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Review of "Fountain House"

By Alan Doyle, Julius Lanoil, and Kenneth Dudek
Columbia University Press, 2013
Review by Abraham Rudnick, M.D., Ph.D., C.P.R.P. on Nov 4th 2014
Fountain House

Fountain House is a book long due. The model of mental health services -- the clubhouse -- that is its focus has been practiced for more than half a century. It originated in New York in the late 1940s, as a self-help initiative of people with mental illness in reaction to de-institutionalization, i.e., the considerable reduction of number of psychiatric hospital beds, which resulted in the discharge to the community of many people with mental illness who then had insufficient support in the community. It was transformed to its current form in the early 1950s by John Beard, the executive director of Fountain House in New York City for more than two decades. In the 1990s it spun off international accreditation for clubhouses. To date, there are hundreds of internationally accredited clubhouses across the world, and many more clubhouses that are not internationally accredited, which demonstrated varying fidelity to the clubhouse model. Although the (international) clubhouse standards are published and the model is widely recognized, this is the first publicly available book that reviews the clubhouse model comprehensively. The authors have been leaders of Fountain House. 

The book addresses relevant history, theory, evidence, practice and policy related to the clubhouse model, using examples from Fountain House. It is written clearly and it provides ample examples and references. As the chapters are not equally weighted in relevance to current issues, and there is some overlap amongst them, I will not review chapter by chapter but rather key themes addressed in the book.

The clubhouse model aims at recovery of people with mental illness, which does not mean cure but rather having a personally meaningful life and valued social roles. It uses a social practice approach, considering that the social environment of people - including people with mental illness - influences their conduct and related mental constructs such as their beliefs and attitudes. All the service users are life long members, and as such, are expected to be part of the working community of the clubhouse unless they are otherwise occupied such as with full time work outside of the clubhouse of if they are acutely sick. The working community consists of the clubhouse members and staff, as well as visiting students and volunteers when available, and operates the clubhouse - from cleaning, to accounting, to helping members in need, and more. These operations are governed by the work ordered day, which is the schedule of activities required to operate the clubhouse and from which the members select their preferred activities daily and longer term. The two key practice aspects of the clubhouse model are transformational design and motivational coaching. Transformation design is the structuring of the clubhouse activities that members take part in to foster their recovery collectively, and motivational coaching is the action that staff - and sometimes members - initiate and maintain with members to foster their recovery individually. Clubhouses facilitate transitional employment, supported employment, supported socialization, and other social interventions, including supported housing by some clubhouses.

There is some promising evidence that clubhouses promote success and satisfaction of their members. Yet the book glosses over some important issues. From a theoretical perspective, clubhouses are more segregated - hence likely more stigmatizing and isolating - than other contemporary psychiatric/psychosocial rehabilitation practices that are offered within regular environments, such as supported recreation in community centres. From an empirical perspective, there is a lack of rigorous evidence in support of clubhouses. For due diligence, I reviewed the relevant literature and spoke to internationally accredited clubhouse leaders in North America; I found only one randomized controlled trial of the clubhouse model from 2008 (published by Cook et al), which found it had better vocational outcomes than Assertive Community Treatment (ACT), although that is not a good comparison as ACT is not well designed to achieve positive vocational outcomes by itself; and clubhouse leaders confirmed the lack of rigorous research in support of the clubhouse model. From a practice perspective, there seems to be some subtle coercion or undue influence involved in the clubhouse model, as participation in the work ordered day is required for membership, although that is not necessarily always conducive to a particular individual's recovery (which admittedly may be a matter of theoretical contention); indeed, on page 130 of the book, there is a startling example of such coercion or influence: 'As the member drew pictures, he began to cry again and verbalize negative recollections of abuse and ridicule. The staff worker calmly but directly said, "If you don't stop crying and talking about the past, we will stop drawing and you will have to leave." "No," the member exclaimed, "I'll stop." And he did so.'

To sum, the book is helpful in clarifying the clubhouse model. More research is needed to examine the clubhouse model's effectiveness, cost-effectiveness, and alignment with a fully recovery-oriented approach and other psychiatric/psychosocial rehabilitation practices.

 

© 2014 Abraham Rudnick (

 

Abraham Rudnick (based in Victoria, BC) is a practising psychiatrist, medical director and associate professor who earned a medical degree, from the Hebrew University in Israel; a master in psychiatry, from Tel Aviv University; a doctorate in philosophy, from Tel Aviv University; and certification as a psychiatric rehabilitation practitioner, from the Psychiatric Rehabilitation Association in the United States.

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