Gold Award: The Wellspring of the Clubhouse Model for Social and Vocational Adjustment of Persons With Serious Mental Illness
The 1999 Achievement Award Winners
The American Psychiatric Association honored five outstanding mental health programs in an awards presentation on October 29 at the opening session of the Institute on Psychiatric Services in New Orleans. Fountain House of New York City, the originator of the clubhouse model of psychosocial rehabilitation, received the Gold Achievement Award in the category of small community-based programs. Project Link of the department of psychiatry at the University of Rochester in Rochester, New York, won the Gold Achievement Award in the category of large academically or institutionally sponsored programs for its initiative to prevent repeated incarceration and hospitalization of persons with severe mental illness. Each of the programs received a $5,000 prize made possible by a grant from Pfizer, Inc., U.S. Pharmaceuticals.
Certificates of significant achievement were awarded to the Clinical Safety Project at Atascadero (Calif.) State Hospital, the Comprehensive Pediatric Care Unit at Lucile Salter Packard Children's Hospital at Stanford University in Palo Alto, California, and the Hamilton-Wentworth Health Service Organization Mental Health Program in Hamilton, Ontario.
The winning programs were selected from among 91 applicants by the 1999 Achievement Awards board, chaired by Lesley M. Blake, M.D., of Chicago. The awards have been presented annually since 1949.
The origins of Fountain House date back to 1943 on the wards of Rockland (N.Y.) State Hospital, where a self-help group was started by patients and social work volunteers. As the group flourished, and patients were discharged into the community, they decided to formally band together for mutual support outside the walls of the hospital.
With the assistance of volunteers, funds were raised to purchase a small brownstone at 412 West 47th Street in midtown Manhattan to be used as a clubhouse. The building came with a small garden and a fountain. In 1948, when the clubhouse sought incorporation as a private not-for-profit agency, the name of Fountain House was adopted, as a symbol of hope and rejuvenation.
The first program of its kind in the U.S., Fountain House pioneered key interventions—such as transitional employment and community residential services—that have become well-respected strategies for facilitating the social and vocational adjustment of men and women with serious mental illness in the community. During its more than 50 years of continued leadership in the clubhouse approach, Fountain House has fought the stigma of mental illness and the barriers created by society's apprehension about community living and community-based activities for persons with serious mental illness.
Fountain House was also instrumental in establishing a training program to encourage replication of the clubhouse model. Today more than 300 clubhouse-model programs in the U.S. and around the world trace their origins to the Fountain House approach to recovery.
In recognition of its achievements in providing services to ease the community adjustment of people with serious mental illness, Fountain House was selected as one of two winners of the Gold Achievement Award for 1999. The award is presented annually by the American Psychiatric Association to outstanding programs for mentally ill and developmentally disabled persons. It includes a $5,000 prize made possible by a grant from Pfizer, Inc., U.S. Pharmaceuticals.
Fountain House was selected as the award winner in the category of small community-based programs. The winner of the award for large academically or institutionally sponsored programs is described in a separate article on page 1477. The awards were presented on October 29 during the opening session of the Institute on Psychiatric Services in New Orleans.
The Fountain House philosophy
Fountain House's mission is to provide opportunities for men and women with mental illness to live, work, and learn together while contributing their talents through a community of mutual support. The aim of the clubhouse is to help people with mental illness to stay out of hospitals while achieving their social, financial, and vocational goals.
The Fountain House vision encompasses the overarching goals of bettering the lives of people with major mental illness everywhere and ultimately of eliminating the stigma of mental illness so that people with mental illness can achieve their potential and be respected as coworkers, neighbors, and friends.
The clubhouse model was conceived as an intentional therapeutic community composed of people with a serious mental illness and generalist staff who work in the clubhouse. The basic premise of the model is that when necessary and cost-effective supports are provided to persons with severe mental illness, the cost of their medical and psychiatric care decreases and their quality of life increases.
Fountain House has been known for its innovative approach of separating club membership from the person's psychiatric diagnosis and its medical treatment. No medications are dispensed at the clubhouse, and no doctors are present. The clubhouse model seeks to provide for the societal, occupational, and interpersonal needs of the person and to form linkages with sources of care elsewhere to meet the person's medical and psychiatric needs. The people with mental illness who are part of the Fountain House community are clubhouse members, rather than patients, consumers, or clients.
Their membership in the clubhouse confers certain rights, including choice in the type of work activities or whether to work at all, choice in selection of a staff worker, access to all their personal records kept at the clubhouse, and a lifetime right of re-entry and community support services. Members also have definite responsibilities, including performing tasks that are essential to operation of the clubhouse. Work, both as a volunteer service within the clubhouse and as paid employment outside the clubhouse, is a major focus of every clubhouse program.
Clubhouse members
Membership in Fountain House is open to anyone with a history of serious mental illness. There is no upper age limit. All clubhouse services are free of charge to members. Referrals for the program come from hospital psychiatric wards, homeless shelters, clinicians, and family members or friends of persons with serious mental illness. Prospective members may refer themselves to the program.
Over its long history, Fountain House has served more than 16,000 individuals. Annually the clubhouse serves more than 1,200 men and women with mental illness from New York City's five boroughs. More than 40 percent of the membership is non-Caucasian: 33 percent are non-Hispanic African Americans, 8 percent are Latino, and 4 percent are Asian.
Fountain House-model programs throughout the world serve more than 25,000 people annually. All members of clubhouse-model programs have been diagnosed with major mental illness. In addition, a substantial proportion have a history of substance abuse, and many have a secondary developmental disability. Virtually all clubhouse members have an income below poverty guidelines and receive public support. In the U.S., members have an average income of $7,000 a year.
An array of services
Fountain House offers its members a wide range of services, including a work-ordered day on site at the clubhouse, opportunities for transitional employment and independent employment in the community, help in finding housing, help with entitlements and money management, and social activities.
Work-ordered day
The basic service offered by the clubhouse is the clubhouse itself, a place where people who are disabled by serious mental illness can go to spend time and take part in meaningful activities. Fountain House in New York City is open 365 days a year.
Through the work-ordered day program, which operates during regular working hours Monday through Friday, clubhouse members work side by side with staff on tasks that are essential to the day-to-day operation of the clubhouse. Members have the opportunity to participate in all the work of the clubhouse, including administration, research, intake and orientation, outreach, hiring, training and evaluation of staff, public relations, advocacy, and evaluation of the effectiveness of the clubhouse. Members are not paid for any clubhouse work. Rather, their volunteer participation helps them regain productive capacities and improve their ability to achieve vocational, educational, and housing goals.
Employment programs
Fountain House originated transitional employment—a program of supported part-time work placements for members—in 1955. Members work at the employer's place of business in the community and are paid at the prevailing wage rate, directly by the employer. The placements are part time and time limited, generally 15 to 20 hours a week and from six to nine months, and placement opportunities are available to members regardless of their success or failure in previous placements. Fountain House staff train the members and will fill in on the job during members' absences.
In 1998 the transitional employment program placed more than 400 Fountain House members at 41 New York companies, including law firms, financial institutions, and publishers. With few exceptions, these members are men and women who have been told that they will never return to work because of the disabling nature of their mental illness.
One goal of the transitional employment program is for members to move into permanent jobs. Members who are ready may participate in Fountain House's independent employment program, which helps them apply competitively for permanent employment in the community and provides support to help members keep the jobs they obtain.
Housing
In the late 1950s, in recognition of the substantial barriers people with mental illness face in obtaining decent, safe, and affordable homes, Fountain House began developing housing programs that reflected its philosophy of member empowerment and autonomy. It now offers an array of housing services ranging from supervised group settings where staff are on site 24 hours a day to supported independent apartments where members have the leases in their own names. Members choose the location of their housing and roommates.
The variety and flexibility of the housing programs enables Fountain House to offer housing solutions that can shorten hospitalizations or prevent them altogether. If a member is hospitalized, other members and staff actively reach out to help the person keep the housing placement. More than 450 clubhouse members participated in the housing program in 1998.
Other services
Case management services provided by Fountain House play an integral role in helping members gain access to opportunities in the community that are not offered at Fountain House. Basic education in literacy and computer skills is offered at the clubhouse, and members receive help in taking advantage of the adult education system in the community, returning to school to obtain degrees, or beginning a vocational training program.
Members are assisted with entitlements, money management, and advocacy issues and are linked to clinical sources in the community for psychiatric, medical, dental, and substance abuse services. The social recreational program, which includes activities offered during evening and weekend hours, helps members who have become fully employed keep in contact with each other and continue to benefit from the supportive relationships they have developed at the clubhouse. Fountain House also operates outreach programs for homeless persons and young adults with mental illness and special programs for deaf members.
Sustaining the clubhouse model
The National Clubhouse Expansion Program was begun at Fountain House in New York City in the late 1970s. Funded for eight years by the National Institute of Mental Health, this replication program eventually attracted substantial funding from Robert Wood Johnson Foundation and Pew Charitable Trusts. In 1995 the National Clubhouse Expansion Program was separately incorporated as the International Center for Clubhouse Development (ICCD). ICCD has coordinated and assisted in the development of Fountain House- model programs worldwide, working with people with mental illness, mental health professionals, family members, volunteers, board members, and local governments to establish and strengthen clubhouses wherever they are needed and wanted.
ICCD provides training in the clubhouse model and consultation in program development. Fountain House in New York City is one of the sites that offer the three-week training course. The international training program has provided comprehensive training to more than 2,000 mental health workers from 396 mental health facilities. As a result of the training, more than 300 community-based programs modeled after Fountain House have been established in the United States and 40 other countries.
The ICCD certification program, begun in 1995, certifies that a clubhouse is operating in compliance with standards that have been designed to ensure that it is a place that offers respect and opportunity to its members. The standards define the clubhouse model of rehabilitation and include provisions addressing the nature of membership, relationships between staff and members, responsibilities of staff, space requirements, services offered by the program, and administrative tasks. Certification assessments are conducted by the faculty of ICCD, experienced clubhouse staff and members who are also responsible for reviewing and approving the standards every two years. More than 150 clubhouses around the world have been certified through the ICCD program.
Staffing and funding
Fountain House and all Fountain House-model programs operate primarily through the volunteer efforts of their membership. Clubhouse members, working with paid staff, perform all necessary tasks that constitute the operations of the club. Members are involved in all areas of decision making and are included on the board of directors. In addition, at any one time, about 10 percent of the paid staff are people with serious mental illness.
The paid staff of Fountain House include 212 full-time and 15 part-time employees. Kenneth J. Dudek, M.S.W., is executive director.
Fountain House taps the expertise of the larger New York community through the employers' advisory council, a group of business leaders who work with staff and members in developing and expanding members' opportunities for paid employment. Community members also participate in Fountain House's council for training, education, and advocacy.
Having remained a grass-roots phenomenon for many decades, Fountain House and the ICCD have only recently initiated services research studies. However the clubhouse model is often included in service evaluations by nonclubhouse researchers, often as a comparison program.
Fountain House research staff are currently participating in an eight-site employment demonstration program funded by the Substance Abuse and Mental Health Services Administration to determine the relative effectiveness of different models of vocational rehabilitation. At one of the eight sites, in Worcester, Massachusetts, researchers are comparing the effectiveness of interventions modeled on the assertive community treatment program and on the Fountain House-clubhouse model. At Fountain House in New York City, program evaluations are done by the research staff, who also carry out quality assurance studies and audits for local, state, federal, and private funding sources.
The clubhouse model of rehabilitation has experienced rapid growth over the past decade. A relatively low-cost intervention, the model has received considerable recognition and strong support from consumer and family advocacy groups. For example, in 1996 Fountain House was named the Mental Health Rehabilitation Program of the Year by the National Alliance for the Mentally Ill. Clubhouse-model interventions have been designated as a preferred mental health service in several states, including Hawaii, Pennsylvania, Massachusetts, Michigan, North Carolina, and Utah.
Most states allow Medicaid reimbursement for clubhouse services or include clubhouse services as part of a prepaid or capitated Medicaid plan. Costs are kept rather low through reliance on bachelor's-level social workers and rehabilitation staff as front-line staff. Usually about half of the clubhouse staff are bachelor's-level practitioners who have received training in the clubhouse model through ICCD.
Fountain House's operating budget for the year ending June 30, 1998, was about $13 million. The budget for clubhouse services is about $6,000 per person per year, and the budget for the residential programs is about $21,000 per person per year. About 80 percent of annual funding comes from city, state, and federal government agencies. Funding from the private sector includes foundation and organization grants, gifts from corporations and individuals, proceeds from fundraising events.
Plans for the future
Fountain House is continuously seeking new ways of developing and providing innovative, state-of-the-art services for men and women with serious mental illness. A major project that is being implemented during 1999 is expanding the clubhouse's clinical linkages to provide additional psychiatric, substance abuse, and preventive medical care services to members living in independent housing, through referral from a mobile team of Fountain House staff and members. This program features proactive outreach and routine contact between the team and all supported-housing residents who are not otherwise engaged in clubhouse programs.
Residents who are most at risk of psychiatric or medical problems will be visited in their homes by team members, and part of the contact will include brief assessments of the resident's need or desire for additional services, with emphasis on psychiatric, medical, or substance abuse treatment. Residents who have not been otherwise engaged in ongoing medical care will be seen by a primary care physician at a Fountain House storefront facility.
Plans for integration of services needed by the resident in the community will be drawn up by the clinical team and implemented by the mobile Fountain House team, in concert with the resident and relevant others. Fountain House members, who have had similar life experiences and who often have better rapport with residents than do professional staff, will be key participants in this outreach effort. The mobile team will also provide services to residents in crisis or help reinitiate services for those who have discontinued treatment.
Fountain House has also taken a leadership role in preparing clubhouses for operating in the managed care environment. Fountain House staff, board members, and members are contributing to the design and formulation of a managed mental health care plan for New York State that will ensure continued or improved access to high-quality services.
Other activities that will affect the future of Fountain House and its members include coalition building with other agencies and programs to improve advocacy in the areas of entitlements, elimination of stigma, and other issues affecting people with serious mental illness. Fountain House also has plans to develop additional services for parents with major mental illness, to expand its program for young adults with mental illness, and to create other new programs in partnership with clinical and medical providers.
While looking forward with plans to expand services to members and increase the influence of its model of rehabilitation, Fountain House continues its accomplishments in concert with the principles it established in 1948. Then, as now, the Fountain House philosophy has held that men and women with serious mental illness have strengths beyond their disabilities and symptoms, and that their common humanity, potential, and wellness can and must be reached. Further, all members of the Fountain House community are entitled to a home, a job, and a chance to succeed with dignity, and all must have direct and real impact in determining the course of their rehabilitation and their lives.
For more information, contact Tom Sweet, Fountain House, 425 West 47th Street, New York, New York 10036; phone, 212-582-0340, ext. 304; fax, 212-397-7354; e-mail, [email protected].
