by Ralph Bilby
This paper is based on a Plenary Address delivered at the Sixth International Seminar on the Clubhouse Model, Greenville, South Carolina, 1991.
On this occasion of our sixth worldwide gathering of the Clubhouse community, there is strong reason to take stock of the status of the principal vocational vehicle we use to help our members fully rejoin society through paid work. That vehicle, of course, is Transitional Employment (TE). In any such gathering it must be noted that TE was the creation of John Beard. Since our last International Seminar, we can point to progress in the use, understanding, diversification, and acceptance of the TE model throughout the Western Hemisphere and now in Europe.
It would be wrong not to point out that there are now many people in the mental health field, representing a range of vocational models and disciplines, who encourage and support Clubhouses and our use of Transitional Employment. We are all most grateful for their support. It is equally true, however, that TE continues to come under frequent criticism. In many published articles, and at numerous mixed gatherings dealing with vocational rehabilitation for individuals with mental illness, TE receives cursory review and is often written off as "an old model,", or "not up to date with current vocational technology." Even more thoughtful critics of TE consistently describe TE as a weak vehicle and, when compared to Supported Employment (SE), a less effective alternative. Although some Clubhouse programs have negotiated support for their TE effort with enlightened state and local vocational rehabilitation counselors, many Clubhouses have been faced with receiving financial support only for Supported Employment, and none for Transitional Employment.
It seems time, then, that we place our cards on the table and respond specifically to the criticisms that are being leveled against Transitional Employment.
1. TE is an unnecessary step in vocational rehabilitation since the major vocational problems faced by individuals with mental illness of job acquisition and learning are sufficiently addressed through SE. We in the Clubhouse community sometimes feel that we are working with individuals within a segment of the population of people with mental illness that our critics have never encountered. We find that our members come to us with a myriad of vocational problems beyond job acquisition and learning. Their work adjustment issues frequently include problems with punctuality, daily attendance, getting along with CO-workers, being able to take supervision, work endurance, staying focused on a task, prioritizing, and resisting the impulse to quit when things don't go the way they expected. As a group, they have generally had little work experience, often not successful, and sometimes no experience at all. They often have difficulty relating in effective ways in business settings. They must struggle with the disabling effects of long-term hospitalizations, psychiatric symptoms, stigma, and the many problems associated with the use of psychotropic medications.
Another key distinction between us and our critics appears to be our differing perception s of the process through which our members make vocational progress. Like many of our staff workers, and certainly including myself, we find that very few of the members are one-trial learners. They often have to struggle repeatedly with adjustment issues and vocational habits before they are able to make the changes necessary for success. For the most part, we do not find that the members can be talked out of their unsuccessful habits. To accomplish this change, the members generally require repeated chances to try and fail and try again through successive TE opportunities.
We are also concerned about our differing perceptions of the time it takes most individuals with mental illness to learn entry-level jobs. Our own experience tell us that despite the understandable initial anxiety the members experience in new job situations, anxiety which often diminishes with multiple placements, the members generally learn their placements quickly, often in a few days or a week. Many of our members feel that having a placement manager on-site for extended periods of time is unnecessary and stigmatizing. A best strategy in training is to give members the opportunity to define how long they feel they need help.
We further question the effectiveness of teasing out the vocational interests of men and women with mental illness who have either not worked successfully or not worked at all. We believe our members are better able to make choices about their vocational interests when those choices are based on multiple real-world work experiences gained through TE. In addition to strengthening successful work habits and skills, TE gives the members exposure to a variety of different jobs in different settings.
Finally, we believe that job developers in any program could develop permanent placements that are better in quality and pay for those consumers who come to them with conformable, current references.
The food service and cleaning industries may be so accustomed to their own staff turnover that they will give trial opportunities to part-time referrals that come with Targeted Jobs Tax Credit vouchers and 2 months or more of onsite staffing. Further research is required, however, to see whether such placements will last, and whether they truly reflect informed consumer choice in most instances.
On these issues, it would indeed seem that there are significant differences between us and our critics. We think that the major vocational problems faced by individuals with mental illness are work adjustment and psychiatric issues, not jut job choice, job acquisition, and job learning.
2. In order to create high member access to the TE system, placements must be simple, generally unattractive jobs.
The underlying basis for this criticism stems from the view that most TE placements consist mainly of food service and janitorial jobs. In actual fact, neither category of work is usually simple. Both types of work tend to be highly physical, often complex, and sometimes dangerous for members who lack dexterity and strength. These characteristics limit member access to these jobs. We certainly feel that such work provides useful vocational experiences for some members. To the extent that some Clubhouses have stopped TE development at food service and janitorial placements, however, we would agree that those systems are at best limited and, to a degree, unattractive. Of course, "attractiveness" is in the eye of the beholder.
Some very basic, lower demand placements, however, are certainly desirable in a placement system that seeks to engage every member in the program. In fact, such placements are the most difficult to find and develop. Clubhouses are always in need of such placements as route messenger, sit-down price tagging, shredding, cart sweeping in parking lots, hanger sorting, or envelope insertion in order to meet the seemingly endless member interests. In addition, the Enclave strategy specifically targets work opportunities where a group of 10-12 members, who do not have the confidence to work independently or repeatedly have been unsuccessful on individual placements, can work at simple tasks, on an abbreviated schedule, with full on-site staff support.
Such simple and routine placements, however, do not meet the evolving interests and abilities of the many members whose long-term vision is that of full-time, clerical-related work. Although all productive work carries dignity and teaches basic work habits and interpersonal skills, the most effective TE system will include a significant percentage of clerical jobs with diverse, fairly complex tasks.
A number of Clubhouses across the United States and Canada have now successfully developed and implemented office assistant placements, in which members perform a variety of tasks on an as-needed basis. Duties may involve delivering and picking up mail, photocopying, filing, faxing, and taking care of special mailings, as well as making trips to the post office or bank. Since each duty is not necessarily performed on a daily basis, training time is somewhat longer than that of more routine placements. Office assistant placements, tend, however, to have higher wages and to be more consistent with full-time office duties. As a result, these placements also provides stronger references.
In addition, such placements have been successfully sustained in offices with as few as nine employees, demonstrating the applicability of this strategy to small communities. Fountain House's three News Assistant placements with The Wall Street Journal, now 7 years old, testify to the sustainable nature of such placements with employers.
Another growing development in Clubhouse-based TE is in the area of data entry. A notable example is the New Foundations Club in Thunder Bay, Ontario, which has two positions with The Ministry of Natural Resources, paying $13 per hour.
In general, we find that the members are most willing to take the gamble on employment and make the most vocational progress for interesting jobs, working in nice settings, for fair rates of pay. It helps, of course, to have smart, secure supervisors, who are faster to pick up on both the business advantages and rehabilitative effectiveness of Transitional Employment. Every Clubhouse making serious efforts to develop an effective TE system recognizes that a diversified placement system, including a significant clerical component, is necessary to meet the varied and developing vocational needs of its membership.
We think that it is important to note that some Clubhouses, such as Lakeside House in Richmond, Virginia and Fountain House in New York, have taken the development of clerical-related placements so far that they now see the need to refocus on the development of a few more food service and janitorial type placements to meet member demand. It is in the range and mix of TE opportunities that creates the most useful system.
3. The TE commitment to absence coverage is excessively and unnecessarily staff intensive and promotes absenteeism.
Absence coverage is perhaps the most unusual, feared (by staff), and widely misunderstood component of TE. Specifically, the coverage commitment provides that, as part of the employer support system, absences will be covered through one of several paid member options or, as a final resort, by a staff worker.
The purposes and value of the coverage commitment serve in part to create a relationship with employers in which a significant placement failure is understood to be a part of the TE process. To sustain the relationship, the program takes on the burden of frequent member changes and unsuccessful starts by covering absences, training each member who tries the job, and bridging the productivity gap between ending and starting members. Without coverage, TE would face the same dilemma as SE. as the program would be under pressure to place only those clients who are predetermined by the staff to be "job ready." Using TE coverage, however, it is possible to show two, three, or four members a particular placement by way of choice, and then to sustain an average failure rate of 50% or more for members who have gone through personnel and full training. If the jobs gets done every day, employers are less likely to examine your completion rate and more likely to become vested in the business and rehabilitative advantages of the program. Coverage also allows us to negotiate more specific duties and hours for placements in order to create higher member accessibility, which in turn constraints training time and cost. If a specific job is guaranteed to be done every day, then we are more likely to be exempted from many companies' normal procedure that requires workers to cross-train for other departmental positions, in order to facilitate their own absence coverage options.
From the point of view of the member's vocational rehabilitation, developing the habit of going to work every day is one of the most common and difficult vocational struggles. Many of the members have spent years or even decades within a mental health system that is highly permissive of absenteeism. Clubhouse attendance itself is properly voluntary. Thus, the expectation of daily attendance on the job often contradicts old habits. With Clubhouse-based TE, an ethic develops within the Clubhouse community that absences must be reported in advance, and that explanations for absences must be credible-both important habits for long-term vocational success. A member will not lose his or her TE job because of one unadvised absence, but the issue of absenteeism is confronted much more directly by placement management staff workers under pressure to provide a coverage solution- and sometimes to do the job themselves.
Internal study at Fountain House indicates that absence coverage comprises only a small percentage of total staff time spent on all placement management components. We found that the average staff time spent on absence coverage of an individual 6-month placement is 11.5 hours, less than our average 11.7 on-site hours spent training for placement starts. The majority of coverage solutions come from the member on the other half of an 8-hour job who can earn extra money and stretch his or her wings for full-time work. One consideration in placement development, then, is to find jobs that can be divided into two or three slots in order to facilitate paid member coverage solutions. Another paid member coverage possibility is a "designated member fill-in," where a second member is taken through personnel and taught the job by the placement manager. Although this system sometimes fits a member's needs, a stronger and more preferable outcome would be to provide most designated member fill-ins with their own 5-day-a -week placement. In those instances in which staff workers must spend extended periods covering a placement while they search for a member to start, the inclusiveness of our selection process or the appropriateness of the job for TE should be carefully reevaluated.
4. Using day program staff workers as generalists to manage TE placement dilutes the expertise that vocational specialists can provide.
The argument that vocational specialists who focus exclusively on client evaluation, job development, training, and support are going to be more effective than generalists who perform such duties as only a part of their responsibilities, rests on the perception that specialists will grow in competence with experience and education. We would agree that there is a learning curve for vocational practitioners, but we also see a number of additional considerations when examining effective placement management.
The Clubhouse community, which sees TE as an intermediary vocational rehabilitation process and an integral part of the Clubhouse program, chooses to manage placements with a range of staff workers, including all of the day program staff, housing workers, secretaries, administrators, and even management. There are a number of compelling arguments for this unusual vocational training strategy.
As a result of their side-by-side work relationship with members, day program staff workers are better able to see beyond members' obvious disabilities and are more likely to appreciate and focus on their strengths. Thus, generalist staff workers are more likely to seek ways to include members in the vocational system, rather than screen them out using the intensive evaluation instruments that are commonly employed in referral systems.
Individual placements potentially can be sustained for years and even decades. This allows TE placement management staff workers to develop an expertise in training many members on a specific job, instead of learning and training a member on a job only once.
Using generalist staff workers, particularly day program staff, to manage the placement system means that Clubhouses are better able to trade on significant relationships between members and staff workers to encourage members to try jobs they might normally lack the confidence to take.
A Clubhouse TE system using broad-based staffing in teams of two is better protected against the loss of employer contacts and operations knowledge resulting from changes in staff than a vocational system that relies on a few specialists.
To the degree that vocational specialization has some merit, Clubhouses themselves find that there are staff workers whose interest and aptitude lead them
to have a higher involvement in TE than other staff workers. The distinction is drawn in that those staff workers continue to share in responsibility for other aspects of the program like advocacy, evening and weekend coverage, housing, and , most importantly, member day program involvement. If Clubhouse staff workers did not have the help of members in their work, we would consider it a waste of our major resource for engagement, which is the real struggle in rehabilitation.
5. Members are forced to take TE placements rather than having the option of going directly to permanent SE placements.
The foundation of this TE criticism is based on the national concern about increasing consumer choice of vocational options. In fact, we in the Clubhouse community feel that we have been much more responsive to the issue of choice, for a much longer time, than any other group in the field. Parenthetically, we believe that a client's vocational choices are negated if he or she is screened out of a program as not "job ready" or dropped because he or she has not been successful on several placements.
We are in complete agreement that Clubhouses should never require that members take a TE placement. If a member's entering vision includes a permanent job of his or her own, however, we do strongly recommend TE as a starting point. Few of our members come to us with a recent, successful work history. TE represents a guaranteed opportunity to get back into the work world without the barrier of competitive interviewing and without the requirement of successful negotiation of complex vocational screening. Our experience also tells us that members will be more successful in their independent job search if they are currently working, as their confidence in interviewing will be higher and they will have a current, comfirmable reference. Furthermore, having a job takes some of the pressure off of accepting less than one's desired vocational goal, when something seems better than nothing. If the goal is to help the members get the best job possible, then TE facilitates this process rather than hinders it.
A few members who join the Clubhouse with strong, recent work histories will prefer to save their SSDI trial work months for full-time work. Although their job search is more stressful, Clubhouses should not stand in the way of their choice and should assist them with the full range of job placement services. A number of Fountain House members have chosen that route, predictably with mixed results. Not infrequently, members who have not succeeded eventually choose to come back to a TE system that gives them better non-competitive jobs than they can get competitively without current references.
Choice is about freedom. We believe that a Clubhouse that provides non-tine-limited prevocational day program experiences and supports, with a range of enclave TE, group placements, individual placements, and assistance with independent employment, in a community where the ethic is to provide repeated work opportunities irrespective of failure, creates much greater freedom of choice than a program whose exclusive vehicle is SE.
6. TE has not been sufficiently researched to determine its long-term efficacy or to justify its status as a national model.
It is simply not true that TE has not been researched. In addition to research done at Fountain House by Mallard and McCrory in 1985, a number of non-Clubhouse researchers have testified to the effectiveness of Clubhouse-based TE as a vehicle leading to independent employment.
There is merit, however, to the argument that TE has not been sufficiently researched, or that research now 6 years old is diminished in its usefulness, For any vocational model, outcomes are certainly the issue. Those of us in the Clubhouse community who have used T over a number of years have no doubts as to its effectiveness as a rehabilitative tool. We are particularly proud of the model's member inclusiveness and the sustainable business relationships that it makes possible to forge. Experiencing and believing in the model's effectiveness, however, is a far dry from proving it through thorough ongoing, replaceable study. To do so requires hard research with large samples over an extended period of time. Such research should also include a diverse sampling from various Clubhouse programs.
We do have some unique drawbacks inherent in our model that have slowed the process of Clubhouse research in the area of employment. To begin with, we aren't very fond of specialists, be they researchers or otherwise. As noted elsewhere, to perform any Clubhouse activity that excludes member participation wastes the valuable member-engaging resource of those staff activities. Members can and do share significantly in the day program Research Unit at Fountain House and in other Clubhouses. The flip side of the members' participation, however, is the concurrent staff responsibility to help the members with their many social service needs, psychiatric crises, housing, socialization, and , in particular, employment opportunities. A Clubhouse research effort faces many problems and demands, and also satisfactions, beyond the effort of gathering information and publishing. If we are slow to publish, it is at least in part because we are all very busy simply making our programs work for our members.
Another factor that slows the process of researching Clubhouse-based employment is the model's insistence on member inclusiveness. This means that an extended time frame is necessary in order to view the model's real potential to achieve independent full-time employment outcomes. If you seek to include people with all levels of severity of mental illness, instead of using intensive screening to exclude those who are not immediately "job ready," you must expect that the vocational rehabilitation process is going to take a lot longer on the average. As a consequence of this "inclusiveness," our employment research must cover many more people over much longer periods of time to be meaningful and useful.
The fact still remains, however, that in this time of contraction in mental health funding and the resulting increase in competition for vocational dollars, we do need to begin to present solid research about the efficacy of our model if we are go get our fair share of the pie. We owe that to our members.
Beyond the economics of survival, TE and independent employment research by Clubhouse programs may uncover many dynamics of the process that can only strengthen our efforts. Led by Gateway House, and including the New Frontier Club and Fountain House, presentations will be made this afternoon that, among other things, will look at the time spent on TE by individual members over a series of placements. The potential for further exploration is enormous. Do enclaves and group placements lead to individual placement success? Is there an optimal frequency of placement opportunities for members who are struggling with TE completions but still want to work? At what types of placements do the members most often succeed, and are these necessarily the strongest vocational experiences? What are the reasons that members fail on placements, and can these failures be prevented with better intervention? Is there a relationship between rate-of-pay and full-time independent employment success? Our model will never be a "technology," but there is still much we can learn and communicate about the process of what we do.
Clubhouses have strong face validity that we have for perhaps too long focused exclusively on building the quality of our programs and expanding our opportunity systems. Many of us now believe that it is ultimately for our own good that the luxury of those times is past. We can and should compete for scarce resources, and research, particularly that research related to vocational outcomes, must be one of our principal methods.*
7. An arbitrary, 6-months completion for TE placements is unnecessarily disruptive for members who have successfully adjusted to a placement.
Training colleagues attending the weekly TE dinner at Fountain House frequently raise the issue of whether members should be made to move on from jobs they like and are performing successfully. Although responses are mixed, the great majority of the members state that although it is hard to change placements, they look back on the various jobs that they have held with different employers and feel that they have been strengthened by the variety of experiences. The purpose of TE is not to place the members in part-time jobs, which for many would be a disability-creating system. Rather, TE is designed to give members multiple opportunities to work through their vocational adjustment problems, build vocational confidence, and establish a comfirmable work history. The members' TE experiences are instrumental, then, in accomplishing the goal of helping them to obtain a good, full-time independent job. One commonly held misconception about TE is that the 6-months completion date is rigidly set. For some members, 6 months represents an attainable employment goal that they strive to achieve, choosing to take a break following a successful completion. Many others, however, prefer to keep working by taking placements back-to-back. A general 6-months target for completion consequently creates a system of forced review for the placement staff. As members approach 6 months, discussions are initiated with the member as to what they would like to do as a next step. Those completing 6 months also become fair game for placement staff workers who are seeking to find members who would be interested in working their placements. Since members have the option to accept or decline placements, it is not unusual for members to look at two or more placements before they find a job that they are interested in trying. As plans for placement changes develop, there is strong imperative (both financial and vocational) to keep successful members on their placement until they are ready to start their next job. Thus, it is not unusual for members to work 7, 8 or 9 months, or even longer, before they move to their next TE. Often, a week or two of desired vacation time can be accommodated during the course of a placement change. In this way, TE becomes a system of sequential employment, rather than individual placements interspersed with lengthy periods of unemployment. Hence, TE can and should be characterized with regard to placement duration as an exceptionally flexible, rather than a rigid, system.
We have seen several programs that, as a result of a change in their funding from TE to SE, now give their clients the option of permanently keeping any TE placement that they like. The results is that their better paid jobs, and in particular their clerical related ones, are quickly taken. What remains for the new entrants into the system is generally food service, janitorial work, and grocery bagging. An advantage of TE is the ability to develop an attractive, functional, diverse, and highly accessible system that hundreds of members will profit from using over many years.
8. Some members stabilize at the TE level but do not move on to full-time, independent employment.
The dilemma of members who do not move beyond the TE level to successful full-time jobs encompasses two groups. The first includes those members who struggle with TE placements throughout their Clubhouse membership and who never use these experiences to move on to full-time independent employment. The second includes those members who develop competence and confidence through their TE placements but resist the move to full-time independent work for a variety of reasons.
Both groups present different challenges to Clubhouses. The former, those who have difficulty over the years sustaining even highly supported TE placements, are generally struggling with a number of factors, including the cyclical nature of their illness, medication, many work adjustment issues, and endurance. Certainly programs using SE as their exclusive vehicle have noted the difficulty of sustaining work for many individuals with mental illness. Distinct, however, is the Clubhouse philosophy, which assumes that it is not possible to know in advance who will and will not eventually succeed vocationally. People do grow and change, particularly when they are given repeated opportunities to try various jobs. Every Clubhouse that has tried TE for several years or more has witnessed the growth of members who initially were not successful on placements, Sometimes the process is rapid, sometimes painfully slow, but our moral and professional responsibility is to continue to provide quality work opportunities for every member who asks for them, or, with our encouragement, is willing to try.
The second group, those members who eventually do well on TE placements but resist the move to full-time independent employment, present a different challenge. In reality, the natural dynamics of Clubhouses and the TE system encourage them eventually to take the plunge. As members see their friends and acquaintances move through TE on to good full-time jobs, the fear of giving up their benefits and trying a full-time job diminishes. Neither are the best of TE systems limitless in their opportunities. Members who have experienced unusually high satisfaction on a few placements will come to the realization that if they want a permanent quality job they will have to find it, hopefully with Clubhouse help, through independent employment.
There comes a time, of course, after a member has tried a number of placements, when the member and staff worker (of his or her choice) must consider whether a half-time or full-time independent job is the desired goal. Often, members will at first believe it is in their best interest to keep a portion of their public benefits and work on a half-time permanent basis. Our own experience tells us that members are much more likely to appreciate and sustain well-paid quality jobs. In the vast majority of instances, however, quality jobs are not to be found in the independent, half-time market. Furthermore, although all placement programs have the vision that a half-time permanent job will eventually lead to a full-time permanent job and can cite instances where this has occurred, our own experience, as well as discussions with other Clubhouses and SE specialists, indicates that upgrading from permanent, part-time to full-time is in fact rare.
9. More than any other model, we believe that Clubhouses best provide the single most important factor in effective vocational rehabilitation for individuals with mental illness, that of staying with its members for the long term.
Clubhouses using TE have not focused sufficiently on helping members move from TE to full-time independent employment.
We could not agree more. John Beard never intended TE to be more than a process, the middle ground of vocational rehabilitation. Independent employment, ideally full-time independent employment free of the need for continued public support, should be the goal of every vocational rehabilitation program. It is the stated goal of the Rehabilitation Services Administration. If Clubhouse opportunities stop at the TE level, we are as much responsible for a disability-creating system as an Se program whose every placement is at the minimally fundable level of 20 hours a week.
Although a significant number of members who have acquired vocational confidence and experience through TE will negotiate their own full-time jobs, Clubhouses cannot depend on that possibility for every member. Our own standards require that in order to be a fully functioning Clubhouse, we must provide an effective and aggressive effort to help member explore independent employment possibilities and issues, prepare resumes, go on job interviews, and resolve the impact of independent employment on their public benefits. The piece most often missing for the independently employed in all vocational programs is ongoing support.
An essential requirement in helping members sustain full-time independent employment is the availability of staff support during hours and days that are accessible to those working full-time. In addition to work day telephone contacts, individual counseling and support groups must be regularly provided during work day evenings and on weekends. A further advantage of Clubhouse employment support is the safety net of TE. If members are unsuccessful in their attempts at independent employment, and perhaps 50% of the members will be, they can quickly reenter the TE placement system while they sort out their next vocational step.
Although we firmly believe that we have the best model available to help people with mental illness to achieve rewarding, independent employment, we must all of us here, including Fountain House, concede the validity of the criticism that our focus and efforts to date are far from adequate. We must never lose the vision of the true freedom our members can achieve through good full-time jobs. We must reprioritize our efforts to facilitate and support independent employment, We must.
10. Enclave TE is a new "workshop" and its value is questionable.
Two years ago, Dick Rex, the Director of the Four Seasons Club in Binghampton, New York, a man I know to have high integrity and courage, came by me to see me while visiting Fountain House. He stated quite frankly that Fountain House had watered down TE and sold out the Clubhouse movement with its "sheltered workshop style enclaves." I suggested that he visit our enclave at Hoffritz and then we should meet again. That evening he said he was wrong, that the Hoffritz enclave was the strongest rehabilitation group he had ever seen for people with severe disabilities, and that he intended to use the concept for his own program. What struck Dick, as it does every visitor to an effective enclave, is the normalization of the work combined with the level of disability of the members who can be included. Consider the following comparisons to sheltered workshops:
Enclaves operate in the company's place of business and work at the same tasks being performed by other employees.
All enclave workers are paid the same prevailing hourly wage for their work, at least the minimum wage, regardless of their individual productivity level.
Furthermore, the members are paid directly by the employer, not the Clubhouse, thus creating a stronger conformable reference.
The staff role in enclaves is to help set up the work, provide quality control, and assist the members with their vocational problems.
The dynamics that make enclaves singularly effective include the fact that employers tend to judge the group's overall productivity instead of that of the individuals. This allows for much higher access for the severely disabled. Continuous on-site staffing adds to the productivity instead of merely charting member performance, further enhancing group performance and employer acceptance. Abbreviated hours and days, such as 3 hours a day, 3 days a week, create a schedule that is more sustainable for the severely disabled than the more common 20 hours a week for individual placement.
For those critics who attack Clubhouses for our "revisionist" enclave TE, we readily concede that enclaves are a more highly supported, less independent vehicle than individual TE placements. For us, however, enclaves represent the missing piece in a vocational stately that seeks to engage every interested member, We think that enclaves are significantly stronger than sheltered workshops as a vocational experience. If there are other vocational models who are having success in placing a large number of clients whose level of disability is equal to those members placed in Clubhouse enclaves, we sincerely invite them to share their methods with us.
I would not presume to believe that these comments have completely addressed every criticism of TE as it is practiced by Clubhouses. Neither do I believe that our many Clubhouse programs are beyond reproach. We at Fountain House are certainly struggling to strengthen and expand our TE opportunity system, as well as to improve our efforts to help our members achieve satisfying, independent jobs of their own. To the extent that it is thoughtful, fair, and open, criticism is an important and necessary ingredient in achieving our goals. We need to open our minds to hear it, thoughtfully consider it, and act on it when it is justified.
Since the presentation of this paper, RSV support of Transitional Employment has been clarified and strengthened: "The Secretary also wishes to point out that under the statute and current program regulations transitional employment is included within the definition of supported employment and is an authorized supported employment model. Thus, transitional employment must be an available supported employment model within each State's program for those individuals with mental illness for whom the State agency has determined this is appropriate, and can be the basis for a successful case closure" (Federal Register, 11/13/91, Vol. 56, No. 219, p. 27782.).
* Almost concurrently with this presentation, the following research outcomes were published in J.H. Noble, Jr. (August, 1991), The Benefits and Costs of Supported Employment for People with Mental Illness and with Traumatic Brain Injury in New York. Amherst, MA: The Research Foundation of State University of New York. "Transitional employment, as provided by Clubhouse programs such as Fountain House in New York City, was found to be more cost effective than the job-coach version of supported employment for people with serious mental illness. The eventual independence employment of 20 percent of Clubhouse participants yields expected lifetime earnings and taxpayers savings of $6.50 for every dollar spent on transitional employment."
