The Clubhouse Model in Action at Fountain House: Designing Communities for People with Serious Mental Illness

People with serious mental illness (SMI) have long been “otherized” in American society. This isolation extends from the disgraced legacy of neglectful, abusive psychiatric institutions, which at their height in 1955 confined more than half a million people with mental illness, to today’s jails and prisons, where nearly half the incarcerated population has a mental illness. Yet for those who are not in these settings, people with SMI are at extreme risk for loneliness and isolation. Public stigma of mental illness — which is pervasive even among health care providers — perpetuates negative stereotypes of people with mental illness and prevents seeing the person behind the diagnosis. It results in many forms of discrimination, including housing and employment, and can be a barrier to treatment engagement. The social consequences of SMI may also contribute to reduced life expectancy, and elevated suicide rates for these individuals compared to the general population.

Background

Fountain House traces its roots to a small group of people with SMI in the 1940s, who were institutionalized at Rockland State Hospital in Orangeburg, New York. They were interested in alleviating the challenges that came up as they and their peers returned home to their communities. They formed a self-help group known as “We Are Not Alone,” which organized support for re-establishing connections with family and friends, finding housing and jobs, and other social and basic needs. They also hosted discussion groups to strengthen their friendships and deepen their understanding of the social barriers they faced in society.

What started 76 years ago as a mutual aid group in a state hospital evolved into a more formal group that met in a building (with a fountain) in Manhattan. Under the leadership of a social worker named John Beard, the aptly named Fountain House presumed that restoring a sense of dignity and purpose for people with SMI was an essential ingredient to recovery, yet one that was often overlooked in traditional clinical treatments.

This pioneering approach became known as the “clubhouse model,” a form of psychosocial rehabilitation where people with SMI are welcomed and valued as “members” and contribute to the clubhouse operations in what is known as a “work-ordered day.” In the work-ordered day, members participate in an array of tasks that are essential for keeping the clubhouse running smoothly. Free and voluntary, members can choose to participate in these tasks in addition to recreational or social activities such as teaching yoga or taking a history class.

 “There is a universal human need to be needed — and we strip that from people with serious mental illness. They become ‘consumers,’ ‘service recipients,’ ‘patients,’ or problems,” said Elliott Madison, Clubhouse Executive Director and Chief Program Officer. “Instead, we give them an expectation that they will live purposeful lives. And we give them experiences of doing things. Maybe they’re small experiences, but they are purposeful and meaningful to others. If you do this — not once, but thousands of times — the vast majority of people are going to end up thriving.”

There are now more than 350 clubhouses across 46 states and replicated in 32 countries. Fountain House continues to be the largest of all clubhouses, serving over 2,000 members who are adults with SMI. Fountain House operates two clubhouses in New York City, with plans to open a third in California later this year.

Fountain House and other accredited clubhouses are unified by a set of 37 “clubhouse standards“ published by Clubhouse International, an organization that promotes the expansion of clubhouses and offers accreditation, training, advocacy, and research. These standards provide a basis for operating the clubhouse intervention, but each clubhouse may adapt them differently to suit their particular community. Below are details how of Fountain House runs their version of the clubhouse model.

Intervention

Fountain House coined the term “social practice” to describe the approach that clubhouses use to support members. The staff who manage units and work directly with members are called “social practitioners,” and they are a diverse mix of mental health professionals, people with lived experience, as well as people without any mental health background. Social practice is a nonclinical approach that aims to empower people with SMI. It is structured around the “work-ordered day,” which connects members to an array of tasks that are essential for keeping the clubhouse running smoothly. The five elements of social practice are:

1. Social design. At Fountain House, both the physical and social environments set the stage of a therapeutic community that staff and members can feel proud of. The physical building creates the capacity to bring members together during the day and break isolation. Megan Kelly, Director of Ancillary Programming at Fountain House, said, “It’s about bringing people together. It’s knowing that someone knows your name and will say ‘hi’ as you walk down 47^th Street and that’s going to make you smile.” Also, the interior is designed to encourage group work, such as large open spaces and large desks that can be shared with other and encourage conversation. The community is also intentionally non-hierarchal.
2. Engagement. Fountain House emphasizes the importance of member choice when it comes to how they engage with the clubhouse each day. Members can choose one of 10 different work units and centers to participate in, from administrative duties to hands-on tasks like gardening and maintenance, and which social practitioner they want to work with.  The units include the Communications Unit, Education Unit, Employment Resource Center, Research Unit, Culinary Unit, Home and Garden Unit. The centers include the Welcome Center, Young Adult Connections Center, Wellness Center, and the Silver Center (for older adults). Because the activities of each unit are necessary for the functioning of the clubhouse, it brings a sense of interconnectedness and builds skills, self-esteem, and self-efficacy.
3. Relationship Development. Clubhouse membership is both a benefit to the individual member as well as a responsibility to other members. For example, a member interested in advancing their own education might join the education unit, though they’re expected to contribute to the needs of others as well, through tutoring and other activities. Arvind Sooknanan, a Fountain House member and a board member, said, “I was able to take ownership of my own recovery — not only mine — but I was able to be an active participant and contributor to the recovery of my fellow members as well.”
4. Natural Feedback and Intervention. Social practitioners at Fountain House are skilled in observing how members participate, noting strengths and areas for growth on a continuous basis, and intervening to enhance people’s resilience in the face of setbacks. “Maybe I see in real-time that a member’s mental health is deteriorating. And then I’ll notice that they’re not attending as regularly as they used to,” said Megan. “I’ll address that, by calling and gently asking how they’re doing and when they’re coming back. And I’ll craft an intervention. Maybe I’ll start by pairing them with another member who shares their interest in Marvel comics to draw them out of that place of being withdrawn and isolated.”
5. Transitional Environments. People with SMI experience discrimination in society, including in labor, education, and housing, which can lead to self-doubt about their own competencies. Transitional environments offer members safe, therapeutic spaces before being in “real world” settings that inherently carry more risk, such as a workplace. For example, Fountain House partners with many employers for supported employment and manages a shop, Fountain House + Body, staffed by members.

Implementation

At Fountain House, membership is open to adults with SMI, specifically schizophrenia, schizoaffective disorder, bipolar disorder, or major depression. Within a year of application, members must provide a signed attestation form by a mental health professional that the member has one of these qualifying disorders. Fountain House members may also have co-occurring disorders, such as substance use disorder, but there is no requirement that they be in recovery for their substance use. Members also do not have to be actively involved in mental health treatment, though many are. Fountain House both gives and receives referrals for mental health treatment programs.

Fountain House and other clubhouses keep staffing levels low enough to be sufficient, but not so high as to impede on the necessity of member contribution to running the clubhouse. For each of the 10 clubhouse work units, there are four social practitioners and one program director. Since Fountain House strives to have at least 30% of their 2,000 members attend each weekday, this means these staff are working alongside typically 60 or more members each day in the units. 

Some social practitioners are people with lived experience of mental illness, which helps them relate with members. In fact, social practitioners may be members of other clubhouses and vice-versa (Fountain House members are supported in finding work at other clubhouses, though generally they will not be employed at the same clubhouse of which they are a member.) Also, training is available. Most of the training for social practitioners at Fountain House is immersive and comes from modeling behavior of other staff, as well as supervision discussions with program directors. Internal trainings include a best practice discussion series led by experienced social practitioners as well as trainings on benefits, housing applications, and case management. Clubhouse International hosts formal training series and webinars.

Staff are tasked with managing overall operations of their unit, such as encouraging members to participate in the work-ordered day activities, etc. Staff are also responsible for providing linkages to mental health and social supports, for members who are interested in these referrals, and providing care management services for eligible members who choose to enroll in the Fountain House care management program.

Ultimately, and by design, there relatively few formal distinctions between clubhouse staff and members, since all are working toward the goal of keeping the clubhouse operating smoothly. At Fountain House, there are currently three members serving on the Board of Directors, and there have always been members on the board throughout the organization’s 76-year history. Many formal decisions at Fountain House are made by consensus with members and staff, which goes back to improving members’ self-esteem and self-efficacy. This includes a wide range of decisions — from determining the lunch menu to hiring a CEO. “So often people with SMI don’t get to choose where they live, who they live with, or what they are allowed to do with their money,” noted Elliot. “They’re made to feel incompetent. Consensus decision-making may not sound effective, but it is effective if you’re trying to help people to trust their own decision-making.”

Financing and Sustainability

Fountain House primarily relies on city and state funding to finance their New York clubhouses. They also receive support from private grants, including many private donors, one of whom donated a farm in New Jersey so members can learn about and cultivate produce for the clubhouse menu. As William McKeever, Director of the Academies at Glengary and Bradenton, both clubhouses in Florida, said, “We get significant support through direct state funding. And we raise approximately 50% of our budget from the private sector, which requires a lot of public relations. That marketing is built in to how we operate.”

New York Medicaid supports select segments of Fountain House: the housing program and care management program, which are distinct from the clubhouse. Fountain House has both a permanent and transitional housing residence for low-income adults, including one 19-unit facility dedicated to Fountain House members who are 55 years and older. Care management with personalized care plans can also be provided and is reimbursed for Medicaid members.

At the federal level, clubhouses are permitted to bill Medicaid as its own service or under “psychosocial rehabilitation,” though not all states cover it. However, there are examples of some states championing clubhouses under Medicaid. According to Summer Berman, representative of Clubhouse Michigan, all 39 clubhouses in Michigan are primarily funded through Medicaid. Lori D'Angelo, PhD, Executive Director of Magnolia Clubhouse in Ohio, described how advocacy with the Ohio Medicaid director and state mental health department director was instrumental in providing a method for clubhouses to bill Medicaid as a type of day-treatment service. The model is now being implemented across Ohio, with start-up funding from the state department and guidance from Magnolia Clubhouse. Medicaid reimburses with a day rate (if a member attends for longer than two and a half hours per day) or by time. Medicaid funding allowed Magnolia to double its budget, while continuing to use local funding to help serve members not enrolled in Medicaid.

Impact

Fountain House and other clubhouses have demonstrated positive impacts in the areas of employment, quality of life, and health care cost savings, as described below. Despite these strong findings, more research may strengthen the evidence base for the clubhouse model and better understand the impact of these programs.

• Research conducted by Fountain House show that members are twice as likely to be employed compared to other adults with SMI. These outcomes are mirrored in similar research done by Clubhouse International across other accredited clubhouses.

• A 2016 systematic review found moderate evidence for improved quality of life, employment, and reduced rates of hospitalization for clubhouse participants.
• A 2018 systemic review of randomized controlled trials found solid evidence that clubhouses increase employment, reduce hospitalizations, and improve relationships and quality of life for people with SMI.
• A 2017 study by New York University found that Fountain House members enrolled in Medicaid had lower Medicaid expenditures than non-members who shared similar baseline characteristics. The cost savings were most significant for members with higher mental health acuity.

Members’ testimony also speaks to Fountain House’s strengths. “Having this place has really saved my life in many ways more than one,” said Arvind. “Sure, I was able to get a full-time job and complete school by being connected to this space, but the number one victory for myself was just being able to stay out of the hospital. To stay out of interactions with police and stay out of shelters. Because at one point in my life I never thought I would be able to move on from those interactions, and I did.”

Insights

Following are key program lessons:

• Staff with education and experience in traditional mental health treatment may need to come to clubhouse work with “fresh eyes.” There is a significant difference between clubhouse work and clinical mental health therapy. Staff are not necessarily informed of members’ specific diagnoses nor are staff in place to explore the nature of or the presenting symptoms of members’ diagnoses. The staffing levels do not support one-on-one sessions and tasks that are very common in many mental health clinics, like case notes, look a little different at Fountain House, where members are welcome to participate in writing them too.
• Managing disruptive behavior is inevitable in any community, including at clubhouses. Conflict can arise in clubhouses that can be disruptive to the community. These conflicts may relate to disruptive behavior on the part of members, who may have co-occurring behavioral health and physical health challenges, trauma histories, or facing profound health-related social needs, such as homelessness. Fountain House takes measures to mitigate these moments. “If someone’s behavior is disruptive to a point, then we talk about taking a break from being in the community,” said Megan. “We still work with them but it becomes about making a plan for them to return, like anger management, substance use support, or [meeting] with their therapist to have a conversation about their behavior.” Newer members, especially those experiencing homelessness or justice-involved, can get additional support from Fountain House’s OnRamps program, which is dedicated to welcoming people with uniquely challenging circumstances.
• Clubhouses alone are not the silver bullet to solving the behavioral health crisis, but an important piece of the behavioral health continuum. People with SMI lead successful lives in the community, but government can take opportunities to better support community-based mental health infrastructure investments. Based on the success of the clubhouse approach, this model should be seen as part of the community-based continuum of mental health care, alongside other critical services they partner with such as outpatient therapy and mobile crisis.

Photo courtesy of the Fountain House.