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Volume 49 Number 4
Edited by Greg Townley and Alicia Lucksted
The Fountain House Clubhouse Model
Written by: Thomasina Borkman
George Mason University
Fountain House Clubhouses seem to be currently regarded as old fashioned and outmoded psychiatric rehabilitation places or, contradictorily, lumped together with less intensive drop-in centers that erroneously refer to themselves as clubhouses (Staples & Stein 2008; Craig 2013). The book Fountain House: Creating Community in Mental Health Practice by Alan Doyle, Julius Lanoil, and Kenneth J. Dudek published by Columbia University Press (2013) challenges these misconceptions. The purpose of the book, reviewed here, is to show FH as a model of a “collaborative recovery center that combines the expertise of the professional social worker (social practice) with the peer support (mutual assistance) of the consumer movement” (Ibid.,p. 138). The authors detail the major values, principles and practices that characterize the FH model today; these were developed before and especially during the tenure of John H. Beard, an innovative Executive Director from 1955–1982 to whom the book is dedicated.
The authors are or were directors and professional leaders of Fountain House, New York with first hand clinical experience working the model as well as having professional knowledge of its concepts and practices. I use the term FH Clubhouse to denote those Clubhouses developed on the basis of the Fountain House model in New York City founded in 1948. This model has developed into an international evidence-based mental health program (on SAMHSA’s registry) with its own democratically-derived standards of peer control and mutual support used to monitor and certify programs that are entitled to the name Clubhouse by the International Center for Clubhouse Development-ICCD.
The FH Clubhouse is a non-governmental non-profit organization that is a hybrid consumer-run organization: the Board and the directors are mostly professionals and businesspersons. However, there is extensive member involvement in policy setting, management decisions and work practices which are guaranteed by the 36 standards of the ICCD which had been created by members and staff (Staples & Stein 2008, Borkman 2013). A non-residential house, it creates a non-stigmatizing “working community” for its members to develop skills, engage in recovery, develop personhood and a self-enhancing collective identity. The underlying structure is the “work ordered” day intended to replicate conventional work life in the community; and the house is organized around work roles/areas (lunch preparation, house maintenance, house tours, etc.) that are vital to the functioning of the house. Members freely choose a work unit and work alongside staff (sometimes professional social workers or not) and peers. Various stages of transitional employment and job placement are also available.
FH began as a mutual help group of ex-patients from a long-term psychiatric hospital. Wealthy philanthropists who were concerned with easing the transition of the ex-patients from hospital to living constructively in New York City purchased a large house on West 47th in 1948. The ex-patients became known as members and were organized as a Fellowship under the legal auspices of the FH Foundation. FH was run like a settlement house of the mid-19th century in which social workers assisted immigrants to adapt to American life. By the time John Beard arrived in 1955 as the new Executive Director, all participants—members, staff, and directors— were squabbling and in disarray (op. cit., p. 28). John Beard dissolved the Fellowship while maintaining their mutual help ethos and applied what he had learned in his graduate social work studies under his mentors Arthur Pearce and the psychiatrist Goertzel in a Detroit mental hospital. Simply stated, these values and beliefs were as follows: patients should be treated humanely and had the potential for improved lives; emphasizing patient’s ego strengths, not their pathology, was the key to patient improvement; and severe psychiatric illness was accompanied by “relationship failure” or depletion of social relationships and social isolation which had to be addressed. Activities based on these principles were developed and known as Activity Group Therapy (AGT) (Beard, Goertzel & Pearce 1958, p. 21).
Beard created the “work ordered” day in which staff and members engage side-by-side in functional work units. A central principle of the working community is “The need to be needed.” “Operationally, the need to be needed structures all house activities in such a way that member participation is required to accomplish the work at hand. A low staff-to-member ratio means that member participation is an essential programmatic reality.” (op. cit., p.50). Underlying the surface activities are directors and staff committed to creating an environment that: (1) creates personalized relationships between professional staff and members that minimizes the hierarchical distance between them; (2) members are free to choose the type, extent and frequency of their involvement; and (3) peers engage in reciprocal learner-teacher roles and relationships with each other and staff. The importance of the house as a community, a space and place dedicated to the FH philosophy and practices is emphasized: “community as a place that encompasses a relational ethic and one’s awareness of being part of a group that is viewed at Fountain House as being essential for recovery.” (op. cit., p.45).
Part 2 deals with “social practice” or how the professional staff role is modified to fit the FH philosophy through transformational design and motivational coaching. Transformational design refers to attending to cultural and structural facets of work activities and the environment that support member’s motivation and empowerment. For example, how do staff frame daily work activities to be real and meaningful, to foster side-by-side relationships and to exemplify the other FH principles? Motivational coaching refers to the one-on-one relationships that staff establish with members; the changes from conventional professional roles to the personal, egalitarian and genuinely human relationships that staff establish with members are the most radical and distinctive sections of the book. They deserve extensive attention!
John Beard’s philosophy and the practices he developed are described not only in concrete terms but also as vivid exemplars of current social and behavioral science theories. Many components of the model were in practice at FH long before the corresponding social or behavioral science theory was developed. An example is the strengths-based or non-medical approach increasingly in use today (Saleebay 1996) as well as empowerment (Simon 1994), and self-efficacy (Bandura 1997). Another practice that exemplifies an important theory that the authors did not note is the “low staff-to-member ratio”, which is now known as “behavior setting theory” (Barker 1968). While the book emphasizes theories of staff behavior, it regrettably neglects equivalent theories connected to peer support and mutual aid (see Brown & Wituk 2010).
The authors do an excellent job of tying together the values, principles, and practices of staff and directors, and clearly explaining how these in turn are related to and are exemplars of contemporary social science theories. This very significant book is especially important because FH’s practices have not previously been explicitly linked to contemporary theory. Some readers seem to be enthralled with theory-based work and minimize or ignore empirical work seemingly unconnected to some proper theory. FH is open to misinterpretation by outside observers because many of its practices look mundane, simplistic, non-technological and unsophisticated. The book provides the rich theoretical basis of these seemingly mundane activities.
The next questions: What independent empirical verification exist that the practices that exemplify the theories describe actual Clubhouses? Where, to what extent and under what conditions is this so? In any case, the book is significant and highly recommended to correct misconceptions about the FH clubhouse model.
Bandura, A. (1997). Self-efficacy: The exercise of control. NY: W. H. Freeman & Company.
Barker, R. G. (1968). Ecological psychology. Stanford, CA: Stanford University Press.
Beard, J. H., Goertzel, V., & Pearce, A. J. (1958). The effectiveness of Activity Group Therapy with chronically regressed adult schizophrenics. International Journal of Group Psychotherapy, 8(2), 123-136.
Borkman, T. (2013). Special issue of Fountain House mental health clubhouses as hybrid self-help organizations. International Journal of Self-Help & Self-Care 7, 1-6.
Brown, L. D., & Wituk, S. (Eds.). (2010). Mental health self-help: Consumer and family initiatives. New York: Springer.
Craig, T. K. J. (2013). Expanding knowledge of peer-based mental health organisations: The experience of clubhouse. International Journal of Self Help and Self Care, 7, 119-130.
Doyle, A., Lanoil, J., & Dudek, K. J. (2013). Fountain House: Creating community in mental health practice. New York: Columbia University Press.
Saleebey, D. (1992). The strengths perspective in social work practice. (5th ed.) Boston: Pearson/Allyn & Bacon.
Simon, B.L. (1994). The empowerment tradition in American social work: A history. New York: Columbia University Press.
Staples, L., & Stein, R. (2008). The clubhouse model: Mental health consumer-provider partnerships for recovery. PP. 177-196 in S. Chambre & M. Goldner, eds. Patients, Consumers and Civil Society: Advances in Medical Sociology, vol. 10. Bingley, UK: Emerald Group Publishing, Ltd.