By Kenneth J. Dudek and Reva Stein
Kenneth J. Dudek is Executive Director of Fountain House in New York.
Reva Stein is Director of the Leadership Development Project in Boston, Massachusetts.
Abstract: This paper will show that programs utilizing the Clubhouse Model can be replicated. The benefit of replication is quality programs, which consumers of services and their families can count on while opening the door to a wide array of job and social opportunities.
In 1985, a group of people in Massachusetts was determined to expand the employment options and support for people who have a major mental illness. The vast majority of clients of the mental health system were unemployed, living on social assistance, and without employment options. The process began with a few people in state government and some in the community determining that the Clubhouse Model, pioneered by Fountain House in New York City, would provide the consistent support within an empowering environment that would make non-segregated, competitive-wage jobs in industry a reality for Massachusetts citizens with psychiatric disabilities. This was coupled with a belief that Clubhouses would provide the support that would enable people who have major mental illness to stay out of the hospital for longer periods of time.
The first step was developing a core group of people who understood the concepts of the Clubhouse and saw merit in bringing the idea to Massachusetts. At this point, there were a few struggling Clubhouse programs in Massachusetts trying to implement this approach with minimal support from any funding source. A core working group composed of family members, potential Clubhouse members, and the Community Support staff of the Department of Mental Health coalesced around a series of visits to Fountain House in 1985 and 1986. These visits were organized by the Community Support staff as a step towards determining if there was support in Massachusetts for expanding Clubhouses as a means of solving some of the significant employment obstacles faced by people with mental illness. During these visits, a working group came together for the common purpose of developing a network of Clubhouses using the Fountain House approach.
The Community Support staff, trained in various aspects of community organizing, set about the task of working within the Department of Mental Health while working closely with the newly developed working group. At this point, the Department of Mental Health had embarked on a statewide initiative called the "Governor's Special Message," which was an attempt to reform and improve services to people with major mental illness. This message consisted of a heavily funded hospital initiative and a moderately funded community initiative (case management, housing, emergency services, and some day programs.). The Department of Mental Health had no interest in Clubhouse programs at this point. Such programs were seen as unnecessary and secondary at best.
It is important to note that at the outset of this campaign to win support for quality Clubhouses in Massachusetts, the Community Support staff had minor roles within the Department of Mental Health and had little access to or influence with people in authority within the Department. What was available was a small amount of funding via a federal grant from the Community Support Program (CSP) at the National Institute of Mental Health. These funds were used to defray a small portion of the initial costs of the visits of Fountain House.
The visits to Fountain House were crucial to the further development of Clubhouse programs. The visits enabled family member and consumers to see for themselves the potential for a fully realized Clubhouse. The actual experience of seeing Fountain House members running the Clubhouse, working real jobs, and taking control of their lives was an emotional and pivotal experience for members of the working group. These experiences forged a strong commitment within the group to do whatever it would take to bring the Fountain House approach to Massachusetts. These visits also created a bond between the families, the consumers, and the Community Support staff. This bond and trust was crucial in combating the political pressure against the Clubhouse approach and the inaccurate information about Clubhouses that was prevalent in Massachusetts.
Over the next five years, the family members, consumers, and Community Support Staff worked as a team on a strategy to develop broad support for quality Clubhouses in Massachusetts. The family members worked to educate themselves and other family members about the Clubhouse approach. Support for the campaign spread throughout the state. This educational work expanded to include the legislature and a skeptical staff at the Department of Mental Health (DMH) who still felt that this service was ancillary to the significant work of the Department. The work of educating the DMH staff continued throughout the entire period and continues to this day. During the five years of this campaign, there were three different commissioners and at least seven different assistant commissioners who had decision-making authority around the issue of Clubhouse development. Without exception, each one needed to be educated and convinced of the validity of this approach.
The working group also faced an uphill struggle with some family members and the state Board of the Alliance for the Mentally Ill (AMI) which was at this time solely focused on revitalizing the state hospitals. Through the persistence of a few family members, the AMI board eventually agreed to adopt the Fountain House approach as their community platform and agreed to the development of the Fountain House committee, which became the first community initiative of the state AMI.
The Community Support staff worked within the Department to advocate for the Clubhouse approach and on a grassroots level with the families and consumers. One of the staff workers had a background in grassroots organizing, which proved a great asset since she proceeded to work on this project as if it were any basic organizing campaign. She met with people around the state, continued organizing trips to Fountain House, and built a constituency for the campaign.
The Fountain House committee embarked on a strategy to educate the legislature and to enlist their support for developing quality Clubhouse in Massachusetts. Over the course of the five years, family members met with their legislators numerous times, including making presentations at legislative hearings. The working group even rented a bus to take several legislators to see Fountain House for themselves.
As the movement to develop quality Clubhouses in Massachusetts grew, some mental health and rehabilitation professionals began to see the budding Clubhouse movement as a threat to their programs. They began to advocate against the development and expansion of the Fountain House model Clubhouses. The CSP staff came under attack at this point, and there was talk of firing them. Families and consumers advocated to keep the CSP staff, and no action was taken against them.
The Fountain House committee in 1986 asked the legislature to award funding to seven new Clubhouses that would use the Fountain House approach. They believed that this would prove to Massachusetts that Clubhouses helped people stay out of the hospital, live successfully in the community, and access real jobs in the labor market. The legislature chose instead to do a feasibility study. This study gave a favorable report on the Clubhouse approach. The working group took this same proposal for seven programs to the legislature the following year. A sum of $300,000 was awarded for two Fountain House model programs. The feasibility study demonstrated that each program required $400,000 in order to provide quality programming and provide the full support necessary to assist people on jobs and in remaining in the community. The expectation was set for DMH to match the funds with new program money that had been made available through the "Governor's Special Message" as well as existing state dollars. In the final analysis, this initial funding was modest, although it began a shifting of resources that eventually led to 10 million dollars of funding for Clubhouse programs in Massachusetts.
As support for quality Clubhouses grew throughout the state, vendors began to jump on the band wagon. Some were honestly determined to develop quality Clubhouses utilizing the Fountain House approach. Others were not committed to this type of service but pursued the funding for it nevertheless. The working group and the CSP staff worked with the Department to assure that as new funds were made available they were targeted to areas that were truly committed to developing quality Clubhouses.
On the local level, families and consumers worked to create a receptive climate for the development of Clubhouses. Some communities developed and incorporated free-standing boards to compete for the Clubhouse contracts. Other communities converted existing programs to Fountain House model Clubhouses. In order to be successful, each agency needed a strong commitment to the Fountain House approach to setting up a Clubhouse. This meant understanding the importance of Transitional Employment; providing well-trained directors and staff; making a commitment to turning over real power to the members of the Clubhouse in partnership with staff workers; being willing to give up all staff-only meetings; being willing to separate the Clubhouse from all clinical involvement (seeing the place for clinical services as residing in clinics and hospitals); and adhering strictly to the voluntary and lifetime membership policy of quality Clubhouses. This commitment further meant that the old way of doing business on many fronts had to cease. The directors and staff workers had to believe that people who have long-term mental illness were fully capable of holding down real jobs within the labor market, living in real homes and apartments, and functioning as self-determining citizens in the community when provided flexible support.
The Massachusetts movement for Clubhouses was successful in developing 18 Clubhouses utilizing the Fountain House approach. The effort is ongoing to assist these clubs in their efforts to provide quality Clubhouses that are truly run as a partnership between members and staff workers. There is now a strong push within these Clubhouses to develop more Transitional Employment jobs as an avenue to independent employment for the membership, to support members as they pursue their educational choices, to expand the Clubhouse into providing supported housing, and to grapple with such issues as substance abuse and transportation.
Quality Clubhouses that work on the principles outlined above require adequate funding. A well-established Clubhouse with an active membership of 200 and an average daily attendance of 100 members should have a budget of $400,00 to $500,000 to operate adequately. Most Clubhouses in this country are under-funded. In 1991, over 50 percent of Clubhouses had budgets of less than $30,000 per annum. Many Clubhouses are under the auspices of other mental health agencies. The income that the Clubhouse itself generates often does not accrue to its program, but is used elsewhere to fund other activities of the parent agenda. An adequate funding base is necessary to assure quality Clubhouses, and ideally, Clubhouses should have control over their budgets.
Over the years, Clubhouses across the country have developed and coalesced around a set of national Standards for Clubhouse Programs. The standards outline what is required of quality Clubhouses. They present a set of principles that guarantee some consistency in programming and help clarify the nature of the Clubhouse.
The most recent development in the Clubhouse movement in Massachusetts is the creation of a coalition of Clubhouses that are committed to the international Standards for the Clubhouse Programs. The coalition rose in response to system-wide budget cuts facing all mental health services. The coalition was successful in convincing the then governor and commissioner to prioritize Clubhouses along with housing and restore the budgets. A sum of $500,000 was returned to the Clubhouses, and they suffered no further cuts.
Of great importance is understanding the basics of community organizing. Most people, especially in mental health, speak a bout organizing and advocacy as something that takes minimum training and thought. Our experience was completely different from this assumption. The involvement of a professional community organizer who worked with families and consumers on defining their own goals and developing a strategy and tactics for meeting these goals was very significant.
A crucial element in the Clubhouse development in Massachusetts was the educating of family members and consumers. The more the families and consumers knew about what a quality Clubhouse consisted of, the harder it was for various mental health professionals to sway them from their course, and many tried. It was clear that seeing was believing, and although family members had heard about many wonderful programs, seeing Fountain House allowed them to compare other programs they knew with a quality Clubhouse. This made all the difference in the world.
Clubhouse programs are positive communities, not stigmatizing programs. It is the experience of many Clubhouses that once people with psychiatric disabilities get past seeing their peers solely in terms of their illness, strong bonds of friendship develop. The idea that people with psychiatric disabilities should not congregate together is based on the stigma of the illness. Integration in the community takes place not he job, living and participating in the community takes place on the job, living and participating in the community wit a base of support that the Clubhouse provides. It is our belief that peer support is a strong method of rehabilitation and that a true partnership of consumers of mental health services, family members, and mental health professionals is the strongest form of effective rehabilitation.
Many significant findings evolved from this campaign. Flexibility of service and individualization of services can be consistent with adhering to a core set of standards, principles, and services A high standard of quality and consistency of approach are excellent ways of meeting the needs of a large group of consumers and their families and, more importantly, achieving the tangible outcomes of jobs, housing, stability in the community, and basic survival. The Clubhouse approach is not just a model program. If implemented to its fullest extent, the Clubhouse can be a comprehensive community service designed to meet the specific needs of people who have a major mental illness. It is an excellent method of empowering a large group of people with psychiatric disabilities while providing a solid base of operations for its members to get their basic needs met including a job, a home, food clothing, financial assistance, an education of their choice, and a network of friends.
