For most, if not all, volunteers, the experience of volunteering globally is a professional and personal highlight. It changes volunteers as mental health professionals and as people. Many of the experiences outlined in this book have been transformative. For those fortunate enough to join professional colleagues in other countries, there are opportunities to learn to see beyond a narrow medical perspective into a broader socio-cultural canvas, especially when working with the limited resources available in many countries. Multiple skills may be needed, and volunteers can expand their repertoire of skills in service development, supervision, teaching and cultural awareness. Encounters with new challenges, resource difficulties and obstacles can help with working practices upon return to the NHS. Volunteering can be unsuccessful as well as successful and this book is about maximising success. The book attempts to demonstrate ways to become a more culturally competent and skilled mental health professional through global volunteer work.
People volunteer at different stages of their careers, from student days to post retirement. The reasons are varied, but common motivations include altruism and the desire to ‘give something back’. Many readers may wish to contribute to the welfare of people overseas with mental illness, alongside some who feel a deep desire to do what they can for those who have little access to mental health care. For people from a diaspora background, there may be a desire to help ‘back home’. For others, it is motivated by a need for refreshment and to gain new perspectives away from the usual daily professional ways of working. Some may feel the desire to contribute to colleagues’ development or make an impact on trainees and the next generation. Other volunteers may crave ethical travel, and some mention the increasing appeal of learning from colleagues in varied and low resource settings. Whatever the reason(s), careful ethical reflection is indeed needed as outlined in Chapters 3 and 4 on ethical consideration.
This book seeks to help prospective volunteers feel more informed, better prepared and inspired to be effective and ethical volunteers. It outlines key principles and practicalities to consider. This book is not intended to be viewed or read from cover to cover as an academic text. Instead, it seeks to be an evidence-based practical guide that readers can interact with depending on their specific interests and needs. It is based on up-to-date evidence in global mental health and the experiences of the authors (which includes both volunteers and those in host countries who are the recipients of voluntary projects). Emphasis is placed on global volunteering undertaken through partnership models of cooperative working with international colleagues.
The book is written with mental health professionals in mind: doctors, nurses, psychologists and other therapists, but we also hope it will be useful for other professionals including those working in social care, students and health-allied volunteers. It is written to be accessible to all career stages. Although the book is primarily structured for UK-based clinicians (with use of related nomenclature), it is hoped that it will have a resonance for an international audience outside of the UK and be of help to those involved in other global volunteering partnerships, including South-South projects. To aid this, definitions of UK-specific nomenclature are contextualised and defined in the appendix.
Key Considerations
Global volunteering can initially be seen as a very simple transaction, but it is actually quite complex and requires purposeful consideration. This section outlines key considerations that the reader should take into account when navigating global mental health volunteering.
Global Mental Health Context
There are huge inequalities around the world in the provision of care for people with mental health difficulties. The gap between need and the provision of services for people with mental health illness is very large indeed, especially in low- and middle-income countries (LMICs)[1]. People with mental illness face stigma, violation of human rights and poverty in many parts of the world. To ensure that those suffering from mental illnesses are neither ignored nor forgotten, there is a need to foster a public mental health approach and help build health system capacity.
The effects of social determinants such as absolute poverty can be particularly prominent in LMICs. Also, volunteers need to be alert to considerations such as gender-based violence, child protection and vulnerable groups. The issues raised can be as varied as social inclusion, confidentiality and different forms of abuse. Prospective volunteers need to be well-informed on matters of human rights, which are a fundamental pillar on which modern global volunteering is now built. Mentally ill and intellectually disabled people are at particular risk of violations of their human rights. This can be a complex area where the volunteer may well need advice, support and supervision. The Royal College of Psychiatrists has a Committee on Human Rights and this group, in addition to the host country’s ethics institutions and colleagues, can be a source of informed advice.
Mutual Learning and Partnership Working
Volunteering to work overseas, particularly in LMICs, has a great deal to teach us. Professionals in high-income countries, including the UK, must guard against promoting ‘medical imperialism’, by which is meant that only we have the ‘right approach’ and that we know best. Attitudes of this kind get in the way of progress and are harmful to making a mutually beneficial relationship where everyone both learns and teaches.
Volunteering is about co-production and partnership. Any volunteering should come after a request from a host country and not something clinicians in the United Kingdom ‘do’ to other countries. As volunteers are guests, there is a need to demonstrate appropriate humility. Volunteering should be in the context of sustainable programmes and skills transfer.
Although many countries have historically adopted Western models of assessment and treatment of mental disorders, there have also been creative and innovative solutions to serve the needs of people in LMICs. We have much to learn from our colleagues overseas; for example, the use of The Friendship Bench in rural Zimbabwe communities[Reference Chibanda, Weiss and Verhey2]. In this project, brief training in basic counselling is given to appropriate community members who can then offer psychological support in problem-solving at the community level. It has been shown to be successful in managing common mental health difficulties and has now been adopted in other countries. Mindfulness too has global roots. Partnership is key – it is a two-way learning and participatory approach.
Flexibility and Attention to Assessed Needs
The mainstay of partnership working is currently the development of mutually agreed training programmes. However, other needs may be identified, and volunteers may be asked to carry out different tasks, from organising written protocols and academic curricula, to helping with team development, supervising clinical work, public health messaging, the promotion of mental health awareness and so many other opportunities. It is important that a volunteer is flexible and responsive to the needs and requests of the local partners. There may be times when you may feel out of your depth, or that you do not yet have the skills necessary for the required tasks. In those circumstances, it is necessary to be transparent with your local partners and problem-solve together.
Knowledge and Skills Required
Psychiatrists and other mental health volunteers will probably need to go beyond their habitual professional comfort zones. Before working with international colleagues, volunteers usually need to refresh their own knowledge and skills across a wide range of mental health topics, including basic principles of care and mental health assessment and management. Thankfully there are some really helpful resources becoming available about working internationally, some of which are listed at the end of the book (see Appendix 1). International volunteers may find themselves covering mental health care for persons of all ages from child to old age and competence may be required in areas such as drug and alcohol misuse and developmental and organic disorders.
Organic disorders presenting as mental illnesses are more common in LMICs as the burden of TB, HIV, other infectious disorders, head injury and epilepsy is much higher. In fact, epilepsy is now included in many WHO mental health-related training materials, including the WHO mhGAP (Mental Health Gap Action Programme)[3]. This includes mhGAP Intervention Guide – Version 2 which a training manual of integrating mental health into primary care that is discussed throughout this book[4]. Primary care volunteers and psychiatrists offering training for colleagues wanting to enhance local primary care skills may find this particularly beneficial.
Working with all people involved in the provision of health and mental health services helps spread awareness, improves skills for everyone and can challenge stigmatisation. One of the many skills that volunteers can learn from working internationally is the value of public mental health messaging and advocacy. Engaging managers, local officials and academics, local non-government organisations (NGOs) and other stakeholders substantially supports the sustainability of projects. It can feel overwhelming even to think about how to develop services, but as mental health professional trainers, it is important to include clinicians in service development projects. In the chapters on the lived experiences of recent volunteers, there are examples of creative and practical ways to enhance training with attention to opportunities to advocate for changes that make a lasting impact.
Experience suggests that people who enjoy successful volunteering experiences with international colleagues usually:
Know enough up-to-date evidence-based basic psychiatry (or their speciality) and are able to adapt their knowledge to new settings in a way that respects culture
Enjoy teaching and learning
Communicate well with colleagues from other cultures and enjoy working creatively and flexibly with new acquaintances
Behave professionally, with respect, courtesy, honesty and humility
Are ready to face challenges, be solution-focused and are prepared to manage outside their comfort zone
Are emotionally mature and tolerate uncertainty and the ‘"grey areas’
Professionalism
Unpaid work in another country requires the same level of professional behaviour, preparation, ongoing training and supervision as paid work. For volunteering to be impactful and professional, it needs to be carefully planned and based on available evidence, mutual respect between colleagues and appropriate support and self-care.
Awareness of Settings, Environment and Safety
Personal safety is an important and common concern for volunteers visiting other countries. It is important to get advice from host countries, and the UK Foreign, Commonwealth & Development Office (FCDO) travel advice should always be adhered to[5]. The FCDO has regularly updated, helpful and reliable information on safety and possible dangers. However, even if the FCDO says that most visits are trouble-free, all travellers, but especially inexperienced travellers, would be wise to keep alert and follow a risk assessment process, and to avoid travelling alone if at all possible. The personal health and safety of oneself as well as colleagues based in other countries can sometimes be an important factor in successfully settling into the practicalities of working in a new environment, and support and supervision may be needed.
Difficult Political Environments
One of the challenges of working in countries with known governmental violations of human rights is finding a way to separate the volunteering work from the government or organisations who are abusing their power. Many charities and international organisations manage to make it clear that providing assistance neither condones nor supports the actions of the government in the country where they are working.
Careers in Global Mental Health
A career path for global mental health is beginning to take shape. There are opportunities in the United Nations (UN), UN-related organisations such as the World Health Organization (WHO) and NGOs based in different countries. For some of these roles, it is necessary to have a postgraduate master’s or PhD degree in public or global health. A diploma in tropical medicine is also welcomed. People in this career need to be prepared to change jobs relatively frequently and move between different countries. At the same time, being grounded and having a home base is also important.
Experience as a volunteer can sometimes assist in accessing courses and jobs internationally. Volunteering may also help people find out whether living and working internationally will really work out as a suitable career choice. Experience in volunteering adds to one’s CV and volunteers often comment that it is frequently the liveliest part of their job interviews.
Finance and Money
Generally, volunteer work is not well-funded, but those people generous enough to volunteer their time and skills should not need to be paying for their own transportation and accommodation. Ideally good projects involve the host organisations paying for and arranging accommodation, transfers and a training venue in the country.
For short projects, volunteers working in the NHS have, historically, taken study leave or unpaid leave. This could change, but the current economic climate suggests that volunteers should anticipate paying for some expenses. Some volunteers think of this as a contribution to charity and to their own development.
Personal Benefit and Gain
Volunteering can undoubtedly help open one’s mind to other ways of working with the clinical and educational challenges which we all face today. It can also be worth recognising that placements can add colour to your CV, in addition to helping develop new skills and enhance existing knowledge.
Limitations Related to Staffing Numbers and Global Recruitment Practices
It is important to be mindful that there are limitations on the impact that volunteers can make in some contexts, particularly given inequalities in health and wealth globally. This is clear when we consider the number of health staff available and working in different parts of the world:
- An estimated shortage of 43 million health workers in 2019 globally (6.4 million doctors, 30.6 million nurses/midwives, 3.3 million dentistry personnel and 2.9 million pharmaceutical personnel) relative to the workforce needed to provide universal health coverage[Reference Haakenstad, Irvine and Knight6].
- A workforce unevenly spread, with high-income countries having 115 per 10,000 population of nurses/midwives whereas low-income countries have an average of 9 nurses/midwives per 10,000[7].
This phenomenon is further exacerbated by the process of high-income countries, including the United Kingdom, recruiting health personnel (including in mental health) to fill domestic gaps. An estimated 15% of health workers globally are from countries outside of their birth or from where they achieved their professional qualification[8].
Global volunteering, in the current model, does not address this directly. Whilst focus on training can help build capacity, there is a need for ‘beyond volunteering’ approaches focused on advocacy domestically to ensure policy and practice is ethical. Indeed, the system of recruitment needs justice not charity to ensure that there is not a greater brain drain and that we are able to build better health systems globally in a sustainable manner.
Part of understanding limitations and tackling such practice is recognising the different power relationships between high-income and other countries, and their organisations and projects. It is worth a prospective volunteer being versed in the increasing literature related to education, training, health and international affairs around decolonisation and ensuring parity of power, decision-making and relationship building.
Volunteering Locally in the United Kingdom
It is important to recognise the considerable value to the development of skills that can be gained through volunteering in the United Kingdom.
Indeed, documenting the details of all the volunteering work undertaken within the UK would produce a very full book indeed. However, as this is beyond the scope of this book, there is limited discussion related to these opportunities. The Volunteering and International Psychiatry Special Interest Group of the Royal College of Psychiatrists (VIPSIG) knows from its annual essay prize that students are promoting mental health awareness as well as volunteering their time in all sorts of creative ways. Volunteers are teaching in religious institutions including churches and mosques, whilst many psychiatrists, senior and junior, give their time to societies and charities ranging from sporting clubs to groups such as Medical Justice.
As an example, Medical Justice welcomes health professional volunteers to visit detainees in detention and write reports and provide opinions. ‘By joining Medical Justice, health professionals can have a positive impact on the lives and health of this most vulnerable group of people in the UK’[9]. Mental health professionals have also volunteered to work with the UK Refugee Council in a variety of ways, especially over the past few years when so many asylum seekers and refugees have been moving across Europe and seeking refuge in the United Kingdom.
There have been so many more acts of kindness and sharing of expertise, especially during the Covid pandemic. Perhaps many of these volunteers have experienced the satisfaction of voluntary work and want to do more. National and international volunteering has become more straightforward now that electronic resources are being developed and we can work in new ways with colleagues anywhere in the world from our own homes.
Conclusion
In reading this book, including the first-hand narrative experiences of a number of volunteers and host recipients, it is hoped that you will feel more prepared, confident and inspired to take your next step in global volunteering. The voluntary placement can take many shapes and sizes. Your placement may be a short- or longer-term one, be based in places where the spoken language is shared or varied, and your day-to-day role may be primary training, teaching, supervising, researching, project managing, capacity building and/or more. The rewards of these placements can be outstanding and transformative for many, both personally and professionally. As a prospective volunteer, we hope that the information contained within this book will give you some additional confidence to jump in and begin to be part of developing a more equitable, ethical and sustainable global mental health voluntary community.
What Is in the Book
The book makes suggestions on negotiating the practicalities of getting from an initial interest in volunteering to the completion of a successful project and safe return home. It is not an exhaustive summary of all possible opportunities and experiences but rather hopes to give a range of representative experiences and advice that inspire, stimulate and enable reflection for the reader.
The book is organised in four sections – the theoretical and practical considerations outlined in Sections 1 and 2 are complemented by the rich narrative accounts and experiences of volunteers in Section 3. Section 4 looks to the future with an exploration of electronic learning and reflections on what might happen next as global mental health voluntary work gathers pace.
The book begins with a review of principles and theory in global volunteering. Herein, Chapter 1 introduces the field of global mental health and the notable theoretical principles to be considered. This includes a review of documents such as the Lancet series on Global Mental Health, the WHO World Mental Health Action Plan and mental health law as well as training delivery tools such as the WHO Mental Health Gap Action Programme (mhGAP)[3]. There is then a focused chapter on humanitarian settings with both theoretical as well as practical considerations (Chapter 2). Principles in humanitarian emergency response include preparedness, the need for multi-sectoral response, ‘building back better’, the role of co-ordination, the prioritisation of safety and the necessity for situational and needs analysis. Key humanitarian tools are introduced including the Inter-Agency Standing Committee (IASC)[10] and SPHERE[11] guidelines. The chapter emphasises that no one should volunteer in isolation, and it is important to be part of a responsible and sustainable programme.
Chapters 3 and 4 then consider key ethical and cultural principles about global volunteering, including discussions of case studies involving challenging ethical scenarios. Finally, this section concludes with a discussion around the benefits of volunteering for the trainee and the UK health system (Chapter 5). This discussion demonstrates that global volunteering can be a win-win opportunity that enhances not only the skills and knowledge of the international community but also brings considerable benefits after return to the UK, including enhanced teaching and clinical skills, leadership capability and cultural awareness.
The second section is a practical guide and toolkit to support global volunteering. The chapters in this section are focused on practical considerations related to preparation, on-site working and project delivery, training, monitoring and evaluation, and post-trip sustainability. Chapter 6 on preparation considers careful planning with host partners, and tips to enable living and working safely in another country. The ‘on the ground’ considerations, particularly cultural understanding and respect upon arrival, are considered in Chapter 7.
Chapter 8 on implementing and delivering training describes how a passion for teaching and learning, especially with confidence in the creative use of interactive teaching techniques, brings the training experience to life and can make it enjoyable for all. The following Chapter 9 introduces a new psychological toolkit with simple psychological interventions suitable for all professionals. There is then an exploration of what happens after a global volunteering trip, with an examination of the process of coming home, supervision, sustainable practice and self-care (Chapter 10). This reiterates the importance of careful preparation throughout an entire project. Finally, this section concludes by considering the necessary steps in monitoring and evaluation and emphasises the need to ensure that metrics are developed with and owned by local partners (Chapter 11).
In the third section, narrative accounts provide rich reflective perspectives on global volunteering. There are narratives from the recipients of volunteer workers as well as global health volunteers giving varied accounts of their lived experiences. Some of these experiences relate to capacity building, humanitarian work, delivering training, receiving training and providing supervision. Some are about short trips and others extend over years. Most involve training and raising awareness about mental health. It will become obvious that each experience is different, and hopefully reflects the framing of work that volunteers have done to try to meet the particular requests and needs of host partners.
The final section relates to the future of global volunteering. Chapter 22 presents ideas and hopes for the future of volunteering using electronic learning possibilities to enhance existing developments and add innovative ideas for the future of services and learning. Whilst the Covid pandemic has highlighted the gross inequalities of health care around the world, it has also given a boost to the development of digital learning resources and an opportunity to deal with the challenge of climate change by making travel less critical to successful work with international and national colleagues. The final chapter, global volunteering moving forward, seeks to contextualise the important considerations raised throughout this book and reflect on the landscape of global volunteering moving forward.
