Resources

The power of volunteers

15 May 2017

A volunteer programme that gives support to vulnerable families demonstrated that a small investment in training and support can bring about enormous change. Pauline Lee, Sarah Cook and Catherine Mee explain more.

Volunteers

Enhancing the parent-infant relationship through training volunteers

  • Pauline Lee - Consultant clinical psychologist - Clinical Lead Tameside and Glossop Early Attachment Service Pennine Care NHS Foundation Trust
  • Sarah Cook - Chief executive Home-Start Oldham, Stockport and Tameside
  • Catherine Mee - Clinical pathway lead, children's universal and universal plus services (Tameside community services) Tameside and Glossop Integrated Care NHS Foundation Trust

KEY WORDS: volunteers, parent-infant mental health, early attachment, training


Abstract

A review of the integrated parent-infant mental health care-pathway in Tameside and Glossop indicated that more support was required for parents who were at risk due to mild to moderate mental health needs. In partnership with Home-Start, the Tameside and Glossop Early Attachment Service and Tameside Health Visiting Service developed an enhanced training for volunteers, delivered by a Home-Start parent-infant mental health coordinator, a health visitor and staff from the Early Attachment Service.

Following work with the volunteer, parents’ experiences and confidence were evaluated using a purpose-designed questionnaire. The group that received the service from the specially trained volunteers showed greatly enhanced levels of confidence about a number of essential aspects relating to the parent-infant relationship. The improvements were so great that they clearly offer a way of potentially enhancing the lives of many children and their parents in the future.

The experiences of the volunteers themselves indicate that they found the training highly beneficial. However, it is clear that the complexity of working with families at this level can deeply affect the people working with them. This must be recognised, both in terms of training staff and volunteers, and in terms of the support available to them.


KEY POINTS

Tameside and Glossop Early Attachment Service aims to meet the needs of all parents.

Nevertheless, some families are isolated and may also be reluctant to seek professional help because of a perceived stigma attached to this.

Volunteers are often more able to engage families who are less willing to be involved with statutory services.

A partnership project with Home-Start and health visiting was developed in which volunteers were given a purpose-designed training around the fostering of sensitive and responsive parent-infant relationships.

The four-day training draws on theories from attachment, infant development, psychoanalysis and neuroscience.

Results showed that this fairly short training course had a remarkable impact on the knowledge and confidence that parents have in building a relationship with their infants.


Introduction

The Charity Commission (2000) defines community capacity as: "...developing the capacity and skills of the members of a community in such a way that they are better able to identify, and help meet, their needs and to participate more fully in society". Volunteers can be seen working in many areas of health and social care. Their contributions are vital, and not just because they offer a way of increasing manpower for very little cost. Indeed, the support given by volunteers is unlikely to be achieved by an equivalent number of paid workers, simply because the nature of the relationship with the family is peer-to-peer, rather than professional to family. This brings huge potential benefits in terms of trust, the ability to engage families who are less willing to be involved with statutory services, and the possibility of developing a relationship with the family, which can make it more likely that positive change can occur in the future (Institute for Voluntary Action Research, 2016).F

This paper is concerned with the delivery of our parent-infant mental health services in Tameside and Glossop; specifically, the vital contribution that trained volunteers have made to families during the perinatal period. The paper presents an evaluation of a training programme for volunteers, instigated by Home-Start Oldham, Stockport and Tameside (HOST), Tameside Health Visiting (through Building Community Capacity) and the Tameside and Glossop Early Attachment Service (EAS).

The evaluation involved two principal components:

1) Statistical evidence of the impact on enhanced volunteer training on families’ experiences of receiving the service.

2) Feedback from the volunteers about their experiences of receiving the training.

Tameside and Glossop parent-infant mental health services

In Tameside and Glossop, through the leadership of the Early Attachment Service (EAS), we have developed a comprehensive and cost-effective parent-infant mental health (PIMH) provision of services across the borough, which aims to meet the needs of all parents, from those with a high level of need, through to a universal provision (Lee & Mee, 2015). Our approach is that parent-infant mental health is everyone’s business, and that the parent-infant relationship should be at the heart of the community.

In Tameside, building community capacity continues to be a priority for health visiting. Health visitors in Tameside receive training in parent-infant mental health, the neonatal behavioural assessment scale (NBAS) (Brazelton, 1972), the newborn observation system (NBO) (Nugent et al., 2007), promotional interviewing, and reflective functioning. In this report, we demonstrate how health visitors, together with EAS and Home-Start, successfully trained volunteers in parent-infant mental health to enhance and enrich their support with families during the perinatal period.

A need for improved support

A review of our integrated parent-infant mental health care pathway in 2012 (Lee & Mee, 2015) indicated that more support was required for parents who were at risk due to mild to moderate mental health needs. The existing professional support available for these parents is limited, and professional interventions cannot replace those functions that would traditionally have been carried out by the communities in which people live. Families are often isolated and may also be reluctant to seek professional help because of a perceived stigma attached to this.

We proposed that what was needed was low level individual support for parents to help them along the five ways to wellbeing, to promote development of positive parent-infant relationships, and to engage families with local children’s centre and other community provision. We saw that this type of proactive parental engagement and support would mean that specialist resources were used more appropriately, whilst promoting long term community support networks.

Partnership project with Home-Start

It was decided that this specific need for support was an ideal opportunity to develop a partnership project with HOST, in which HOST volunteers would be given purpose-designed training on fostering sensitive and responsive parent-infant relationships. The project would be evaluated primarily in terms of parents’ perceptions of the knowledge they gained about their infant, comparing volunteers who receive the standard preparatory course (covering topics such as child protection, confidentiality, family values and stress factors). In particular, we were hoping to see improvements in knowledge about understanding the importance of the primary relationship between infant and parent, and increased confidence about being able to foster and develop that relationship.

Home-Start Oldham, Stockport & Tameside

Home-Start Oldham, Stockport & Tameside (HOST) is one of a network of over 300 independent Home-Start schemes that operate across the UK. Each Home-Start scheme is a registered charity with the mission to support parents to give their children the best possible start in life. To do this, Home-Start recruits, trains and supports volunteers (who are parents themselves) to provide weekly home-visiting support to families who have a wide range of needs, and at least one child under the age of five.

HOST is a well-established Home-Start scheme that has been operating in Tameside for 17 years. In 2014, HOST appointed a new parent infant mental health (PIMH) co-ordinator to work in close partnership with EAS, funded by the Clinical Commissioning Group (CCG). Through this partnership, the EAS has been able to offer regular supervision (individual and group), specialist training and development opportunities (e.g., Solihull Parenting, NBO, Mellow Parenting) to the PIMH co-ordinator and the Home-Start co-ordinators. The PIMH coordinator is very much a ‘conduit’. She benefits from being a part of the EAS team and brings the knowledge and learning from this into the wider Home-Start team. Equally, the EAS team is able to develop a greater understanding of the full potential of using volunteers to support the development of the parent-infant relationship. The EAS have gained confidence in the support that can be offered by non-clinical staff due to being involved in the high quality of training and supervision given to volunteers.


Method

The evaluation is a pre and post design where we use Tameside, Oldham, Stockport as a natural baseline (before PIMH training), which we hoped would show even more positive evaluations after the PIMH training was launched.

The following are descriptions of the existing Home-Start training of volunteers, and the additional specialist training, which is the focus of this evaluation.

The existing Home-Start training

All Home-Start volunteers complete a 10-week preparation course before being carefully matched to a family in order to offer a package of support that is individually tailored to each family’s needs. Once matched, the volunteer will visit the family for 2-3 hours per week and will offer a wide range of practical help and provide much needed emotional support. This process is then overseen by Home-Start co-ordinators who provide regular support and supervision to each volunteer and who regularly review support with each family, to ensure that needs are being met and that any new support needs are identified.

The volunteer enhanced PIMH training

The four-day training draws on theories from attachment, infant development, psychoanalysis and neuroscience. It focuses on pregnancy through to six months of age, from the varying perspectives of the parent, the infant and the parent-infant relationship. In particular, the following are covered: the importance of early brain development, perinatal mental health, reflective functioning, Solihull Approach, New Born Behavioural Observation System (NBO), infant observation, emotional development of the baby, risks in relationships, and the concept of “ghosts in the nursery” (Fraiberg, Adelson & Shapiro,1975).

The training is delivered through an experiential approach where information is shared and volunteers are encouraged to share their thoughts, feelings and past / current experiences. The arena of parent-infant mental health is particularly emotive and inevitably can stir up thoughts and feelings in all of us of how we were as infants and children, how we were parented and how we parent our own children. The volunteers are taken on an emotional journey, which enhances their grasp and understanding of parent-infant mental health. The diversity of the three facilitators in terms of their knowledge, skills and experience (PIMH co-ordinator from HOST, health visitor and EAS specialist) allows for a good balance and different ports of entry for the volunteers to engage with the training. The facilitators are sensitive and emotionally supportive to the experiences of the volunteers. Many of the concepts that are discussed are experienced live in the training, such as mirroring of emotions and containment.

The training translates theory into practice, to facilitate volunteers’ ability to integrate their learning in their support with families. This is achieved through group exercises, bringing in various resources (e.g. camera, keep sake books, making dream catchers, books for babies), and encouraging volunteers to think about how these might be used to support the parent-infant relationship.

In addition, verbal feedback is given by the volunteers at the end of each training session. They are also encouraged to write their likes and dislikes about the session on post-it notes. This provides the facilitators with an emotional temperature gauge of how the session was experienced and what needs to be adapted or considered in the following session. For example, volunteers may indicate they found watching a film clip distressing, but unable to share this with the group. The facilitators may decide to send a text to the volunteers asking if they were all OK and that they are available to meet with any of them.

The families are offered a tailored package of intervention that is dependent on their individual needs. This could be supporting the development of the parent-infant relationship through reflective functioning of the parents, increased intuition with their baby’s communication cues and helping parents think about their babies thinking minds. The PIMH coordinator matches a PIMH-trained volunteer with the family who visits on a weekly basis and follows a committed action plan agreed by the family, volunteer and coordinator.

The training is delivered by the PIMH co-ordinator, health visitor and early attachment staff. The partnership with health visiting is part of the Building Community Capacity initiative as directed by the Health Visitor Implementation Plan (2011-2015).

The samples

HOST placed a notice on its website indicating that there was an opportunity for volunteers who had completed the standard Home-Start preparatory training to receive additional training in parent-infant mental health. The notice lead to a strong interest, far greater than the places available, and therefore a waiting list was established.

Therefore, the comparison samples include people who were interested in the training. One group were individuals who had already received the additional training, while the second group were yet to do so.

At the time of writing, a total of 52 volunteers have been trained in PIMH. Of these, 20 had reached the point where they had been matched with a family and completed the evaluation questionnaire, and had also completed the feedback interview.

The comparison group comprised 76 volunteers who had yet to receive the PIMH training, but had completed the evaluation questionnaire with a family.

Data collection

The questionnaire for parents

We devised a simple questionnaire that all families (regardless of whether or not they had a PIMH trained volunteer) would complete at their six-month review and at the end of their Home-Start support. The questionnaire looked at particular knowledge areas which were covered in the PIMH training.

All families with a child 2 years and under, or who was pregnant, were asked to complete the questionnaire. Coordinators were asked to give them out to families once the work with a volunteer had been continuing for at least six months, and when the family were being discharged from Home-Start.

Feedback from volunteers

At the end of the enhanced training, volunteers were asked to complete a one-page evaluation sheet, which asked them to list three things they learned on the training and what aspects of the training they could integrate in their support with families.


Results

Parents’ views about the service they received

Table 1 shows the comparison between groups for each subject on the questionnaire. It can be seen that in all but two there is a significantly higher rating by the parents who had received the service from the trained volunteers.

Table 1: Comparison of parents’ ratings in relation to the two groups of volunteers 

†Scoring on the questionnaire: Certainly True = 3, Partly True = 2. Not True=1. Don’t Know = 0
Mann-Whitney U test*

Many of the comparisons are quite dramatic, particularly in issues relating to the relationship between babies and parents. This includes the understanding of stress, baby states, sleep and soothing. Overall, it was very clear that the parents receiving a service from the specially trained volunteers felt more confident in building a good relationship with their infant.

Volunteers’ view of the training they received

As part of our consultations, we conducted three focus groups with volunteers, one in each of our three areas.

We also wanted to talk to volunteers who had completed our PIMH training and were now using their new knowledge in their work with families. All the volunteers said that the preparation course was enjoyable and useful in preparing them for their work as a Home-Start volunteer, but they felt they had gained much more in depth knowledge from our PIMH course:

“I enjoyed it more than the prep course. Even though it was only a few weeks we got close as a group. It was quite emotional at times, I was able to think about experiences that others had had, for example, having a premature baby. It gave an insight into different things.”

One of the things the volunteers valued was the fact that our course is co-delivered with professionals from the EAS and health visiting:

“They have worked with a lot of families too. You get more information from professionals about more serious things. It’s a professional telling us. It wasn’t too technical, though. I wanted to keep coming back.”

Volunteers enjoyed the resources that were used on the course, such as several life-sized foetal models:

“How the baby grows inside you. The models of the baby at different stages during pregnancy – talking to the baby in the womb is not so silly!”

The PIMH course had clearly had an impact on each of the volunteers and had encouraged them to think very differently about parent-infant relationships:

“Of all the courses I have been on, it’s the PIMHS course that has completely made a difference to my thinking. There were lots of things I never thought about. I wasn’t taught how to be a mum, I thought it was innate, but realise now that it isn’t.”

Volunteers found the course to be very emotional at times, as it encouraged them to think about their own parents and their own experiences of having children:

“I opened up on the PIMHS course. I had a cry at one point and felt silly. I spoke to Nancy about feeling silly – she said it was ok and helped others too. I was shocked that after just a couple of weeks I was able to share like that as I don’t usually. I didn’t regret it, though – others shared and it helped me with understanding other things.”

“People opening up has helped me to get a better understanding to help others. It’s nice to know it’s not just your own experience – it makes it real with real people. For example, when you go to a toddler group everyone says it’s all great, it’s good to know that others don’t find it that way.”

“It was therapy for yourself too, reassurance for what I did and not beating myself up. I can turn that experience to good use. People don’t recognise the effect that PND has on a baby.”

The volunteers had been able to put this new knowledge into use with their Home-Start families:

“As I was doing the course, I was matched with a family where mum had no maternal instincts. She ignored the baby. The course helped me to help her. I went back to the child to help her to see what the child needed. When the child does this, do that. She learnt to react to the child. I wouldn’t have done what I did without the course, it gave me confidence.”

“I am working with a family with a 3 year old. Mum had a c-section. She has got an older child. She doesn’t have a bond with either of them. I realise the impact of mum’s own childhood and can give suggestions of how to help.”

“Mum used to just plonk the baby down and prop a bottle up. I got her out and cuddled and fed her. Mum watched and then began to do the same. I let her get on with it rather than comment.”

“The family I am with have a four year old and a one year old. Mum has PND. I started the PIMHS course and began to observe more and look at what the baby is telling us. Mum said it was clingy. At first, she was focussing on the four year old and not interacting much with the baby, she said the baby was boring. I started to make a fuss of the baby, shouting her name and laughing and talking to her. The four year old wanted to play with a ball and I said the baby could play too. He said she was too young to play but we started rolling the ball and I said that she can play too. The ball went behind her, Mum told the boy to get the ball but I encouraged the baby to look for the ball. I haven’t been saying what to do, but just showing. I have noticed that the baby is now more independent, Mum is including the baby more and there is more interaction.”

“Originally I was to support emotionally and get mum out. Then I did the PIMHS course and was able to interact with the child while listening to mum. I feel that mum is now interacting with the child and Mum feels she is coping much better. Before the course I would have focussed on the practical things.”

Several volunteers stated that the knowledge gained on the course had impacted their whole way of thinking, not just in relation to their Home-Start volunteer work, but in their life in general:

“Retrospectively, I have thought about people I knew when I was young and realise that their problems may have been that they were suffering from depression. There was a lady on our street who used to go knocking on people’s doors – she probably just wanted to speak to someone. It’s also made me more understanding of my children’s friends and I give them time as they may have had a difficult past.”

“Ghosts and angels in the nursery – it made me think – I thought everyone who has a baby was the same but when I spoke out I realised that everyone’s experience is different – when you have your own children you put things in different ways. If you have PND your life is turned upside down and you still have a baby to care for.”


Discussion

This evaluation has clearly demonstrated that a fairly short, targeted training course for volunteers can have a remarkable impact. Based on the 52 volunteers trained so far, the most valuable and helpful concepts are: ghosts in the nursery, containment, the relationship between parent and infant starting in pregnancy, baby states and baby cues. Feedback from volunteers has been that the course has had a real impact on the way they support their Home-Start family because they have a deeper knowledge of how to support parents to understand and respond to the needs of their child.

Overall, the impact on parents’ experiences appears to have been even more dramatic than we could have hoped for. We are optimistic that this relatively modest expenditure of time and expertise will have real benefits for them, their children and the society in which they live.

The other point that the feedback has highlighted is the complexity of working with families at this level of intimacy. The relationship between parent and baby has got obvious practical aspects, like breastfeeding, but also has profound aspects relating to the parents’ own upbringings and experience. As such, it can equally have an impact on the people working with them. It is essential to recognise this, both in terms of staff and volunteer training, and in terms of the subsequent support available to them. All the things that can go wrong in the families with whom they work are things that could potentially go wrong with any of us, and this inevitably has emotional effects upon the workers as well as the families.

Of course, the beneficial effects for families can also enhance the lives of the people working with them. The comments from the volunteers above show this quite clearly. One volunteer subsequently wrote that the training promoted a sense of empathy with new parents, and made her rethink her approaches to this topic. She said: “The training makes you think about your own experiences with your own children too.”

For health visitors, there have been wide ranging benefits to this approach. In every direction, there has been improved networking and understanding of one another’s roles and available services, and this has helped support families. Some families have not engaged with health visitors and other agencies but have accepted the befriending approach offered by Home-Start volunteers. This in turn can support families to engage with services when they are ready. A healthy parent-infant relationship is the essential starting point for positive physical and mental health outcomes.

Acknowledgements:

This work was funded by both the CCG and Public Health commissioners. Their support and commitment to the ongoing development of early intervention services were vital. We are deeply grateful to Nancy Bradshaw, Mina Warden and Maureen Lancaster, for their passion, expertise and sensitivity in delivering the training.


References

Brazelton, T.B. (1972). Neonatal Behavioral Assessment Scale (Monograph). London: National Spastics Society.

Charity Commission (2000). The promotion of building community capacity. Reviews of the charity register, RR5. London Charity Commission.

Fraiberg, S., Adelson, E. & Shapiro, V. (1975) Ghosts in the Nursery: A Psychoanalytic Approach to the Problems of Impaired Infant-Mother Relationships. Journal of the American Academy of Child Psychiatry, 14, 387-421.

Institute For Voluntary Action Research (2016). Volunteering and early childhood outcomes: a review of the evidence. Big Lottery Fund: London

Lee, P., & Mee, C. (2015). The Tameside and Glossop Early Attachment Service: Meeting the emotional needs of parents and their babies. Community Practitioner, 88(8), 31-5.

NHS England (2014). 2015-2016 National Health Visiting Core Service Specification

Nugent, J. K., Keefer, C. H., Minear, S., Johnson, L. C. & Blanchard, Y. (2007). Understanding newborn behavior early relationships: The newborn behavioural observations (NBO) system handbook. Maryland: Paul H. Brooks Publishing Co.

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