volunteers are not expected to be experts in mental disorders.Suggestions have been made that the volunteer-patient relationship benefits from professional mediation [31], a point underscored by mental health professionals in this study.Volunteers also struggled to balance addressing patients' needs and meeting scheme expectations, often feeling overwhelmed by the prospect of assuming too much responsibility, a concern also identified in previous research [25,26].
Considering the potential role of technology in volunteering, including its advantages and disadvantages, technology's ability to offer flexibility for patients with varying needs and preferences was lauded.A survey investigating patient preferences in interacting with volunteers reported an almost equal split between those favouring face-to-face and digital interactions [32], highlighting the importance of diverse options.However, potential drawbacks included technology's 1 3 inaccessibility to those digitally excluded and the risk of misuse, aligning with existing literature on mental health provisions [33].The absence of face-to-face contact was seen as detracting from a key element of volunteer support, which previous research has identified as the primary weakness of online services [34,35].
Examining the broader impact of volunteering within mental health care, volunteering was predominantly considered supplementary to mental health services, designed to address distinct needs in patient's recovery journey.This concurs with descriptions of volunteering in mental health reported in other studies [36].

Conclusions
Mental health professionals and volunteers in the UK view voluntary programmes as valuable.This study findings highlight the nuanced nature of volunteer-patient relationships, ranging from friendship to professionalism.Professionals favoured structured, boundary-oriented approaches, while volunteers prioritize personalised, flexible connections.Addressing social agendas emerged as pivotal, with professionals emphasising practical interventions and volunteers, emotional support.These results raise awareness to volunteering's broader impact, supplementing mental health care to address distinct patient needs.

Table 2
Theme: "An act of friendship but not a true friendship" *sub-themes for both mental health professionals and volunteers *sub-themes for both mental health professionals and volunteers "Helping people access things in their local community, so sort of promote social inclusion."(MentalHealthProfessional Focus Group 4, Participant 3) "they can often be quite an isolated group who doesn't…[who]finds it quite difficult to even make new social contacts or to feel motivated to maintain old social contacts, and so it's just providing them with more social support."(Volunteer Focus Group 1, Participant 1)

Table 4 Theme
"I think for it to be effective and maintain safety and recovery there has to be some sort of basic training."(Mental Health Professional Focus Group 2, Participant 1) "I also think quite strongly that the training shouldn't just be you know a couple of sessions at the beginning.I think it should be revisited on a regular basis; some sort of opportunities for training."(Volunteer Focus Group 2, Participant 1)

Table 5 )
. Volunteers lacking knowledge of mental health disorders could potentially encounter issues where they may not know how to sensitively navigate a patient's symptoms, being unable to provide an adequate level of support."…I'd worry for people who obviously aren't trained in mental health, that they might miss things, or not pick up something really important" (Mental Health Professional Focus Group 4, Participant 2) "…it was very difficult sometimes to understand what he was thinking and to kind of follow his thought process."(Volunteer Focus Group 2, Participant 3

Table 7
Theme: "Impact on wider mental health care"