Community is an essential word in the vocabulary of any group of people that is engaged in the recovery of people living with mental illness. At Fountain House we call it a working community. My task here is to define the word community, indicate how the word aptly describes the daily currency of exchanges that occur at Fountain House, and explain why community is so crucial to our understanding of how we support our members in their recovery.
What’s in a Name?
But first, a story. An incident occurred at Fountain House a number of years ago that triggered this inquiry into community as the defining notion of Fountain House. Graduate degree students attending Fountain House on their field work placement were returning to their classes in social work reporting they spent their time watering plants or peeling potatoes. Their professors were perplexed, some infuriated. We at Fountain House were engaging their students in blatantly mundane activities unworthy of a professional. Social work as practiced at Fountain House seemed to fly in the face of their efforts to invest their students with a professional mantle, that of an expert. At the time, I felt that misconceptions were at issue. But I knew that we had to buttress the description of our work in a credible theory that held academic clout if what we do at Fountain House was to be considered appropriate professional practice in mental health. What was needed was to find the right name for what we do.
Human beings use names to understand what they are doing. It has to do with how our brains work. The names we use shape how we think about reality, what we see. So if we were going to communicate with the university professors and enable them to visualize what we do at Fountain House, we had to give our practice a name. Academics call it a "model." We needed a name with conceptual salience that would leap out from the page announcing: "I am a credible model!"
Names in Our History
Actually Fountain House has been pretty adept throughout its history in adopting names to explain its unique essence. From its beginnings, Fountain House viewed itself as an innovation in social work practice and differentiated itself from its contemporaries by employing special terms to describe itself that were indicative of its distinctive inner dynamics. Fountain House described itself variously as a social club, a work place, a family, and today a working community.
The first descriptor employed was as a social club. This name dates back to the time of WANA, the We Are Not Alone Society, which was a member-driven predecessor to Fountain House. Naming Fountain House a club indicated to patients who were leaving Rockland State mental hospital that opportunities awaited them upon their arrival in New York City; namely, the benefits of housing, education, companionship, and employment associated with the ethnic social clubs of post-war America.
Membership in a club also captured the sense of the peer-to-peer programmatic approach that permeated the early Fountain House. The doctors at Rockland State believed that peer support could be used with patients with mental illness in the same way they were treating patients for alcoholism. (Both Alcoholics Anonymous and the early Fountain House have their origins in a peer support model). The argument was that the patients’ shared experience made them credible coaches with each other. Thus calling Fountain House a club, where former patients were now considered members, signaled to those leaving the hospital that they would find a group of people like themselves who would help them make the adjustment back into society, just like the AA program did for people living with alcoholism.
John Beard arrived on the front steps of Fountain House in 1955, seven years after its opening. He was its fourth executive director. Frankly, he was the founder of how we think of Fountain House today. His ideas were based on a form of task group methodology he learned at Eloise, the hospital where he did his field practice as a master's degree student in social work in Detroit. At Eloise, Beard worked under the direction of a young psychiatrist Arthur Pearce to establish a curative environment for the patients by doing ordinary everyday things on the hospital ward―like wood working, painting, reading plays together, or making popcorn. They knew that, in engaging their patients in these activities, they were dealing with the healthy part of the person, not their psychoses. (Beard was in effect practicing what we refer to today as a strength-based approach.)
The team called their work AGT for "activity group therapy," and his work in this respect reflected similar initiatives going on at the same time in England under Maxwell Jones called therapeutic communities. Beard and Pearce broadly summarized their successes with their patients by noting: “the patient’s new experience in participation with others on a basic reality level seems to promote a process of reinstituting lost capacities; and that ‘AGT’ can play an important part in facilitating adjustment in the community, thereby potentially lessening the probability of re-hospitalization." (1)
Arriving at Fountain House, Beard secularized the activity group methodology he learned in the hospital environment of Eloise, replacing generic activities with a workplace framework during the day―the "day program" as he called it. Beard maintained that by adhering to a regimen of work during the day followed by social and recreational activities in the evenings and on weekends―in other words living a normal life like everyone else―members would feel better and be able to get on with their lives despite their illness. Creating a place in society for people with mental illness where the ordinary flow of life would take place was Beard's treatment approach to recovery in mental illness.
One of the most widespread descriptors adopted by the early Fountain House was that it operated like a “family.” It was a popular term that is commonly heard at regional and international clubhouse seminars. The term attempts to get at the primacy of relationships in the side-by-side way of working that fosters opportunities for personal growth that is the hallmark of the Fountain House approach. While the notion of a family has proved to be an acceptable metaphor to describe the operations of a clubhouse among ourselves, it does not work as a conceptual model to be applied in any broad scale diffusion in mental health practice sponsored under government contracts.
At the end of his life, John Beard referred to the essence of Fountain House as a community that was intentionally designed to provide a restorative environment for severely disabled psychiatric patients. The term, community, describes the nature of Fountain House as a unique contemporary intervention in mental health. The concept community is also crucial in situating the approach of Fountain House within the broader intellectual traditions of community psychiatry and social work, authenticating it as a credible model in social work. Why Community Works
Community is the perfect word to describe a practice in psychiatric recovery. Participation in human community is exactly what is denied to people once diagnosed with a serious mental illness. Fountain House members are excluded from relationships that occur in various domains of ordinary life―as an employee, as a student, as a friend. At Fountain House we seek to restore these human relationships within the contexts in which they naturally occur: such as, family, school, work, having a home. Thus communities are the right solution for the problem at hand, namely, isolation. From a functional point of view, community is our treatment in mental health practice.
Community also establishes meaning in member lives. Working communities do not create jobs or tasks that have been drained of their relational content. In community, in the words of the protagonist in The Godfather, everything is personal. Communities are relational endeavors where what I do matters. As Mark Maragnano explained in his article (2) on setting up work in the clubhouse, members take on roles in organizing the work of the house. Roles are relational; it is how I as an individual fit into broader groups. Forming communities is how we reconstruct the social nature of reality, in effect giving members a place where they can make substantive contributions that makes their lives meaningful.
Community is an apt description for an enterprise such as a clubhouse, which operates like a large task group.Clubhouses provide daily activities and chores framed by purpose and structured relationships with assumed roles and responsibilities. It is why we at Fountain House call it a working community.
There is also a tangible emotional content to all our exchanges - you can feel how Fountain House works. The sense of community creates an emotional congruence between the individual and the group, a good feeling about how one is being treated with respect and appreciation, which invites participants to voluntarily assume personal responsibility for the operations of the house. It is readily noticed in any authentic Fountain House-model program you visit in the world.
This feeling when one enters Fountain House does not happen by chance. Working communities are highly intentional in design and reflect the application of fundamental principles that govern the nature of member and staff relationships in mental health practice. First, we establish a need for member involvement in every activity we do by purposely understaffing. Combine that with the principle of member choice; the majority of the workforce we attract exercises choice in every aspect of their involvement. Members determine whether or not they will come to work on any one day as well as with whom and how they will work once they arrive at our front steps. Finally, we expect staff to carry out their responsibilities side-by-side with members. Beyond the “Staff Generalist”
Such an operation requires employing staff with a high degree of professional expertise: that of the social practitioner. Social practice is our professional expertise in restoring the social networks of the members as an aid in their recovery. There are two aspects to the expertise of the social practitioner that we have been able to identify.
The first, which we call transformational design, deals with the repertoire of skills and understandings that staff workers employ in transforming the immediate social environment in which the members and staff associate on a daily basis. Shared leadership in decision-making (i.e., consensus decision-making), modeling, and inspiring purpose are all standard tools in the hands of task-group facilitators at Fountain House. Fountain House further expects its staff to extend its transformational reach and be community change agents in advocating for social justice for its members. In effect the exercise of transformational design by staff, as well as others including members, transforms the structural ecology of the places we call clubhouses into numerous opportunities for participation and meaningful contributions on the part of the membership. We do this by transforming the standard processes of an ordinary workday into a social environment in which members feel that they have a rightful place and can make a voluntary, yet meaningful contribution despite their illnesses.
The second staff strategy, motivational coaching, concerns itself with the manner in which staff form significant, one-on-one relationships with members in support of recovery. In their coaching role, staff are encouraged to initiate significant relationships with members to remove impediments to participation and encourage risk taking―helping them bridge any chasms in their paths arising from fears and anxiety about embarking on a new undertaking. Coaching dictates the manner in which this is done so as to respect member self-determination, dignity, and choice. Moving the Conversation Forward
So in calling Fountain House a working community, we establish our practice as both a model that is unique in its treatment, community, and as a profession in social work, that of the social practitioner. Furthermore, in defining our work as creating community, we are in fact continuing a tradition that is overlooked in contemporary mental health practice but has deep conceptual roots in the traditions of group work in psychiatry and in the Settlement Movement of social work.
With community as a framework we have long practiced what contemporary social workers have only recently come to appreciate as best practices in social work. We establish Fountain House as a place where clients are valued for their strengths and intentions and where real, measurable empowerment is the result. The nature of the relationships among those involved in Fountain House, its quality of social exchange, is what separates us from other mental health agencies and challenges society at large in its treatment of people living with mental illness. We do not just espouse the values of human rights, collaboration, and empowerment by our words. Rather, we state them, as we do in the Standards (3), as declarative sentences of how we actually operate a clubhouse. In practicing the Standards, clubhouses thus build social justice into the architecture of their daily work.
Community has been at the root of our thinking about the nature of the Fountain House approach in mental health practice for the last ten years. Community at Fountain House embraces related terminology such as working communities, social practice, transformational design, and coaching in an effort to give all of us a way to speak to the academic community and the world at large. We invite you to join us in a dialogue about community and how community and its related concepts can help in improving the work we do on behalf of member recovery in our book Fountain House: Creating Community in Mental Health Practice. (4)
Alan Doyle, EdD Director of Education, Fountain House Paper presented at the 17th International Seminar, St. Louis MO October 20, 2013
(1) Beard et al. 1Beard, J. H., Goertzel, V., & Pearce, A. J. (1958). The effectiveness of Activity Group Therapy with chronically regressed adult schizophrenics. International Journal of Group Psychotherapy, 8 (2), p. 136.
(2) Maragnano, M. (2004). "Supported employment in the clubhouse," The Clubhouse Community Journal, 5 (August), 39-42.
(3) Series of practices developed in 1989 by Fountain House together with other established clubhouses in the world that defined the essential practices of the Fountain House approach. (Propst, R. N. (1992). Standards for clubhouse programs: How and why they were developed. Psychosocial Rehabilitation Journal, 16(2), 25-30.)
(4) Doyle, A., Lanoil, J., & Dudek,K. (2013). Fountain House: Creating community in mental health practice. New York, Columbia University Press.
The Veterans' Vision, Fountain Gallery's first ever exhibition devoted to the art of military veterans and their families, will open on Thursday, November 7th with a reception from 6 - 8 pm. This group show will feature artworks by four veterans and one Gold Star Family.
Obesity has been an issue for me for most of my life. Unfortunately, I have not taken my weight and my health as seriously as I should, and that has caused a change in the quality of my life. I’ve been encouraged by many people at Fountain House to partake in the wonderful activities that the Wellness Unit provides, and I’ve often declined due to frustration and fear. Seeing how the change in my quality of my life has impacted the things I want to do, I’ve been very inspired by the pre-diabetes group (YMCA’s Diabetes Prevention Program) that is offered weekly at Fountain House.
On Wednesdays, the pre-diabetes group meets in the Wellness Unit at 10:00 am. It is led by a woman named Judy, who is an employee of the YMCA near Lincoln Center. Her specialty is working with people who have eating issues that have led to a pre-diabetic condition. With her support and the methodology she teaches, she hopes that we can adjust our eating habits and thereby prevent the onset of diabetes.
Each week, Judy discusses a particular topic, teaching us how to eat properly. It is my belief that diabetes is caused by poor eating habits, many of which we as Fountain House members possess.
The first week she showed us how to track our food by writing down everything that we ate. That meant we had to be honest, even if we were eating high carbohydrate snacks that were detrimental to our health. She gave us each a package with very well defined instructions as to how to go about this. We needed to log our weight daily and keep a graph to monitor our progress. Often people with eating disorders are unaware of what they are eating, and they put things into their mouths that are not good for them. It was through this that we could get a gauge of what we were doing.
She then went on to have us track the fats in our food, learning how to decipher the various contents of any of the foods that we were eating. We were all prone to snack, so she brought in a series of delectable snacks and showed us how to decipher which was the better of the pack. It was not necessarily the one that we wanted to pick when we were hungry.
It is still at the beginning of the group, so there is so much more for us to learn. Changing the way we eat is a learning process. However, we are learning that what we do with our lives today impacts how we live our lives in the future. We have an opportunity to discuss our issues in a safe, supportive environment, where we can learn from our peers – other Fountain House members - as well as from Judy, who is trained in this matter.
I am very grateful for this group. It is very hard for me. Tasks like writing the paper and doing unit work are far easier, but learning how to be honest with the food and exercise that I do in my life has allowed me to look forward to a much healthier life, with a higher quality of life.
Patrick Kennedy recently launched The Kennedy Forum to coincide with the 50th anniversary of President Kennedy's signing of the Community Mental Health Act, the landmark legislation that signaled a sea change in the way people living with mental illness receive treatment. We applaud the Kennedy legacy, our friend Patrick, and the 50 years of the Community Mental Health Act. It was born of an immense vision; however we, like Patrick, think that the implementation of the Act is incomplete.
The Community Mental Health Act was meant to develop and fund programs so that people with the most serious mental illnesses – schizophrenia, bipolar disorder, major depression - could live successfully in the community. Somehow this effort is failing the group that was intended to be its priority, and prisons have become the de facto mental hospitals of the new century.
The reasons for this failure are complex. I do think that people involved with community mental health bear some responsibility. It is evident that we have not developed a network of places of support sufficient to help the group who needs us the most. There is a disconnect between the needs of the neediest and the funding and services available.
State governments clearly bear some significant responsibility for the problem since they reaped the funds from the closing of state mental hospitals but did not allocate them to community care. Instead they accelerated their use of Medicaid funding, a medical insurance system that lacks an efficient funding stream for the community support programs that are so vital for this group to live productively and successfully. Ironically, now state governments are caught in an ever-expanding Medicaid mill.
In order to truly fulfill the promise of the Community Mental Health Act, we must develop more places for people with the most serious mental illnesses, and states must step up to pay for the community supports that Medicaid is not designed to provide.
As many Fountain House members know, a hospital stay can be an isolating and scary experience for the patient. Whether a person is sick mentally or physically, the patient often has trouble accessing the hospital resources that would help him or her improve. Also, while a member often enjoys good support while attending Fountain House, a hospitalized member may find that he is somewhat forgotten. The shortcoming of support is particularly dire in cases when the member does not have relatives who can help.
Fountain House members and staff are working together to develop new forms of outreach that offer more support to members who are outside the clubhouse. Activities that fill part of this need are mobile outreach, conference calls, and in-reach visits.
Fountain House mobile outreach aims to extend support by visiting Fountain House members who are in hospitals, nursing homes, or homebound. Members and staff travel to the ailing members and provide relief in the form of general support, advice, food, FH literature, and other benefits to ease their isolation and help them get well. Many times a kind gesture to the suffering member is all that is needed. Mobile outreach teams network with hospital or nursing home staff to help provide for the special needs that are common among FH members. Also, when the health care facility is aware that the patient has an advocate in Fountain House, the facility is much more inclined to treat the FH member better.
Education Unit Leader Susan Lieblich understood the need of reaching out to the sick and, about two years ago, started organizing monthly day trips by van to ailing members. Around this time, I independently started visiting hospitalized members by subway about once or twice a week. My initial efforts ended after only a few months, since planning many visits a month required a lot of time, and I did not have much help. Also, it was difficult to decide whom to visit, since in any given week there were about a dozen sick members. Later, I transferred to the Education Unit to work with Susan on mobile outreach. I augmented Susan’s work by taking groups by subway to visit sick members about twice a month. Former Fellow Sister Agnes and now Education Unit Worker Bevin Reilly have helped plan the visits
Last March we began coordinating conference calls among members and staff at the clubhouse and members who are in nursing homes, homebound, or otherwise can’t get to Fountain House. Norman Feldman, who arranges the calls, said that the conference calls allow members to say hi to people they know and keep in touch.
The idea for these conference calls came from a meeting with the Geriatric Mental Health Alliance of New York (GMHANY). GMHANY made other suggestions, including considering ways of providing support to older members in the community before they become nursing home residents. Programs to help people stay at home rather than go to a nursing home are called Aging in Place programs. Some things that could comprise an Aging in Place program at Fountain House:
Younger members could work as home health aides, doing housekeeping work for older members who are no longer able to. With help from the Employment and Education programs, this could also develop into paid work in the health care field..
The Cook and Carry program that Culinary used to have could be revived as something similar to Meals on Wheels, which provides food to the age.
Members and staff could make repairs to older members’ apartments.
Employment could work with older members, who face age discrimination and other difficulties in finding work.
In-reach visits involve strengthening the bond between members residing in nursing homes and Fountain House by transporting the members to Fountain House for a day visit. Several members have made day visits, and we hope to eventually have an in-reach day every month, with a coffee club where older members can renew acquaintances.
We'd like mobile outreach, regular conference calls,and in-reach visits to become standard parts of outreach at Fountain House, just as other forms of outreach are currently standard.
Jonathan N. Brachman Education Unit, Fountain House
"I am now the most miserable man living. If what I felt were distributed to the whole human family there would not be one happy face on the earth. I must die or be better it appears to me. I awfully forbode I shall not.”