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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

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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

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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

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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

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