Download - Psychosocial rehabilitation in the SPMI population An independent study on Clubhouse Model
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Breaking the Vicious Cycle: Psychosocial Rehabilitation in the SPMI PopulationAn Independent Study on Clubhouse Model.
Brent Johnson, BASW; LSW.
Submitted in Partial Fulfillment
of the Requirements for the Degree of
Masters of Social Work
Advanced Standing Alternative Program
The Ohio State University
July of 2015Century Health, Inc.
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Clients that suffer from severe and persistent mental illness (SPMI) despite available treatment
are challenged by many difficulties in society, such as homelessness, comorbid psychiatric and
physiological illnesses, significantly shorter lives than the general population, increased chance
of incarceration or suicide, isolation from family and friends, lack of work/ vocation/ overall
purpose, or education, social marginalization, and various other psychosocial stressors. To
address these issues experienced by this population and break the “vicious cycle” they are
ensnared in, communities and those in the helping professions must develop and implement
creative, multi-faceted, and evidence-based models. The following independent study examines
theory, outcomes, and application of one possible approach: The Clubhouse Model. This method
is examined through a literature review of various peer-reviewed empirical sources and also
explores two local programs in Northwest Ohio that incorporate many characteristics of the
model into their psychosocial rehabilitation programs. This includes the Northwest Ohio
Psychiatric Hospital in Toledo, and The Connection Center in Bowling Green. The research also
incorporates on-site interviews of consumers regarding their experiences in these programs.
The benefits of Clubhouses as well as eclectic models that incorporate Clubhouse standards in
their program seem to produce a multitude of benefits. Some of these advantages include
enhanced sense of empowerment, psychosocial sense of community, sense of belonging,
increased hope, employment, augmented skills, increased involvement in community activities,
enhanced access to medical/psychiatric services, and many other benefits all of which seemed to
be part of a multidisciplinary program that is cost-effective as compared to other widely used and
evidenced-based models. Given this research, communities and behavioral healthcare agencies
should consider pushing for implementation of Clubhouse programs to rehabilitate those
suffering from severe and persistent mental illness.
Abstract
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Acknowledgements
I would like to extend my thanks and acknowledgement towards my field liaison Nancy
Stephani whose guidance and suggestions kept me “on track.” I also would like to show my
gratitude to the staff of Northwest Ohio Psychiatric Hospital including Steven Hildreth, for
allowing me to interview him, showing me participants as they were engaged in the programs
available, and permitting me to interview these consumers. Verna Mullins who works for
Behavioral Connections and directs The Connection Center also has my thanks for allowing me
to tour the program, become involved in the activities for which members participated, and for
allowing me to interview the members. Lastly, my appreciation goes out to my friends who
helped me revise this paper and for the services of the OSU Writing Center. Everyone
mentioned played a significant role in my education on this wonderful model as well as being
able to produce a quality paper of this length.
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Table of Contents
Table of Contents……………………………………………………………………………………………... i
I. Introduction/Rationales………………………………………………………………………………… 1
II. Population……………..……………………………………………………………………………………… 2
III. Theory/Model……………………………………………………………………………………………. 4
IV. Application and Implementation………………………………………………………………. 10
A. Outcomes of Clubhouse: An Evidenced Based Practice………………………….. 10
B. Local Programs Using Clubhouse Within Their Eclectic Model………………… 23
B1: The Connection Center: Site Visit and Interviews….......................... 23
B2: North West Ohio Psychiatric Hospital: Site Visit and Interviews…… 31
V. Conclusions, Reflections, and Possible Application to Hancock County………. 33
VI. References…………………………………………………………………………………………… 37-39
i.
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I. Introduction
Individuals with a passion for assisting others with the end goal of jumping hurdles
presented by mental illness and granting the ability to live a more meaningful life often leads to
the pursuit of a career in the helping professions. While enhancing functionality and overall
livelihood is what clinicians often want for their clients, complications in the profession, such as
services impacted by burnout among staff, bureaucracy and associated limits to treatment
provision, lack of funding for essential programs, as well as other factors, interfere with reaching
this objective. Moreover, the behavioral healthcare profession often, due to its roots in the
medical model, “treatment is successful with elimination of symptoms” has left out the most
important part of helping clients: to achieve rehabilitation and truly flourish.
As a Bachelor’s level case manager working on an ACT team (Assertive Community
Treatment), I see the multidisciplinary team strive to help our clients thrive. However, due to
various difficulties encountered by the population (i.e. social deficits/poor social functioning and
conflicts in performing or accessing basic aspects needed for living a meaningful life), as well as
barriers to obtain resources and community in our county, I see patients, often times, isolated
from family, community, and not working, volunteering or engaging in some area to occupy
their time in a meaningful manner. I see clients who are so dependent on the system, who, yes
needed disability to meet their basic needs, but then lost any extrinsic incentive to work,
volunteer, be involved in community, or live active lifestyles. The desire to work and its
accompanying feeling of empowerment is lost. This is an unfortunate latent effect (obviously in
addition to their condition) of becoming dependent on the system. Repeated encounters of
dismissiveness, judgement, or “haughtiness” by community members, coupled with reoccurring
“functionality struggles,” such as the diminished ability to achieve/maintain meaningful
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relationships, gainful employment, as well as meeting basic needs, reinforce feelings of
inadequacy, “learned helplessness,” and other self-deprecating thought patterns.
The following independent study researches the important process of psychosocial
rehabilitation for this marginalized population. Helping these individuals sharpen memory,
increase social skills/independent activity of daily living, and enhance involvement with the
community and meaningful activity, as well as yield a sense of “I can do this!” is a facet I find
very important to this professional field. Therefore, the rationale of this paper is to explore
research performed on the Clubhouse model within the context of psychiatric rehabilitation and
enhancement in the lives of the SPMI population.
II. The Population
According to the most recent report by the Substance Abuse Mental Health Services
Association (2012) or SAMHSA, about 11 million people in the United States -- 4.8 percent of
the population--suffer from a severe and persistent mental illness (SPMI). The New York Office
of Mental Health (2012) or OMH notes that, to be considered SPMI, one must meet criteria for at
least one disorder as defined by the Diagnostic and Statistical Manual (DSM) V, or DSM IV-TR
for those agencies still using it. This condition is not to be solely substance dependence/abuse
diagnosis, organic brain disorders, social dysfunctions, or developmental delays (OMH, 2012).
Furthermore, the individual must experience at least two of the following: significant
difficulties in self-care (i.e. issues with compliance with medical advice or seeking out medical
care), significant impairment in Independent Activities of Daily Living (i.e. maintaining stable
housing, poor money management, poor hygiene, or poor use of community services),
ineptitude in establishing meaningful social relationships (compliance with social norms, poor
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social skills, inability to keep consistent relationships and appropriate/healthy use of leisure
time), or deficits in concentration, inability or excessive difficulty in completing tasks in a timely
manner (i.e. work and school). Limitations in these areas can present themselves in many ways,
such as repeated failure to complete simple tasks within the constraints of a time period and the
inability to complete objectives autonomously, both of which, often are also characterized by
frequent errors (OMH, 2012).
The SPMI population also struggles from health deficits at a much higher rate than the
general population. According to Mckay and Pelletier (2007), seventy-eight percent of those
who are considered SPMI suffer from at least one chronic medical condition. They are also
significantly more likely than the general population to be obese, have diabetes, contract an
STD/HIV, have a substance dependence diagnosis, high cholesterol or other chronic conditions
and, on average, live a total of twenty-five years less than the general populace (Mckay and
Pelletier, 2007; Norman, 2006). The population is also more at risk for homelessness, poverty,
psychiatric hospitalization, incarceration, comorbid mental health, substance abuse or chronic
physical condition, and suicide than the general population (Norman, 2006; Raeburn et al, 2013;
SAMHSA, 2012).
While medication-somatic services, counseling, peer support, and Community
Psychiatric Support Treatment (CPST) services can make a difference, many clients often feel
uncomfortable or intimidated by the treatment settings due to various reasons such as paranoia,
anxiety, or overall level of discomfort in this setting (Aquila et al., 2006). This may contribute
to why just under forty percent of the SPMI population is not linked into mental health services
(SAMHSA, 2012). The SPMI population who do receive services most commonly receive
medication services (54%) and then outpatient services (38%), while only 6.8% receive inpatient
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services (SAMHSA, 2012). However, those who are integrated in these services can still exhibit
isolation from the community, lack of meaningful activity and relationships, poor self-care, and
occupational issues.
For those both with and without service provisions, it is vital to receive services in a
variety of ways that augment daily functioning, presence of important relationships and
meaningful activity, along with involvement in community. Consequently the field of behavioral
healthcare/community mental health, as well as communities themselves, must continue to strive
for innovative, eclectic, and evidence-based approaches to rehabilitate the SPMI population. The
remainder of this paper will comprise of a literature review of Clubhouse Model which is
comprehensive of rationales/theory behind the model followed by a description of outcomes. It
will also include coverage of two site visits (conducted by writer) which display the application
and practice of Clubhouse Model combined with other psychosocial rehabilitation models within
Northwest Ohio. Implementation of Clubhouse in communities may be the answer for the SPMI
population who are seeking or would benefit from achieving psychosocial rehabilitation.
IV. Theories and structure of Clubhouse Model
The treatment for the SPMI must be extensive in order to address symptoms,
deficiencies, and needs associated with the conditions and lifestyles of this population. The
standard treatment often includes community psychiatric support treatment, as the population
often needs a “guide” to help them through services and to establish report so the clinicians are
trusted and get them into the treatment they require. Assertive Community Treatment is
typically reserved for those who are sicker (i.e. more hospitalizations, recurrent homelessness,
poor psychiatric compliance, and jail) in this population and includes more outreach and contact
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from a multidisciplinary team (Center of Evidence-Based Practices, 2011). This, in addition to
med somatic, individual/group therapy, occupational therapy and peer support make up some of
the services received by the SPMI population designed to help them live in the community.
While the previously mentioned tactics do make a great amount of difference in
addressing the positive and negative symptoms of schizophrenia spectrum disorders, major mood
disorders and other comorbid conditions experienced by the SPMI population, the presence of
resources in the community to enhance functioning on an informal and formal basis to address
their lifestyles plagued by the social deficits, occupational shortfalls, and poverty of
self-care/ability to meet basic needs are imperative. One key way to address these challenges is
through the implementation and provision of services within the community and services of a
Clubhouse. Clubhouses offer community rapport and belonging to increase engagement and
participation, while those benefiting learn skills and change their thinking to address these areas
that need changed. The Clubhouse itself has the same resources as the community and skills that
are so needed in this population, in a way that defines people as members, rather than by their
disability (SAMHSA, 2012).
Design, implementation, and maintenance of Clubhouse Model belongs to, is regulated
by, and is somewhat standardized by an international organization called the International Center
of Clubhouse Development (ICCD), which has values and requirements that the more than 300
certified Clubhouses in the world adhere to, as well as many “eclectic,” yet non ICCD-accredited
programs use (ICCD, 2013). To understand the Clubhouse model, it is key to be cognizant of the
principles, standards, and underlying theories associated.
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SAMHSA (2014) considers Clubhouse to be a “non-traditional setting” for mental health
rehabilitation with emphasis placed on informal, non-clinical services yielding community
integration, meaningful relationships, employment, and includes linking clients to mental
health/medical services. According to the ICCD (2013), Clubhouse model consists of a
community-based facility that serves those with severe and persistent mental illness and allows
them to access meaningful peer relationships, employment services and associated training,
housing services, skill building sessions, education and access to medical and psychiatric
services. ICCD (2015) also notes that Clubhouses are to be a safe environment which encourage
the sense of belonging and help individuals become more empowered, productive members of
society.
Certainly this model presents services that address key struggles experienced by SPMI
population, such as poor health, isolation, and lack of meaningful relationships, occupational
issues, and chronic unemployment as identified in the previous section. According to the
executive director of ICCD, Joel D. Corcoran, knowing the struggles of the SPMI population
who are "alone, overlooked, and invisible in their own communities…despite what many may
believe, are capable of rehabilitation” (ICCD, 2015).
Corcoran also discusses the “potential” of those suffering from severe mental illness,
asserting that they are capable of enhancing meaning in life, securing gainful employment,
establishing and maintaining meaningful relationships and taking part in community while
meeting their basic, medical, and psychiatric needs (ICCD, 2015). Corcoran notes: "at long last
we are coming to the realization that people with mental illness can live, work, and participate in
their community just as any other citizen" (ICCD, 2015). Part of this may be due to changes in
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structure between inpatient, long-term hospitalizations to community housing and the
improvements on medications in the area of efficacy and side effects.
According to Aquila et al (2006), deinstitutionalization was made possible by the advent
of atypical antipsychotics (both oral and long-acting injectable forms) for those with
Schizophrenia Spectrum Disorder as well as SSRIs and SNRIs and SDRIs combined with mood
stabilizers for those with major mood symptoms experienced in Bipolar Affective /Major
Mood/Schizoaffective disorders. One key point of progression with these new medications (in
addition to addressing the symptoms) is the decrease of prevalence and significance of side
effects such as tardive dyskinesia, weight gain, and somnolence leading not just for the SPMI
population to be able to live in the community, but most importantly makes rehabilitation and
independence more possible for many individuals. Corcoran declares his yearning for every
community to have a clubhouse, which he states would stand among other community resources
(i.e. library, school, or post office), but as “a local base of support for millions of people living
with mental illness” (ICCD, 2015). He argues that this would be a pivotal step in social
progression, leading to the diminishment of isolation, hopelessness, and despair in this
population, thus giving them hope and “a reason to wake up in the morning” (ICCD, 2015).
The principles of Clubhouse Model certainly display, at least on a theoretical basis, a
community-based, person-in-the-environment, informal strength-based model that should yield
rehabilitation and empowerment among other benefits. An additional advantage of this model is
for Clubhouses to adhere to these important ICCD standards, which requires them to perform
audits every two years (ICCD, 2015). Clubhouses that wish to be ICCD certified must adhere to
8 major standards. The standard of “membership,” or the first standard, is that those who
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participate do so voluntarily and, therefore, are able to equally access the opportunities available
to them. Moreover, they are to be called “members,” which offers them an identity different
than one of being mentally ill or disabled; rather this model offers them an identity as a
participant and intricate component of a reciprocal relationship between self and community
(ICCD, 2015). “Relationships” are another standard which is defined by the way that peers
interact with one another and the way members and staff work together. The process is
collaborative between members and staff; each have roles in the upkeep and augmentation of the
clubhouse, along with access and say in meetings and decisions the clubhouse makes, such as
hiring or new program development (ICCD, 2015).
The next standard of “space” is defined by the Clubhouse having its own identity,
including its own name, mailing address, and phone number from other entities (though it may
work with other entities such as behavioral health centers or colleges). The Clubhouse is to be
constructed and located in an environment that is “attractive, dignified, and safe” where
important work can be carried out towards the rehabilitation of individuals and the community.
Another key standard of Clubhouse Model, and perhaps one of the most well-known, is the
“work-ordered day,” which allows members to integrate in a more normalized, routine-based
lifestyle as people in mainstream society tend to follow (ICCD, 2015). The work inside the
Clubhouse is directly related to enhancing the Clubhouse itself, but also includes community
volunteer work. Members are not paid for this to encourage them to do this, instead, to value and
contribute to the community, making them able to feel that they are a true part of this community
and, subsequently, augmenting feelings of belonging and empowerment. Skill building is another
benefit with this work, as well as a sense of pride in the community within the Clubhouse
(ICCD, 2015). Additional adherence to this principle is displayed by Clubhouses being open at
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least 5 days a week during typical work hours and often during holidays. Staff and members
both plan the daily schedule and associated activities.
“Employment” is another standard and must be considered transitional employment
opportunities, supported employment opportunities, or independent learning opportunities within
the Clubhouse itself. Clubhouses often use their connections in the community to link their
members to gainful employment (ICCD, 2013). Clubhouses tend to have skill building trainings,
such as resume writing, and interviewing skills courses. Among the standards is “education,” as
it is key in this model for all Clubhouse members to have the opportunity to at least obtain a
graduate equivalent diploma. Another listed standard is “function,” which is characterized
simply by the fact that the member’s needs are met with an emphasis on social, healthcare, and
employment services (ICCD, 2015).
Lastly, “funding, governance, and administration” is the eighth standard. ICCD (2015)
describes this as the overseeing and management of the clubhouse which is characterized by
members and staff members working equally and “side by side” on elements of budget, hiring,
and other key aspects of services and resources the Clubhouse offers. Clubhouses must also
have an independent board of directors; in the case that it is affiliated with a sponsoring agency,
it must have a separate advisory board and individuals from the Clubhouse community that
address “the legal legislation employment development, consumer and community support, and
advocacy of the Clubhouse” (ICCD, 2015). While it is an intricate model, the Clubhouse
encourages principles that would greatly benefit the SPMI population through manifesting within
the realm of possibility the integration into the community and having a key role in the
Clubhouse. This leads to empowerment, as well as meeting many resources and needs through
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the community, such as health and wellness education, and meaningful relationships all within
the least restrictive environment.
V. Evidence Based Practices: Peer reviewed outcome research and
application/program development.
A. Literature Review of Data and Studies Outcomes:
The theory of Clubhouse Model does certainly seem sound as it seeks to empower
individuals through prideful community involvement. The theory is designed to assist individuals
in service linkage, employment, attainment and enrichment of meaningful relationships, as well
as enhancement of their overall functionality, and quality of life. In addition to the importance of
having a comprehensive theory behind this model, it is also crucial that the services pan out in a
way that makes favorable changes in the community at a reasonable cost as to entice an entity or
community to implement the model. This section reviews multiple sources that seem to indicate
these positive changes are experienced by Clubhouse members.
The Substance Abuse Mental Health Services Association (2013), considers Clubhouse to
be an evidence-based model. In their review of outcomes data, they have found that Clubhouse
model yields three major benefits to the SPMI individuals that it serves. This includes an
increased quality of life, augmented perception of recovery and engagement in treatment, and
employment (SAMHSA 2014).
Many other peer-reviewed studies also yield similar results; the evidence of at least three
studies, through self-report of the Clubhouse members sampled, have similar conclusions of all
three domains of outcomes that SAMHSA has established this model to produce. One study by
Herman, Onaga, Pernice-Duca, Ferguson (2005), published in the American Journal of
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Community Psychology, showcased the psychosocial sense of community (defined as a sense of
belonging to a larger dependable structure), as well as other reported key traits of clubhouses,
sampling 10 ICCD accredited Clubhouse programs in the United States. In the study, researchers
organized and facilitated focus groups of members, having them sort a large quantity of
statements of services and outcomes in different categories that they found applied most to their
experience through a technique called “concept mapping” (Herman, 2005). The study found that
members selected items which could be grouped in four generalized areas which included:
recovery, social connections, membership, and tasks/roles (Herman et al., 2005).
To further understand these areas it is important to look at some of the data from the
analysis section. Examples of frequently selected options for “recovery” included that Clubhouse
“helps me cope; helps me get self-esteem; get a sense of being appreciated—I get calls if I do not
show up; you have pride in yourself; helps me deal with my mental illness” to name a few
(Herman et al., 2005). Items for “social connectedness” included clubhouse helps: “sharpen my
communication skills, helps me go to outings and events, belong to a subculture and helps me
develop social skills” while tasks and roles included items such as: “gives me something to look
forward to and gets me out of the house; I have a specific job to do when I go in; place to learn to
work with others; have something to keep you busy all the time; and helps you find a job”
(Herman et al., 2005). Lastly, “membership” items that typically were selected included: “feel
understood; safe environment; promotes unity; teaches me how to get along with different
people and feel accepted by them; rebuilding trust with others again, and to feel understood.”
In addition to the categories of what Clubhouse provided for them, they also rated aspects
of their Clubhouse by value on a measurement tool from 1-5 where 1 was unimportant and 5 was
very important. Recovery, choice and control, partnership, psychosocial sense of community,
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social support outcomes and social relationships were found to be the most important values and
averaged at least a 4 on this scale (Herman et al., 2005). In the same study, Clubhouse staff that
were interviewed found that affirmation and support of members as evidenced by items such as
“self-improvement, as well as asking about goals and dreams,” and shared experiences (i.e.
volunteering and participating in community projects/after-hours natural relationships among
members and staff) to be two components of their Clubhouses that are most significant. Staff
sampled also tended to rank items such as tasks and roles (i.e. members helping members as well
as having enough purposeful activities for members), and Clubhouse organization (i.e. each
person ensuring the Clubhouse is a safe place and members interviewing for new staff) to be two
of the other most important aspects offered (Herman et al., 2005).
The second study published in Scandinavian Journal of Caring Sciences by Norman
(2006) found similar results; they utilized a combination of cognitive maps, taped interviews,
flipcharts, and notes. Researchers found three aspects most reported as important services offered
at Clubhouses including: meaningful relationships, work tasks/employment, and a supportive,
safe environment. Many members stated that before Clubhouse they felt isolated and/or uneasy
to when it came to interacting with others (Norman, 2006). They also mentioned there were
helpful employment services, being able to have peer role models or be role models for others,
and many mentioned when they would attend less for various reasons (i.e. paranoia, learned
helplessness, or lack of resources) that the Clubhouse would do outreach to them. Additional
details included that members felt the Clubhouse promoted possible employment and
encouraged/helped them to address psychiatric and medical conditions through formal treatment
(Norman, 2006).
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Supplemental to the research from these sources is a third study which compares the
Clubhouse model with another widely used informal community care model: the peer run drop in
center (PRD). Performed by Mowbray, Woodward, Holter, MacFarlane, and Bybee (2008) and
published in the Journal of Behavioral Health, the study compares a pair of 31 “geographically
matched” CRDs and Clubhouses and sampled around 90% of their members at 787 consumers in
the CRD and 892 participants at Clubhouses (Mowbray et al., 2008). Testing materials included
the Colorado Symptom Inventory, The State Hope Scale, The Personal Outcomes Global
Quality of Life Inventory as well as another set of demographic related questions (i.e. asking
diagnosis or if they are on SSI). Mowbray et al. (2008) found that more Clubhouse members
reported received regular mental health treatment than the Consumer Run Drop in Center sample
reported.
Clubhouse members were also more likely than CRD members to be oriented to recovery
with 71.2% of Clubhouse sample as compared to the 52.3% of the CRD sample answering
questions affirming belief and understanding in the steps and involvement in their recovery
process (Mowbray et al., 2008). Individuals taking part in the Clubhouse model also reported a
higher quality of life than the CRD sample (Mowbray et al., 2008). Clubhouse members spent
more time and more days involved at their facility than those of CRD Center (Mowbray et al.,
2008). Active involvement, therefore, is a strength of the Clubhouse model as these results
indicate a higher rate of engagement in the community, which is akin to the principles of this
model of an environment that enhances its members reducing stagnation with active engagement
within this community.
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Additional studies, though the crux and focus on the research was on one specific domain
of outcomes, also found similar conclusions in these areas SAMHSA found to be strengths of the
model. Macias, Rodican, Hargreaves, Jones, Barreira, & Wang (2006) indicate that Clubhouses
tend to lead members to be more integrated into treatment as well as develop social skills/make
friends, augment self-esteem, and safe environment, while Lysaker, Bond, Davis, Bryson, and
Bell, M. D. (2005), as well as Aquila, Malamud, Sweet, and Kelleher (2006) found, within their
samples, an increased self-esteem and perception of recovery, and lastly Schonebaum, Boyd, and
Dudek (2006) and Raeburn (2013) also assert that those in their studies reported greater access
to community resources and development of healthy relationships with peers and staff.
Supplementary to SAMHSA’s (2014) findings and the other cited studies of outcomes in
the domains of quality of life, perception of recovery and vocational rehabilitation, other sources
indicate further outcomes on the benefits of Clubhouse model. One key area of research is how
Clubhouses have implemented programs to address the drastically increased likelihood of the
SPMI population to suffer from chronic medical conditions as compared to the general
population with conditions such as diabetes, morbid obesity, heart problems, and HIV/AIDS
(Norman, 2006; Raeburn et al, 2013; SAMHSA, 2012). At least three major, peer reviewed
sources have been published on this issue.
In addition to these vital benefits, Clubhouses also address the chronic health conditions
that this population is significantly more likely to suffer from. At least two key studies evidence
this effort and overall attempt of Clubhouses to provide services to remedy these concerns.
While the literature review in this paper did not yield results comparing clients before and after
Clubhouse on health due to difficulties with this population (i.e. surveying paranoid
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schizophrenics who are not integrated in services is challenging to say the least), it does indicate
that services are widely provided in the Clubhouse model to prevent or otherwise address these
issues. One study, published in the Journal of Psychiatric Rehabilitation by Mckay and Pelletier
(2007) surveyed 219 directors of Clubhouses and their members in 31 states and 18 other
countries. Clubhouse directors sampled identified smoking cessation, nutritional education, and
weight loss programs as the top three important initiatives in regard to health and wellness
required for their members (Mckay and Pelletier (2007). Of the services provided to address this,
77% surveyed indicated that they had programs for physical exercise, 70% indicated they had
nutritional education groups, and 68% had health education groups (Pelletier, 2007). SAMHSA’s
(2012) mental health report indicates that Clubhouses surveyed reported higher percentage of
programs offered in these areas with 90% providing services to assist members to access benefits
(i.e. SSI/SSDI, Medicaid, and SNAP), 84% providing wellness, nutrition, and health promotion
activity, 79% providing linkage to physical health/dental care services, and 71% providing
transportation to the Clubhouse and appointments in the community.
Working with other local entities is common for Clubhouses in their attempt to integrate
their members in community and meet their needs; addressing the medical needs of their
members is no exception. At least one peer reviewed source, the Journal of Medscape General
Medicine, looks into this. In this study, Aquila, Malamud, Sweet, and Kelleher (2006) take a
look at Fountain House (the original Clubhouse) in New York City and its physical health and a
program implemented through the Clubhouse to have through a multidisciplinary team between
two New York City facilities, as well as St. Lukes/Rosevelt Hospital Centers to implement a
health program which began in 1992. “The Store Front,” as the program is called, offers these
services and was built in close proximity to the Clubhouse so members could easily access it
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when it became clear that the members of the Clubhouse desperately needed medical care, yet
were unable to access it as well as needed. Aquila et al. (2006) notes that the Store Front has
three part-time psychiatrists, one part time personal care physician (PCP), one part time nurse
and clerical staff.
The store front offers services such as regular Weight Watchers, diabetes education, and
nutritional education groups, a combined 12 steps chemical dependency and psychotropic
medications education group, and smoking cessation meetings. The program also implements
linkage and coordinated services between mental health professionals and community agencies
(Aquila et al., 2006). Aquila et al. (2006) note that this frequently grants Clubhouse members
access to the integrated services and empowers them to receive diagnosis and treatment to
address various conditions they are challenged by (Aquila et al., 2006). The study includes a few
examples of Clubhouse members, two of which were given as examples, where the center found
they had medical conditions such as cancer while the other found they had a disease of the gall
bladder, which they were able to discover from receiving services from this program (Aquila et
al., 2006). Through these services, this study implies a decrease in costly emergency services,
such as ER visits, psychiatric admissions, and medical admits, improvement in physical and
mental health for individuals, personalized and customized treatment plans, and enhanced
communication from various service providers as advantages (Aquila et al., 2006).
Additional to confronting health issues in the population, Clubhouse model seeks to yield
rehabilitation through work, skill building, and tasks. An overwhelming majority of Clubhouses
offer some kind of assistance with finding employment and building the skills required to obtain
hire; according to SAMHSA (2012), with Clubhouses often offering more than one type of
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employment service, 97 % of Clubhouses provide transitional employment, 95 % independent
employment, and 94 % supportive employment. Quite a few members are also working; for
example Plotnick and Salzer (2008) in a study of twenty nine Clubhouses found that on average,
31% of the members were employed. While identified by self-report of members earlier in this
section as a helpful and important aspect of Clubhouse model, outcome data seems to reveal that
Clubhouse model is strong in the area of employment. At least three major, peer-reviewed
sources identify encouraging outcomes in this area within Clubhouses.
In addition to the fact that the overwhelming majority of Clubhouses provide some type
of vocational rehabilitation and a high percentage of members are employed, the research seems
to show that these programs are successful by quality standards as evidenced by the high rates of
job retention. In one study published in the Journal of Psychiatric Services by Schonebaum,
Boyd, and Dudek (2006), the team compares Program of Assertive Community Treatment
(PACT) and Clubhouse models in a five-year longitudinal study of 170 SPMI individuals. The
PACT program selected was new in the area with emphasis on employment and was selected as
a control group due to ACT’s reputable history as an evidenced-based practice. Both achieved
high rates of employment.
While Schonebaum (2006) found that 74% of PACT participants were placed in a job and
only 60% of the Clubhouse sample were placed in a job, Clubhouse members worked more
weeks on the job at 21.8 weeks (compared to 13.1 weeks) or 66% longer than PACT; they also
secured higher paying jobs (Schonebaum, 2006). Macias, Rodican, Hargreaves, Jones, Barreira,
and Wang (2006) who did a comparable study between vocationally-integrated ACT and
Clubhouse model found similar results; Clubhouse model yielded better pay and longer work in
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samples. The study found Clubhouse members worked 494 hours while the ACT sample worked
234 hours on average; Clubhouses also made an average of 3456 dollars compared to 1252
dollars made by the ACT sample (Macias et al, 2006).
Vocational rehabilitation, in general, as well as within Clubhouse model, is more
important than just for reasons of working more and receiving money; the key in this is
psychosocial rehabilitation. To address cognitive barriers/attitudes towards ability to work, at
least one Clubhouse elected to work with researchers to implement a program in additional to
their own employment program to address the common cognitive distortions associated with this
population. This demonstrates the Clubhouse model’s effectiveness of combining their own
programs with other community services, which is commonplace and typically quite effective.
The study was published in the Journal of Rehabilitation, Research, and Development by
Lysaker, Bond, Davis, Bryson, and Bell (2005). In a 26-week randomized control trial with
researcher returning for follow up testing five months later, Lysaker et al (2005), took a sample
of 50 participants diagnosed with either schizophrenia or schizoaffective disorder with an
average of 10.5 lifetime psychiatric admissions, all of which had been unemployed for at least
two years and were referred by a clinician. They were then split into two separate groups, one
where participants received the standard support services and those who were assigned to receive
Clubhouse services and services from the Indianapolis Vocational Inventory Program (IVIP).
The combined program (IVIP and Clubhouse Services), unlike the standard services, also
involved three, hour-long sessions of courses/group each week. These sessions utilized
cognitive behavioral therapy psychoeducation to address the disempowering beliefs and thoughts
as well as identifying/modifying cognitive distortions members had about their ability to work
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and adapt into community (i.e. “I am terrible at work and I cannot perform my job” and “I never
will be able to work like everyone else; I am inadequate”) (Lysaker et al., 2005). The researchers
utilized The Bech Hopelessness Scale, The Rosenberg Self-Esteem Scale, and The Work
Behavioral Inventory which is a 35 item tool designed to measure the quality of work values and
outcomes of the severely and persistently mentally ill population when working (Lysaker et al.,
2005).
After providing intervention and concluding the tests, the researchers found that the
group receiving Clubhouse services combined with CBT services from IVIV scored significantly
higher in areas of self-esteem and hope, job retention, weeks and hours worked, along with
evidence of a slight decrease in overall symptoms, decreased hopelessness, and performed better
in their jobs than those receiving the standard services (i.e. areas such as following directions or
completing tasks correctly as evidenced by measurement of The Work Behavioral Inventory
results). Lysaker et al., (2005) also note that this group sustained these favorable changes more
than the control group at the five month mark where the participants in both groups sampled
were retested. This study, in addition to showing the effectiveness of a supportive empowering
environment, also suggests that the SPMI population, when empowered and given a sense of
belonging, meaning, and hope are capable of changing unhealthy thought patterns and engage in
more effective, goal-directed behavior.
Additional to its employment benefits, Clubhouses seem to be effective enough through
their various services, (i.e. community support, and augmentation of skills/goal directed
behaviors and routines) that rehabilitation of some members to complete extensive tasks not
expected of the severely and persistently mentally disabled become possible. Completing college
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level course work is one such area. In one study, conducted by Weiss, Maddox, Vanderwaerden,
and Szilvagyi (2004) published in the American Journal of Psychiatric Rehabilitation,
researchers worked with the University of Michigan Social Work Program and a local Clubhouse
to have members holding a GED or equivalent enroll in a two college level courses split over
two semesters and served multiple groups of members over one year and repeated with different
members for four years. The program was approved by the Joint Commission on Accreditation
of Healthcare Organizations as well as the Commission on Accreditation of Rehabilitation
Facilities also known as CARF (Weiss et al., 2004). All participants in the study were considered
SPMI. The researchers utilized the Classroom Academic Support Model to complete this.
In the first semester of the program, 16 important skills were learned such as “orientation
to student life, learning about the campus in college services, understanding the role of self-
concept problem, solving stress management/being a successful student, communication skills,
career choices as well as test taking skills” (Weiss et al., 2004). The second semester included
“basic study skills, time management techniques, concentration/memory, paper writing and using
computers” to name a few. Moreover, the program encouraged socialization during the class
breaks by having participants meet in a common room outside of the classroom to dialog—a key
point of this study to note when considering the social deficits and tendency for self-isolation in
this population.
The researchers measured outcomes qualitatively through interviews. Participants
concluded that after completion of the program many reported they felt more “able,” were
substantially more hopeful, and believed that they could pursue and maintain some form of
gainful employment (Weiss et al., 2004). Moreover, some participants who were interviewed
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earlier had been recorded to be unsure of their ability or unable to work or go to school; later on
many of these participants ended up going to college or working after being able to change these
beliefs (Weiss et al., 2004). Although the study does not directly measure the benefits of
Clubhouse as compared to other specific evidence based models, it does show that Clubhouse
members who were considered severely and persistently mentally ill with the support of the
community and program were able to complete two semesters of college level course teaching
basic skills and continued on this “learning curve” of empowerment and rehabilitation.
While reflecting on the many outcomes that Clubhouse seem to yield to the SPMI
population in their communities is paramount, when implementing such programs, the cost of
implementation and design must also be considered. Just as any program, it takes ample
quantities of funding to initiate and implement a program, but Clubhouse model does seem to be
quite cost effective considering the services it provides. One study in Pennsylvania of 29
Clubhouses statewide conducts cost-benefit analyses of the services offered and compares to the
costs of other widely used programs. The study was published in the Psychiatric Rehabilitation
Journal and conducted by Potnick and Salzer (2008). The study notes that the state of
Pennsylvania heavily relies on the services of Clubhouse which provides on average over
180,000 units of contact for over 2400 SPMI individuals across the state annually.
The research indicated a 31% employment rate of Clubhouse members as well as daily
contact and participation for many members. Participation across the program as well as
community outreach contacted indicated 717 contacts on average per day in the Clubhouse
programs surveyed (Potnick and Salzer, 2008). Researchers in this study also discuss another
widely used, evidence-based model that is standard in Pennsylvania called the Partial
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Hospitalization Model (PHP) which encompasses community housing of clients, but involves
clients spending up to seven days a week in a Community Mental Health Center or hospital
setting (Potnick and Salzer, 2008). So this section of the study in essence compares a model
where SPMI individuals participate in informal community support (Clubhouse) to SPMI
individuals who commute to formal community support services (institutions). The researchers
assert that both programs make a substantial impact on reducing psychiatric inpatient admissions
and address various symptoms/concerns in this population. Potnick and Salzer (2008) do
maintain both Clubhouse mode as well as PHPs as evidence based practices and strongly argue
in favor of their benefits and necessity, but in an analysis of cost to outcomes, conclude that in
Pennsylvania that Clubhouses yield 43 percent less cost than the PHP’s. Contributors to this
may include the fact that PHP’s are reimbursed higher, although they provide less hours of
contact than Clubhouses. The researchers note that if the PHP provided as many units of
services, due to this increase, the difference state wide in cost would be around 7.5 million
dollars (Potnick and Salzer, 2008).
Certainly more research comparing cost-benefits analyses of Clubhouses to those of other
evidence-based models is key, however it does seem due to the high amount of informal services
being provided by members taking key roles in the administration and implementation of this
model, that it is a significantly more cost-effective than models that are entirely agency-run and
based off of higher reimbursement of professionals while also missing out on advantages of
belonging to a community/accessing meaningful time with peers. By instead integrating
professionals (rather than having them as the sole support system) and members as well as
members who have achieved a high state of recovery and achievement, money can be saved, and
the results still seems to be very positive in the process of psychosocial rehabilitation,
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employment, and mental/physiological health of the SPMI population accessing the services of
Clubhouses.
Keeping an eclectic model when working with many informal services is very important
as it is vital that members receive services from trained professionals. Clubhouse should be a
supplement, but not a substitute for a psychiatrist, MD, CPST, or Counselor. Some deviance
from the Clubhouse model through adding some formal services, while also holding many of its
key ideals, is not uncommon and may be one way to expand on the model. Examples of this
concept will be reviewed in the following section.
B. Application Section and Local Program Development
B1. The Connections Center: Interview of the director and qualitative research on 8 of the clients
present and willing to interview.
For those on SSI/SSDI and suffering from severe and persistent mental illness, many
communities have drop in centers, Clubhouses, and various other resources. One program that
is based off of much of the theory and domains of research behind Clubhouse model/other
models is found in Bowling Green Ohio and is called the Connection Center. To augment the
understanding of this center and services, I conducted an interview with Verna Mullins (In-
Person Interview, 2015) who runs the Connection Center as well as 8 clients present this day and
willing to discuss their experiences. Mullins (2015) has held the position of Director of
Psychiatric Rehabilitation and Employment Services at Behavioral Connections since 2000.
She also proposed research to convince those providing funding to modify the Connection
Center to have many programs, much of which is based on Clubhouse Model.
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The Connection Center presently serves 150 regular members typically diagnosed with
schizophrenic spectrum disorders, major mood disorders comorbid with disorders such as
substance use, anxiety, ADHD, personality disorders, and chronic medical conditions. The center
averages 25-35 clients daily, while holiday events and parties typically average 50-70 clients;
participation for many is made possible due to the availability of transportation paid for by the
Connections Center (Mullins, 2015). Anyone with a severe mental health condition can be a
member and typically she notes become a part of the Connection Center through self-referral,
walk in, agency referral, community referral, or member referral.
Mullins (2015) in the interview quotes Clubhouse international: “a Clubhouse is a
community of people who are working together; recovery from mental illness.” Mullins (2015)
goes on to note that the mission of the Connections Center is to “do together what we cannot do
alone.” She also states that the center strives to provide a “supportive, comprehensive, safe and
self-empowering environment” for the SPMI population by using the Psychosocial
Rehabilitation Clubhouse Model combined with additional services. Mullins (2015) also argues
for the importance of creating a positive image of those with mental illness and heavily stresses
the importance and goal of the center to address mental health stigma by increasing awareness,
community integration, and participating in community service projects (Mullins, 2015). She
also discusses the importance of vocational and social skills, self-expression, autonomous
functioning, and peer support as well as encouraging self-awareness and understanding of mental
illness (Mullins, 2015).
Mullins (2015) notes that five of eight key principles, and much of the remaining three
from Clubhouse model are held up in her program while efforts to address the other principles
are made, but not necessarily done so to fulfill ICCD certification criteria. She notes that the
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Connection Center is Holistic, Inclusive, Responsive, Sustaining, and Cost Effective. Holistic,
as through one single caring environment, it offers members opportunities for friendship,
education, vocation, as well as increased access to psychiatric and medication-somatic services.
‘Inclusive’ is demonstrated by member’s ability and practice of learning from/following the
example of other members who are making progress towards achieving personal aspirations and
goals (Mullins, 2015).
Moreover, Mullins (2015) asserts that the domain of responsiveness is held up by the
reflective feedback given by staff and members which leads to increased progress in goals, while
the program is sustained, and aids members in becoming more productive in society and their
lives. The principle of cost-effectiveness, Mullins (2015) argues, is held up by reducing need
for costly and arduous interventions such as psychiatric admission and incarceration as
involvement here provides a safe environment and increases involvement with peers, family, and
community. While many aspects of the Connection Center are in line with Clubhouse
International Standards, Mullins (2015), admits that it does have some key differences.
The most key difference she states is that the funding comes from Behavioral
Connections funding and is part of the agency, which contrasts with the Clubhouse model in that
it calls for the Clubhouse to be an independent entity (see ICCD, 2015). Moreover, Mullins
(2015) notes that while residential services in Clubhouses typically are on site, whereas the
Connection Center refers and links clients to housing programs through the local ADAMHS
Board and housing/transitional group homes owned by Behavioral Connections in the
community. Employment services are provided by outside sources by employment specialists
and qualified mental health specialists (QMHSs) and licensed social workers (LSWs) who work
at the center, rather than by peers/members which is standard for Clubhouse Model.
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Mullins (2015) also verbalizes that in smaller communities such as Bowling Green, it
would be difficult to finance the Connection Center without the help and linkage/other services
offered by a community mental health agency. Moreover, she also states that the Connection
Center is able to offer many distinctive services that a Clubhouse would be unable to provide
without its alinement with a mental health agency. “This is an eclectic model that fits the needs
of our clients while remaining in the parameters of affordability; it is a hybrid” (Mullins 2015).
The Connection Center is not ICCD certified but is accredited through the Joint Commission of
Accreditation of Health Care Organizations as well as the Commission on Accreditation of
Rehabilitation Facilities (CARF).
Despite these differences, the Connection Center strives to link clients with similar
services and operates behind the same theory/purposes the Clubhouse model stands for (Mullins,
2015). Most importantly, like Clubhouses, the Connection Center strives to establish a sense of
community and access to peers and resources. The program seeks to rehabilitate and, as Mullins
(2015) also notes, sees clients as “members” and views them by their “talents and potential” and
seeks to augment these areas rather than having a fixation on their mental illness condition. The
program does also lead to individuals finding housing, obtaining employment and skill building,
as well as having a safe and sober environment where they can engage in meaningful activities as
well as “work-like-scheduled” days—a key aspect of Clubhouse model (Mullins, 2015).
Moreover, like Clubhouse model, the Connection Center’s board is comprised by multiple
“members” who take an active role in the design of classes, events/outings, leading many groups,
and programs.
The Connection Center indeed does offer many different services that Clubhouses do not
typically offer. Accesses to qualified mental health specialists (QMHSes), several of which are
Johnson 27
licensed social workers, is one key advantage as these professionals are able to provide
interventions that peers in a Clubhouse may not be able to produce. Mullins (2015), notes that
her staff are well versed in crisis intervention, which is very useful as “my staff have more report
because they see the members more frequently than their other providers”; crisis intervention is
frequently needed in this setting and often clients present in crisis on a weekly basis. Mullins
(2015) also contests that through its connection to a mental health agency and the ADAMHS
board, it also allows for a more smooth referral process to residential, psychopharmacology/
counseling, and employment services. This is an advantage as many studies identify the
improvement of linkage to psychiatric and medical services as a key improvement needed in
many Clubhouses (see Raeburn et al. 2013; Mowbray, 2008; McKay and Pelletier, 2007; Aquila
et al., 2006).
Specific to the Connection Center is a plethora of activities, services, and groups. The
program is designed into six units which allow it to meet various standards of running the center
which include the Membership Unit, the Business Unit, Café Unit, Career Unit, Creative Unit,
and Environmental Unit (Mullins, 2015). In the Membership Unit, writer observed members and
QMHS staff work on planning a recreational activity to go to the pool; in this unit they typically
plan social and recreational activities, work on advocacy (sometimes along NAMI and other
organizations) and education; also key, Mullins (2015) notes, is that this is where during the
structured schedule clients and staff identify those in the community or in the center who need
more outreach and formulate plans to carry this out.
In the Business Unit, members write a monthly newsletter; often those touring the center
are guided by members who are greeters and guides (Mullins, 2015). In the Cafe Unit, staff and
clients utilize transportation provided by center to plan and shop for groceries and make food
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available at the center; members work as the cashier and perform weekly inventory; this allows
them, notes Mullins (2015) to work on responsibility, have team work, as well as work
experience which serves as skills they can sharpen and apply in work or volunteering.
Also witnessed during the site visit was a case manager (with employment specialist
experience) “in action” helping clients in the career unit; she is hired to work two days a week at
the center Mullins (2015) notes. In this unit a Job Club Support Group exists where members
work with each other and staff such as with a caseworker on job searching skills, resume writing,
mock interviews, cover letter skills et cetera; some also use this section to work on their GED or
other education which often is a key part in the job search. Clients also sharpen skills on
computers (i.e. Microsoft Office or job searching on online resources) and use a program through
Luminosity for cognitive enhancement purposes; there is also an employment services dinner
once a year to recognize those working or volunteering (Mullins, 2015). Organization of the
Connection Center on planning volunteer work was also observed; several members were
working on preparations for the annual community “rummage sale” for example.
Mullins (2015) also discusses at length the importance of expression and creativity to the
Connection Center. There is a member-lead creative writing group and poetry group; there are
also art and music workshops. On the site visit, I sat in on a music work shop where members
participated in an activity where they intentionally sang the wrong lyrics in the songs; members
interacted and laughed and went over how music is helpful in coping. During a different time
slot, members were painting and discussing with group what they created (facilitated by a client)
while the music group was facilitated by a QMHS. Additional groups either in practice or being
planned included an exercise group comprised by walking together, basketball, and swimming to
name a few. Workshops on benefits, nutrition, health and wellness (involving education to
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address chronic medical conditions and healthy cooking/nutrition classes for example) are also
offered (Mullins, 2015).
The Environmental Unit also was observed on the site visit, which is characterized by
upkeep and appearance of the unit and center that is maintained and enhanced by members. The
clients clean the center and plant flowers/gardens outside or create and create/display art work;
The Mural and Mediation Garden is one such product of their work. Members also take care of
inventory and purchasing alongside staff; seasoned members train new members on tasks and
responsibilities (Mullins, 2015) which displays the excellent ICCD standard of members taking
part and viewing this as a community for which they serve an active role.
Those who run the Connections Center include members, staff, and an advisory board.
Staff represents Behavioral Connections and act as mentors and motivators notes Mullins (2015).
The advisory board, she states, are interested members of the community and members who
work on setting policy and decide who to hire. The board is made of 14 members including 7
community members, 6 Connection Center members, and 1 staff member (Mullins, 2015). The
center strives through networking and public advocates and advertisement, networking, volunteer
work to achieve awareness, participation and fundraising. The center works with the local
university on various community projects several times each year and typically has a doctoral
intern from Bowling Green State University who works with clients on a rehabilitative project of
their choosing (Mullins, 2015). One notable project for example was a large chalk board where
clients filled in “one thing I would love to do before I die”.
Mullins (2015) notes that while the employment program differs from typical Clubhouse
model it does have many helpful aspects. All employment specialists working with the clients
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are assigned QMHS staff; the WEP (work experience program) includes sheltered workshops as
well as working with peers, the specialists, and members who are designated to various duties.
The program sees employment retention, symptom management and work with other
employment agencies (Mullins, 2015).
The interview with Mullins (2015) also indicates heavy community involvement of the
Connection Centers with others. Some community work that they do includes but is not limited
to a planned sale (raise money for Christmas sale), diaper drive (for local food charities), St. Al’s
rummage sale (helped purchase CC meditation garden and purchase center and art drive), Teddy
Bear drive (for local first responders to give to children during crisis and humane society donated
items and money to sustain supplies to shelter animals). Mullins also notes that members also
participate in the art walk, car shows, Black Swamp Farmers Market, trick or treat, holiday
parade, “holly days,” and sidewalk sales. Mullins (2015) states also that members do wood
working with BG high school and FFA students. BGSU doctoral interns, BGFSU name projects,
social work mini internships and weekly radio show updates on WBGU, which also evidence
community involvement of the center. The center offers many outings as well such as sporting
events, movies, and shopping (Mullins, 2015).
The benefits of the program were also seen in the feedback received by members
interviewed. I overwhelmingly saw that they spoke well of the center and reported many
benefits in my dialog with the 8 members willing to participate with the simple prompt of “Why
does the community need this center?” and “What is different in your life because of it?” In
reference to their mental health, one reported “It keeps my mental health stable. I don’t know
what I would do without it”; many reported that it was easier to receive psychiatric services due
to transportation and “so I don’t have to go alone.”
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Several members talked about how isolated they were before coming to the center and
one even said “It gives me a reason to wake up; I like the routine.” Two of the 8 reported that
they presently held jobs and credited the Connection Center for this as well. From the interview
with Mullins, site visit observations, and feedback from the sample of members, it was clear to
me from this research that the Connection Center produces many benefits yielding psychosocial
rehabilitation. Benefits coming to mind include enhanced assertiveness, cognition, activities of
daily living, independent living (using community resources, home management, time
management, medication management, and safety in home and community), vocational interests
and pursuits, role development, self-awareness, interpersonal and social skills, stress
management, self-sufficiency as well as health/wellness. Psychosocial rehabilitation and
enhanced meaning in life certainly seemed evident within this program.
B2. North West Psychiatric Hospital Vocational/Rehabilitation Program.
Though partially peripheral to Clubhouse Model, considering psychosocial rehabilitation
services offered in psychiatric hospitals (which often is part of the experience for the SPMI
population) may be one important way to prepare clients and increase likelihood in their
participation in community resources such as Clubhouses. One local program of psychosocial
rehabilitation and leading to a greater potential in resources such as Clubhouses is directed by
Steven Hildreth who is a licensed social worker with many years of experience working with the
SPMI population. His program exists at Northwest Ohio Psychiatric Hospital which serves 27
counties in Ohio.
During the interview with Hildreth (In-Person Interview, 2015) he notes that his
vocational/ rehabilitation program works with between 15-20% of the clients of Northwest Ohio
Johnson 32
Psychiatric Hospital. Hildreth (2015) notes that some of his clients work in the vocational
program for a shorter time such as a month, while others have been in the program for over a
decade (i.e. forensic clients who are NGRI Not Guilty for Reason of Insanity). The first step for
entering this program is a referral from a treatment team on one of the psychiatric units when
deemed appropriate, and as a good candidate of the program.
Hildreth (2015) notes that he works with several outside agencies for this program which
begins upon referral. They are assessed by a computer program for GED skills such as
achievement and aptitude in the areas of reading, writing, and math. Those without a GED or
high school diploma are assisted in obtaining this before completing the program. Steve also
assesses their work capability and also considering their volunteer, activities and work
experience to determine an appropriate placement. Clients work aside staff hired to upkeep and
provide services in the hospital. Some of these duties include cleaning/laundry, recycling,
working in the kitchen (i.e. taking part in meal plan design, gathering ingredients for food and
prep, cleaning rooms, halls, and stair cases, keeping a large garden in the front and back which
includes planting flowers, fruits, and vegetables, as well as landscaping). Additional
occupations include working with the mobile library services, washing state vehicles, and even
working, painting/working on arts and crafts or pottery, on event planning with recreational
therapy program.
Staff members are educated in special trainings to work with SPMI population with
Hildreth who works on skill-building, meeting with the clients individually and in groups.
Hildreth (2015) notes that this is beneficial as it establishes report with staff members and allows
them to engage in goal-directed behavior and learning skills they can use towards vocation and
functioning in the community upon release. Clients are offered incentives for completing
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program and are paid minimum wage for their work. Hilldreth (2015) notes this is around 10
hours a week; two hours per weekday. Clients are to save 1500 dollars over time which they are
to have to help them start out once they are discharged from the hospital, which usually involves
a group home, Clubhouse residential services, ADAMHS board housing, or a “half-way house.”
Several clients I interviewed (a small sample of five) generally noted that being able to
use their own money is something helpful with independence and empowerment. Several
statements of those interviewed evidence this. “I have been on disability so long. I never
thought before now that I could work or even support myself. Now when I get out, I can actually
start something new”. “Getting off the unit is good, but I really think when I am out of here I
will have a chance.” Clients are also able to spend money and even go on outings. Hildreth
(2015) notes that two outings occur a month which clients once they achieve approval from their
treatment team, are able to go on outings such as the zoo, bowling, parks, or concerts. Certainly
this is beneficial here as it enhances the clients’ comfort and overall sense of empowerment
regarding re-integration into the community. Other relevant skills are enhanced through various
exercises such as mock interviews, resume writing, getting along with coworkers, and job search
skills. Hildreth (2015) reports that many clients upon discharge are referred to local Clubhouses
if the county they return to has one.
V. Reflection, Further Research Ideas, and Application on Hancock County
Incontrovertibly when considering psychiatric rehabilitation in the SPMI population,
programs in order to be cogitated for implementation in the community, must be evidence-based
and have outcomes convincing enough to entice stakeholders of mental health programs/other
sources and the general community, to receive adequate funding for implementation.
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Interventions must be cost-effective, yet yield outcomes that in addition to reducing psychiatric
hospitalizations and incarcerations, also enhance the quality of life and functionality of the
individuals treated. Clubhouse Model through the research reviewed seems to indicate
outcomes that are akin with these standards, addressing the struggles this population has in the
social domain (i.e. isolation from family/friends and poor social skills), with self-care (i.e.
hygiene or addressing medical issues), or occupational issues (i.e. being unable to work).
The literature review also indicates that the model is effective at yielding high rates of
participation in their members as well as a sense of recovery and empowerment. Despite
producing all of these beneficial outcomes, Clubhouse Model is significantly less expensive than
other models (i.e. See Clubhouse vs Partial Hospitalization Program Study by Plotnick and
Salzer, 2008) in providing services for various reasons such as a significantly lower
reimbursement rates. The model holds advantages of having more contact and informal support
that many other programs simply are unable to offer.
This is not to say that the Clubhouse is a substitute for professional healthcare services,
which in many sources is cited as an area of need to advance in this model (i.e. need for mental
health or physical health care services on site). Literature review including the cited article
about the “Store Front” suggested perhaps that having Clubhouses reach out and becoming
involved with other community entities could be one way to address this deficiency, whereas the
evidence from the Verna Mullins interview, site visit, and client interviews suggests that a hybrid
of Clubhouse model that holds the majority of its principles, but also hires qualified mental
health practitioners and is affiliated with housing, medical, and psychiatric services may be an
appropriate alternative. Further research of successful Clubhouses or “hybrids” of Clubhouses
Johnson 35
may yield further results that ICCD, SAMHSA, NAMI, NASW, and other organizations may
consider researching to continue to improve the services Clubhouses offer.
Certainly in practice with working with the SPMI population, the reality is that there are
many who would benefit and thrive from Clubhouse services, but may not go due to overall
discomfort, feelings of helplessness, or paranoia they may encounter. Yet rehabilitation
programs in psychiatric hospitals for longer term stays such as Steve Hildreth’s program are
beneficial as consumers are not only taught skills essential to rehabilitation, but go to outings that
offer them the chance to enhance their comfort in the community and feasibly will lead to them
upon discharge to become involved in important community organizations such as Clubhouse
model.
Local communities such as Findlay, Ohio, have Focus on Friends, that is going in the
direction of an AoD Recovery PRC, which from the literature review may attract those with
substance use disorders more than those with schizophrenic spectrum disorders and major mood
disorders as indicated by the cited study comparing Clubhouses to PRCs. Some concern within
the last community psychiatric support meeting at my agency was verbalized by several
clinicians about the culture and atmosphere of Focus on Friends changing in aversive ways for
SPMI case-managed clients.
While this PRC is very much needed in addition to the new half-way houses the local
ADAMHS board is opening to address Hancock County’s drug and alcohol program as well as
the implementation and access of medication assisted therapy (MAT) programs for AoD issues,
it would be helpful for Hancock County to consider implementation of a program similar to the
Connection Center in Bowling Green in order to balance out the need for SPMI community
Johnson 36
resources. This would enhance participation in community and provision of informal services
and would be an excellent resource for ACT/IDDT and Standard IDDT case managers to
recommend to those they serve. To address the Clubhouse’s need to have more on-site services,
Hancock County may consider making the program a “Hybrid” like the Connection Center.
This would prove to be an invaluable service as clients could be linked in well with CPST
services, med-somatic services, and also could take a more active role in local organizations such
as Blanchard Valley Center, Awakening Minds Art, The University of Findlay, KanDu Studeo,
Owens Community College, and NAMI. The potential is here and would enhance a sense of
community for not only the county but the clients as it would truly give them a shot at
rehabilitation through addressing isolation, self-care issues, and occupational issues in a cost-
effective and helpful way.
Johnson 37
References
Aquila, R., Malamud, T. J., Sweet, T., & Kelleher, J. D. (2006). The Store Front, Fountain
House, and the rehabilitation alliance. Medscape General Medicine.
Center for Evidence Based Practices. (2011). Assertive Community Treatment. Retrieved June
24, 2015, from https://www.centerforebp.case.edu/practices/act.
Herman, S. E., Onaga, E., Pernice-Duca, F., Oh, S., & Ferguson , C. (2005). Sense of community
in Clubhouse programs: Member and staff concepts. American Journal of Community
Psychology, 36,343-356.
Hildreth, S. (2015, May 21). Psychiatric and vocational rehabilitation program at North West
Ohio Psychiatric Hospital [personal interview].
International Center for Clubhouse Development (2015). Creating community: Changing the
world of mental health. Retrieved May 14, 2015.
International Center for Clubhouse Development (2013). Clubhouse International annual
report, 2012. Retrieved May 24, 2015.
Lysaker, P. H., Bond, G., Davis, L. W., Bryson, G. J., & Bell, M. D. (2005). Enhanced cognitive-
behavioral therapy for vocational rehabilitation in schizophrenia: Effects on hope and
work. Journal Of Rehabilitation Research & Development, 42(5), 673-682.
McKay, C. E., & Pelletier, J. R. (2007). Health promotion in Clubhouse programs: Needs,
barriers, and current and planned activities. Psychiatric Rehabilitation Journal, 31(2),
155-159.doi:10.2975/31.2.2007.155.159.
Macias, C., Rodican, C. F., Hargreaves, W. A., Jones, D. R., Barreira, P. J., & Wang, Q.
(2006). Supported employment outcomes of a randomized controlled trial of ACT
and Clubhouse Models. Journal of Psychiatric Services, 57(10), 1406-1415.
Johnson 38
Mowbray, C. T., Woodward, A. T., Holter, M. C., MacFarlane, P., & Bybee, D. (2009).
Characteristics of users of consumer-run drop-in centers versus Clubhouses.
Journal of Behavioral Health Services and Research, 36(3), 361-371.
Mullins, V. (2015, May 27). Psychiatric and vocational rehabilitation at The Connection Center
[personal interview].
New York Office of Mental Health. (2012) Severe and persistent mental illness. Retrieved June
14, 2015, from http://www.omh.ny.gov/omhweb/guidance/serious_persistent_mental
_illness.html.
Norman, C. (2006). The Fountain House movement, an alternative rehabilitation model for
people with mental health problems, members' descriptions of what works. Scandinavian
Journal of Caring Sciences, 20, 184-192.
Plotnick, D. F., & Salzer, M. S. (2008). Clubhouse costs and implications for policy analysis in
the context of system transformation initiatives. Psychiatric Rehabilitation Journal,
32(2), 128-131.
Schonebaum, A.D.,Boyd, J.K. & Dudek, K.J. (2006). A comparison of competitive employment
outcomes for the Clubhouse and PACT models. Journal of Psychiatric Services, 57
(10):1416-20.
Substance Abuse and Mental Health Services Administration. (2012). Mental Health, United
States, 2010. HHS Publication No. (SMA) 12-4681. Rockville, MD: Substance Abuse
and Mental Health Services Administration.
Substance Abuse and Mental Health Services Administration. (2014). Intervention Summary –
ICCD Clubhouse Model. Retrieved June 7, 2015, from http://www.nre pp.samhsa.gov
/ViewIntervention.aspx?id=189.
Johnson 39
Raeburn T. (2013). An overview of the Clubhouse model of psychiatric rehabilitation.
Australasian Psychiatry, 21, 376-378.
Weiss, J., Maddox, D., Vanderwaerden, M., & Szilvagyi, S. (2004). The tri-county scholars
program: Bridging the Clubhouse and community college. American Journal Of
Psychiatric Rehabilitation, 7(3), 281-300. doi:10.1080/15487760490884676.