Last week was the final session in the Return to Balance series: a yoga, meditation, and massage class offered in the Wellness Unit. The team of teachers – Shoko, Elizabeth, Ruth, and our own, Anna - planned a wonderful celebration.
First, we set up for the class. Ruth led an introductory exercise with a ball; when a class member threw the ball to us, we had to share a thought about what we learned or how the class has helped us. I used Elizabeth’s basic quote, “Learn to listen to your body.” This activity was followed by a full class – from chairs to mats. After the class, Anna presented special cards to our guest teachers, and Ruth awarded a beautiful certificate to each participant. We whisked the mats and exercise balls away and moved the tables together. After all that work, we visited over a light, healthy dinner.
Being aware of your body is very helpful. Drink lots of water. Eat well. Exercise. Walk. Meditate. Breathe deeply. Stand straight. If you practice every day, your body will feel better and you will get stronger. We celebrated last week, but what we learned will not end with the class.
Many mental health consumers have the financial resources to enjoy their weekend leisure time but cannot, because they lack the social opportunities to fully participate. The Consumer Dinner Club that I coordinate attempts to provide a chance for consumers to congregate and better enjoy their weekends by offering the one resource that they may lack – each other.
The Consumer Dinner Club started with a modest group of three - my girlfriend, my best guy friend, and me. All three of us had met as Fountain House members and were used to frequenting diners in the Hell’s Kitchen area. We wanted to embrace more members, and also the limited diner-restaurants in Hell’s Kitchen were becoming tiresome. I decided to ask other FH members if they would provide me with their emails and cell numbers so that I could invite them to a restaurant elsewhere in Manhattan. Almost everyone who I spoke to said that they wanted to come and gave me their contact information.
In the beginning, I relied on members’ suggestions of restaurants (now I do my research on yelp.com, a web site that posts astute restaurant reviews.) At the start of the week, I send out my email invitation. The invitation lists details about the restaurant, such as its name and location. I also include some anecdotal remarks, such as what menu items may be best and the approximate cost of the meal. If the restaurant takes reservations (I usually choose restaurants that offer reservations and are group-friendly), I make a tentative reservation at the restaurant immediately. I ask that people RSVP by the end of the week, so that I can call the restaurant with a more accurate count.
In previous FH gatherings outside the house, prior to the formation of the Consumer Dinner Club, we have had a number of issues. Sometimes members would come mainly to hang out and would either order too little or tip too low (often very low). Also some members would come and behave inappropriately and embarrass the group.
Therefore, I have a few rules with regard to the Consumer Dinner Club. Firstly, everyone who comes must order dinner and everyone must tip 20% on their pre-tax balance. As is common with people on fixed incomes, Fountain House members have been used to getting a separate check for each person, so that each individual could tip what he or she preferred. This is still a good method for impromptu gatherings, but I wanted to ensure that people tipped adequately, so that we could be appreciated by the restaurant wait staff and management. The group receives only one check and I calculate each individual’s or couple’s amount owed, which is based on what they order and a 20% tip (as well as sales tax.
Secondly, to limit behavioral problems, I maintain control over who may attend the Consumer Dinner Club events. Club members are told that any guests they wish to bring must be approved by me. Usually I know the members’ desired guests and can assess whether or not they would cause trouble. In general, a Dinner Club member’s significant other or good friend will be welcome. If an attendee causes a problem, that person will not receive an invite again. I try to be ethical in my decision-making; I am mindful that although I may not like a Dinner Club member, the member may not be a problem to the group and therefore is welcome at the events. If I am ever overly concerned that my approach is becoming draconian, I am mindful that even Fountain House has rules about who may attend at the Clubhouse.
Thus far the Dinner Club events have gone well and our attendance continues to rise. At our last dinner we had a group of thirteen. Those who attend are genuinely excited about the events and enjoy them. We usually go out to dinner at a Manhattan restaurant and also a café afterwards to chat further. I try to choose a new restaurant each time. Currently, I plan two dinners a month. The events can be a little pricey for some members, so I suggest that members with small incomes try to come occasionally.
I am gratified that I am able to provide a service that is truly needed. Dinner Club members are able to develop better friendships with each other outside of Fountain House. At present the major attendees are Fountain House people, but I am thinking about opening the program to the entire consumer community in New York City.
In addition to the settlement house movement and milieu therapy, John Beard – the innovative social worker and former executive director who developed the Fountain House strength-based treatment approach - may have been influenced by his contemporaries, the Humanist psychologists of the 1950s.
How did therapeutic communities also influence Fountain House? In the ten years I worked closely with John, I never heard him mention Maslow, Rogers, Fromm, Horney, or Jung, or for that matter, any ideas he labeled as humanistic; nevertheless he believed that staff must be genuine and offer members basic acceptance and a significant relationship - beliefs consistent with Rogers’s client-centered therapy. John also felt strongly that all people need relationships, a feeling of rootedness, the opportunity to be creative, a sense of identity and a frame of orientation: the list of necessary human needs proposed by the famous Humanist Erich Fromm and prominently represented in the Fountain House community.
In general, Humanism in the 20th century was a reaction to the pessimism and lack of human choice embedded in both psychoanalytic and behaviorist theory. It optimistically speaks to our inherent potential as human beings. The concept dates back to Aristotle who stated 1) the individual is constantly trying to realize positive values from a core of human nature that moves from simple to complex 2) relationships should be concerned with sharing, giving, and taking care of each other and 3) people act from both self-benefiting and other-benefiting virtues. (Peterson and Seligman, Character Strengths and Virtues: A Handbook and Classification, 2004, pp. 22-25).
Nevertheless, as Rogers explained, there are negative events which can thwart a person’s natural upward movement and create pathology. As a result, this deep yearning for positive fulfillment can become weak and difficult to hear, but it can be stimulated to an increasingly noisy level by a social environment that supports it by focusing on people’s strengths. This idea of belonging to a social environment that supports self fulfillment is echoed by Maslow, who believed that belonging is a prerequisite to the development of a person’s self-esteem and self actualization.
In Karen Horney’s Neurosis and Human Growth, the client has a built-in propensity for self- realization. This hopeful notion is also consistent with Carl Roger’s Organistic Valuing Process, (1959), Abraham Maslow’s Self-Actualization (1968), Jung’s Concept of Individualization, as well as John Beard’s "need to be needed " conceptualization. The real need for member assistance in the Fountain House community creates a focus on members' strengths, as opposed to a focus on their pathology, an operational necessity. Other strength-based approaches utilize verbal analysis and social persuasion to build confidence but we believe, like Bandura, that talk alone cannot achieve the consistent changes in human behavior that build self-efficacy and esteem. Also this need for member participation in all of the activities of the Fountain House community destroys the traditional hierarchical relationship between staff and members and paves the way for significant, authentic relationships.
While observing the treatment of the physically disabled at the Rusk Institute in New York City, Beard became interested in the use of supports, like prosthetic devices and ramps, to create a hopeful reality for the disabled. This is manifest in his concept of “invisible social ramps” - the invisible supports built into programs and practices in the Fountain House community that make the larger community more accessible to members.
John Beard never formally identified himself as a Humanist, but these humanistic principles formed the basis of the treatment approach he developed at Fountain House:
an optimistic belief in human potential
the importance of relationships and belonging to a supportive community as prerequisite to self actualization
his two groundbreaking contributions to social theory and practice: his conceptualizations of his "need to be needed "and "invisible social ramps."
Had he been prone to writing, I believe John would be recognized as one of the leading humanistic practitioners of the 20th century.
Finally, the ideas of the Humanist psychologists, which include an optimism about the capacity of people and hopeful expectations for their future prospects, come to life in the Fountain House community, because as John Beard taught, our function is to help facilitate a member’s movement toward self-actualization by strengthening and building upon his or her existing strengths.
The next and final element in this series looks at today's strength-based treatment theories, which provide frameworks for the ideas we share and predate.
Julius Lanoil Education and Wellness Consultant, Fountain House
The documentary, Kings Park, produced by Lucy Winer was shown on Wednesday June, 20th at the SVA Theater in New York City. More than 150 people attended this event, many of whom were Fountain House members, panel speakers, and supporters.
Kings Park, a psychiatric institution located on Long Island, was established in 1885 and closed in 1996. At its peak in the 1950s, it housed over 9,000 patients. When the ward was open, it was a harbor for the people with mental illness who could not be taken care of outside of the institution. In the film, Lucy Winer interviews many of the patients and staff who used to work at Kings Park in order to show what psychiatric wards were like before de-institutionalization in the 1960's.
Kings Park was nothing like the hospitals we have today. In fact, few psychiatric facilities that resemble it remain open. In the documentary, the institution is depicted as a gruesome and disparaging space. As the facility was taped in its end stages with peeling wall paint, no furniture, and the absence of apparatuses, it may very well reflect the rooms as they truly were before closure. While revisiting the hospital, Lucy recalls that in the day room, there was nothing to enliven the place at all. The day room, she says, was just as bare as it appeared when she was filming.
In short, Kings Park was portrayed as a disaster, yet it was a necessity because patients had no other place to go. Some called it a safe haven, but the majority considered it to be worse than hell. Some patients stayed for many years while others, like Lucy Winer, were there only for a few months. As she delves into the past, she remembers being tormented by her stay on the hospital’s floor for violent women when she was 17 years old.
Lucy’s story is troubling and deeply concerning. She was diagnosed with schizophrenia and admitted to the hospital because of suicide attempts. Though revisiting Kings Park was deeply personal, she finds that there was more to say about Kings Park than just her own experience. Beyond this, Lucy finds a plethora of roles that the psychiatric facility played in society and mental health care.
She starts her journey by finding the providers who had her psychiatric medical records, and she soon realizes that, without the recollections of other people, she may never be able to tell the full story of Kings Park. As she interviews people, some patients remember awful experiences such as abuse, maltreatment, repeated and unnecessary restraint, and over usage of shock therapy.
Though the past of Kings Park may be irrelevant since few of these hospitals remain, the story’s ironic twist is that present-day facilities for many mentally ill people may be reverting back to resembling Kings Park. But this time, they are not psychiatric wards. Instead, these facilities are prisons, housing thousands of inmates, many of who have mental illness and are not receiving the services that they need.
The saddest part of the story is that it can truly be the luck of the draw that some mentally ill people gain access to places like Fountain House or Hands Along Long Island (HALI) clubhouse, which initially developed as a place for former patients from Kings Park psychiatric hospital. Throughout the panel discussion at the end, one psychiatrist who visited state prisons and administered psychiatric treatment to inmates discussed that there is hope for these people, but ultimately, the systematic criminalization of the mentally ill isn’t fair.
All in all, the film opened my eyes to the old realities of what hospital stays were like and makes me very grateful for not living in those days. In a time and place where Thorazine was the only dispensable medicine allowed and attendants were the only personnel in hospitals, many people were at a disadvantage and in a position to deeply fear assistance. Most of all, the film showed me how lucky I am to be at Fountain House, especially when so many people in the penal system are sentenced to time in prison, when all they may truly need is a community and some treatment to support them.
The strength-based approach to treatment originated in the writings of Aristotle, but its more modern development began in the 17th century. Moral treatment, as it was called, was supported by John Locke and other early Humanists. Humanism - with its emphasis on the worth and dignity of all people, the commonality of all human experience, the rejection of inappropriate authority, and optimism about the capacity of people - can be seen as the first context in which a focus on human strength building occurred.
In the world of mental illness, moral treatment - represented by, William Battie, William Tuke, Benjamin Rush and Philippe Pinel - was the first approach created on the belief that patients had skills and abilities that could be utilized in their treatment. For example, in England, William Tuke founded York Retreat where he created a family-style ethos. Patients performed chores to give them a sense of contribution, and there was a daily routine of both work and leisure. In the United States in the late 18th century, Benjamin Rush, eminent physician and humanitarian, developed humane approaches to treatment. He required hospitals to hire intelligent and sensitive attendants to work closely with patients, reading and talking to them and taking them for walks.
Also in the 1920s, the settlement house movement in the USA was another strength-based movement that influenced the Fountain House treatment approach. Similar to Fountain House-model programs, it related to the concrete needs of people in the local communities. Its emphasis on helping people fulfill the American dream through self-help, empowerment, family, community, support, training, social services and recreational activities had a powerful effect on John Beard through his social work training.
In 1945, in order to treat the so-called shell-shocked soldiers who had served in World War II, two hospitals were set up in England – Northfield Hospital in Birmingham and Mill Hill in London. Under the leadership of Dr. Main at Northfield and Dr. Maxwell Jones at Mill Hill, the strength-based ideas embodied in these hospital-based therapeutic communities gained full expression.
Stuart Whitely summarizes some of the tenets of this treatment in his article The Evolution of The Therapeutic Community. (Italics mine.) “When the leader interacts at the level of the group, his power can be magnified rather than dissipated.” At Fountain House, we call this working side by side. “It is not so much the occupation of the group but the participation in the group activity which is the curative factor.” It’s not the work but the therapeutic processes the work engenders. “Responsibility-sharing and mutual self-help lead to a decrease in passivity and dependence and to the abandonment of the sick role.” Members are asked to help themselves and others and to make choices. “Negative sanctions are less effective than positive reward in changing behavior.”
Unfortunately, the ideas developed in the therapeutic community movement failed to gain full realization because of conflicts between proponents of a strength-based treatment approach and the proponents of the psychotherapeutic treatment approach. Later, an offshoot of the therapeutic community, called milieu therapy, would have a powerful effect on Dr. Arthur Peirce - John Beard’s supervisor at Wayne County hospital in Eloise, Michigan. There, in 1950, they practiced AGT, the immediate forerunner of the Fountain House strength-based treatment approach.
The next element in this series looks at the influence of the Humanist Psychologists of the 1950s on the evolution of the Fountain House strength-based treatment approach.
Julius Lanoil Consultant, Education and Wellness Consultant, Fountain House
Magnolia Clubhouse was proud to cosponsor and present at the recent Partners in Wellness symposium held at Fountain House. The Clubhouse model continues to evolve, and Fountain House continues to innovate and lead our evolution. Magnolia Clubhouse is located in Cleveland, Ohio. Originally known as Hill House, we were established in 1961 as one of the first centers of psychiatric rehabilitation in the country. We’ve had historic ties with Fountain House since our inception.
In March of 2009 we invited Dr. Ralph Aquila to present with us at a statewide Community Psychiatry Conference. Dr. Aquila included his work with the Storefront Clinic, now the Sidney Baer Center, on the “Rehabilitation Alliance,” the integration of psychiatric services and primary care with the Clubhouse community. As a result of this presentation, the director of the Ohio Department of Mental Health and the director of our County Alcohol Drug Addiction and Mental Health Services Board encouraged us to replicate the Storefront Clinic.
The Clubhouse community of Magnolia Clubhouse enthusiastically entered into the process of implementing the “Rehabilitation Alliance.” We renovated our Carriage House and now offer primary care through collaboration with a nearby Federally Qualified Health Care Facility (FQHC), onsite in the Carriage House Clinic. Dr. Walter Clark, the medical director of the FQHC is our primary care doctor. Dr. Patrick Runnels is our medical director and provides psychiatric services. He is also the director of University Hospitals Case Medical Center’s Fellowship in Community and Public Psychiatry, and we're a part of the education of the fellows. As good fortune would have it, Dr. Runnels did his fellowship at Columbia University and trained with Dr. Aquila at the Storefront. Our nurse is also employed by the Cleveland Clinic in the Psychiatric Detoxification Unit so our clinic employs professionals from both major hospitals in Cleveland.
Our team is excited to work with the Clubhouse community, and everyone is enthusiastic about the community of hope and growth they are a part of. Members are receiving the integrated care they deserve. We hope to reverse the current tragic tide for those who live with mental illness and ensure that our members do not have lives that are 25 years shorter than others. In addition, the psychiatric services are enriched by the interaction and experiences of our members in the fullness of their recovery with the Clubhouse community. The Clubhouse is fully committed to supporting wellness, and it’s a joy to be a part of the strength of this alliance.
I am personally grateful to have been encouraged and guided by Fountain House and Dr. Aquila in implementing this innovation. We’re helping more Clubhouse communities understand how this replication can be accomplished. We believe this implementation at Magnolia Clubhouse has contributed to furthering our strength in the community mental health system both locally and across the state and will further the growth of the model in Ohio.
We are also committed to furthering the growth of the Clubhouse model across the country and across the world so that this method of rehabilitation and reintegration will be as understood and primary as medication. Our goal is that this integration within a Clubhouse community and the Clubhouse model itself will be available to all those who live with mental illness who wish to be a part of it. Clubhouses across the world are a human rights movement promoting social justice. At Magnolia Clubhouse, we believe the “Rehabilitation Alliance” is a very important and vital part of comprehensive community mental health care, social justice for those who live with mental illness, and the rebuilding of fuller, healthier and longer lives.
Lori D’Angelo, PhD Executive Director, Magnolia Clubhouse
The Sidney Baer Center model of treatment is a showcase for what only recently in the United States is recognized as best practice for persons with serious mental illness (SMI). The Patient Protection and Affordable Care Act of 2010, written to reduce the costs of care while optimizing the quality of care, identifies two paramount treatment needs for persons with SMI:
1) the need for medical care at the same time as, and integrated with, psychiatric care
2) the need for psychiatrists and other mental health specialists to play a leading role in other professionals’ care of those suffering from SMI.
The Sidney Baer Center has been demonstrating this treatment, and its enormous successes, for more than 20 years.
The greatest driver of Medicaid costs is hospitalizations. And the predominant profile of those hospitalized are people with mental illness (70%), substance abusers (73%), and dual diagnosed (54%). Among those hospitalized, 60% have housing problems, 28% are homeless, and 24% are staying with family or friends.
Sixty-eight percent of persons suffering a mental health disorder have a comorbid medical problem, and 29% of those with a medical disorder have a comorbid mental health condition.
There are 600,000 persons in the mental health treatment system in NY, costing the State $7bn; the Substance Abuse system serves 250,000, at the cost of $1.7 bn. Fully 20% of these individuals, discharged from inpatient units, are readmitted within 30 days. (NYSDOH Medicaid Redesign Team report, 2011).
These figures illustrate a system of care which is at once exorbitantly expensive and dysfunctional. It offers neither an appropriate level of care, nor a full complement of needed services, to those in our society living with mental illness and co-morbid disorders.
Fountain House’s system of care, incorporating a full medical practice along with the core units of community, is a solution to the bleak picture described above. The Sidney Baer Center has been offering integrated care for many years, as well as referral for more intensive treatment if necessary. And staff has been coordinating with other staff at Fountain House to ensure that members receive services which can accelerate recovery - a safe place to live, friends and colleagues to reduce isolation, and the opportunity to work. This model of recovery works, it is inexpensive, and it is humane.
It should be emulated, and soon, throughout the world.
Madeleine Tramm, PhD President, Tramm Consulting Group Fountain House Council on Training, Education, and Advocacy
I have been in Weight Wise, which meets on Tuesdays and Thursdays at 3 pm, for four weeks. I decided to go to Weight Wise to try to lose some weight. I have tried to lose weight many times using different programs and crash diets. None of it worked.
I think Weight Wise is different in that it teaches healthy eating, which is really important. The physical activity has been the hardest part for me, but I am getting better and taking the stairs at my house. I have been losing weight every week and feeling healthier.
I have earned over 100 Weight Wise points and expect to go to the next level in 3 weeks. This is very exciting to see something actually work for me. I find support from the other people, especially Louis, who was the first to get to Level 2, very inspirational. I look forward to continuing my healthy eating and doing more exercise.
Panel discussions were organized to address both local and national issues. The first panel presented the development of our integrated care model as initially conceptualized in cooperation with Dr. Ralph Aquila and St. Lukes’s/Roosevelt Hospital. A second panel included members and staff from Fountain House and the Sidney Baer Center, who described the everyday working out of the network of relationships between all the people who might be involved in each individual member’s wellness program. The third panel of the day was a presentation by Magnolia Clubhouse of their successful effort to duplicate our integrated healthcare model by providing a small psychiatric and medical clinic located close to their clubhouse in Cleveland.
On the second day of the symposium, we heard from outside experts on changes in the insurance industry and on state and federal initiatives to redesign health delivery and Medicaid systems. A final panel addressed the need for well-designed research studies that would evaluate the efficacy of our model of care for the enhancement of our members’ wellness.
The fundamental issue posed for all of us was whether it is feasible to replicate this model at other clubhouses across the country; for the participants in this symposium, the answer was clearly in the affirmative. The open discussion between participants also dealt directly with some difficult issues, e.g. conflicts that can arise for clubhouse staff in working in collaboration with members and their doctors; and the long-term worries that we all share about public funding for healthcare in the immediate future. On the whole, however, participants were optimistic about the opportunities we see for enhancing our partnerships for wellness.
In planning for the future, we have agreed to maintain regular contacts with the groups participating in this Symposium to keep each other updated on the progress of our programs. We will also pursue discussions of possible joint research projects involving more than one clubhouse, and consider the possibility of presentations of these ideas at upcoming regional or international conferences.
Howard Owens, MD Chair of the Council for Training, Education, and Advocacy Fountain House