The Clubhouse Model for Depression and Serious Mental Illnesses

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CLINICAL CONVERSATIONS

Psychiatric Times® sat down with Jeanie Tse, MD, senior medical director at Fountain House, to discuss the Clubhouse model of psychosocial rehabilitation and its benefits for patients with depression and other serious mental illnesses (SMIs).

Psychiatric Times: What is the Clubhouse model? How does it work, and how does it benefit patients with SMI?

Jeanie Tse, MD: The ​​Clubhouse model¹ of psychosocial rehabilitation uses community as a therapeutic modality to support recovery from SMI. The community is intentionally designed for and by its members—individuals living with SMI—who work side-by-side with staff in a non-hierarchical environment where everyone works to operate the Clubhouse together. This purposeful work, to help not only yourself but others using the Clubhouse, gives individuals a sense of belonging and helps them develop skills that bridge to participation in the broader outside community.

The focus in the Clubhouse is on the whole person and on what they bring to the table in terms of their talents and skills and hard work; it is not on illness or diagnosis. Members support each other around the social drivers of health, ensuring that their friends have access to safe housing, food, and medical care. Clubhouse membership is lifelong, ensuring that an individual with SMI always has a place to obtain support when needed.

Fountain House,² the first Clubhouse, started in the 1940s when a group of patients leaving Rockland Psychiatric Center established a peer support group to help each other reintegrate into the community after living most of their adult lives in the hospital. In the 75 years since, Fountain House has given rise to more than 300 Clubhouses worldwide.

The Clubhouse movement has a set of standards³ and an accreditation process maintained by Clubhouse International. The standards preserve the member-driven values of the Clubhouse, including the primacy of the “work-ordered day.” Members come voluntarily to the Clubhouse and choose what work they would like to do in the Clubhouse on any given day, whether it is preparing lunch, writing for the newsletter, tending the garden, or entering research data.

One essential feature of Clubhouses is that supported employment opportunities are offered, with voluntary work and then short-term job placements preparing members for permanent job placement.

PT: Are any aspects of the Clubhouse model particularly beneficial for individuals with depression? If so, what are they?

Tse: Engagement in activities that combat hopelessness, helplessness, and social isolation are key to the benefit for individuals with depression. Members and staff work side-by-side in a non-hierarchical environment, developing meaningful relationships through authentic social interactions that honor members’ contributions and counteract stigma, fostering self-efficacy and a “need to be needed.” The focus on the needs of the whole person ensures that the social drivers of depression, including housing and food insecurity and untreated medical problems, are addressed as well.

PT: What are the broader economic and societal benefits of Clubhouses? How does this impact mental health care?

Tse: Empirical studies highlight Clubhouse as a cost-effective model of care. Members achieve greater rates of employment, longer job tenure, and higher pay. Further, Clubhouses are credited with reducing psychiatric hospitalizations and readmission, reducing symptoms of psychosis, improving social support, increasing self-esteem, reducing internalized stigma, and improving quality of life.

As Fountain House’s most recent research⁴ further demonstrates, Clubhouses not only improve the life trajectories of individuals with mental illness but also drive down the secondary costs of untreated mental illness—saving the country nearly $700 million annually in lost wages, disability benefits, repeat emergency room visits, and criminal justice impacts. If Clubhouses were scaled to reach even just 5% of the 15.4 million adults in the United States living with SMI, we would see a net societal benefit of more than $8.5 billion a year. But most states have yet to leverage their authority under Medicaid to reimburse for these services.

PT: How do you perceive the role of community-based interventions like Clubhouses in complementing traditional psychiatric treatments? How can mental health clinicians actively support and integrate these models into their patients’ care plans?

Tse: When my patient joins the Clubhouse, I know that I am going to get a better idea of who this person is, beyond the symptom questions I ask in an office. I get to know that a certain person can run a book club or is really good at teaching people how to make fried rice. And whereas I only see somebody once every month or every 3 months, this person might have contact with their friends at the Clubhouse every day, and that support for daily growth is really important.

I also want to introduce the concept of the rehabilitation alliance. When a Clubhouse works with a medical provider or psychiatrist in service of a member, the patient can feel empowered by the support of all their friends in the Clubhouse to speak up for themselves with their doctor, and that empowerment of the member supports shared decision-making where the doctor and the member are on an equal plane, with the doctor offering knowledge and opinions and the member using that information to make decisions that support their goals. The decision is then made by consensus rather than solely on the psychiatrist’s opinion and advice.

At the same time, when a Clubhouse community has vetted a certain doctor and members have recommended them to each other, this can also strengthen an individual patient’s relationship with and trust in that doctor, despite their former misgivings about doctors in general. With the knowledge that the member is supported by the Clubhouse, a psychiatrist can also feel more comfortable with lowering medication doses, knowing that if anything happened (eg, if the dose went too low and the member was having difficulty with symptoms), the Clubhouse would reach out to the psychiatrist to let them know. This allows us to use a lot less medication.

I think it is important for clinicians to see Clubhouses in action. Mental health care can be discouraging and sometimes dehumanizing, particularly on inpatient units. I remember as a resident only seeing individuals with SMI at the height of their illness who were sometimes not getting better for a long time. Seeing patients when they are well and when they are affirming their identities not defined by their illness gives trainees hope, and it helps them to understand what recovery looks like. It helps them to keep doing the important work they do to serve these members so they can live full and fulfilling lives.

So, how can psychiatric or medical providers facilitate the rehabilitation alliance? One simple way is to know where the Clubhouses are nearest to you.⁵ If there is not a clubhouse close to you, you can perhaps support the development of one or services that are developed, informed, or governed by individuals with lived experience of SMI. Supporting the rehabilitation alliance means helping patients or members feel empowered to take responsibility for their health care and to participate in activities that support their identities not defined by their illness.

If there is a Clubhouse that you are able to work with, then using the Clubhouse staff member or social practitioner as a trust broker to support the relationship you have with the member and to help the member advocate for themselves is very important, always aiming to work through a process of shared decision making.

PT: How can mental health clinicians contribute to the evidence base supporting the effectiveness of Clubhouses as an adjunct to traditional psychiatric interventions for patients with depression and other SMIs? What research opportunities do you see in exploring the long-term impact of Clubhouse participation on patient outcomes?

Tse: Fountain House has a number of research initiatives⁶ underway, primarily participatory action research that is led and informed by Clubhouse members. We have a growing database that will be able to yield further long-term data and drive research agendas toward informing better outcomes for individuals with SMI.

Jeanie Tse, MD

We would be very much interested in working with academic partners to develop the scope and sophistication of our research.

To learn more about Clubhouses and how you can partner with them, you can also access this free CME offering⁷ through NEI Global.

Dr Tse is the senior medical director at Fountain House and an associate professor of psychiatry at NYU School of Medicine.

References

1. What is a clubhouse? Fountain House. Accessed March 18, 2024. https://www.fountainhouse.org/about/clubhouse-model

2. About. Fountain House. Accessed March 18, 2024. https://www.fountainhouse.org/about

3. Quality standards. Clubhouse International. Accessed March 18, 2024. https://clubhouse-intl.org/resources/quality-standards/

4. New research: community-based recovery model for serious mental illness can reduce societal costs by billions. Fountain House. News release. February 7, 2024. Accessed March 18, 2024. https://www.fountainhouse.org/news/new-research-community-based-recovery-model-for-serious-mental-illness-can-reduce-societal-costs-by-billions

5. Clubhouse directory. Clubhouse International. Accessed March 18, 2024. https://clubhouse-intl.org/what-we-do/international-directory/

6. Research. Fountain House. Accessed March 18, 2024. https://www.fountainhouse.org/get-involved/research

7. Partners in care. Fountain House. Accessed March 18, 2024. https://www.fountainhouse.org/get-involved/training-and-development/partners-in-care