Article for House Discussion June 15th

Attitudes and Structure in the Clubhouse Model

By Roberta Vorspan

Roberta Vorspan, M.S., is Assistant Director of Education, Van Ameringen Center for Education and Research, Fountain House, Inc., New York, New York

Editor’s Note: This paper is based on an address given at the Vermont Conference on Community Rehabilitation, September, 16th-18th, 1986, at Stowe, Vermont.

I spend most of my time at Fountain House working with colleagues from all around the world who come to Fountain House to see and to understand what it is that we are all about.  Immersed in this constant exchange of ideas with mental health professionals and consumers, I have been forced to quickly let go of any notion that what we do at Fountain House can be easily explained by describing a particular structure, program, or organization.  At this point in our evolution, we are much more inclined to speak about the Fountain House “culture” or “world,” than to speak of it as a specific type of program. I think that it is much more important, though also much more difficult, to focus on the beliefs and attitudes that inspire the structure of the program, rather than on the structure itself. To say that Fountain House is a vocationally- oriented psychiatric rehabilitation program is to say little at all about the rehabilitation that is actually offered at Fountain House.

The core attitudes and philosophy of the Clubhouse, though so basic, are enormously difficult to articulate and objectify.  For me, I think that the most powerful way that I can begin to convey what “rehabilitation” means at Fountain House is to do it from the inside, using my own personal journey and experience to come near to what I have found to be the radical “basics” of what the model is.

I went off to Sarah Lawrence College in the late 60’s, and in the spirit of the times, graduated with the very practical majors of dance and religion. After leaving the safe,

protected and vaguely unreal atmosphere of school, I wandered out into the real world and wasn’t much impressed by it. I became convinced that I couldn’t possibly be expected to navigate the chaos of life until and unless I understood fully what the purpose of life was. I began a serious, full-time study of and immersion into a religion that wrenched me further and further from the family that I loved and on which I depended. I was in a completely untenable situation, leaning both on my new and all-embracing faith, and on my family, which were leaning in totally opposite directions from each other. After a few years of trying to maintain this impossible balance, I fell, and when I fell, fell far and hard and landed in a psychiatric hospital.

I believe that I was, like most people who suddenly find that their lives have come undone and have landed in the hospital, looking for someone or something safe to lean on. The structure of our traditional psychiatric hospitals and day programs, I found, clearly encouraged this dependency.  As a patient, you are quickly rid of the symbols and realities of whatever independence you may have attained. Your license, your keys, your bankbook and your money are taken from you, “for your own protection.” You are separated from your friends, family, “outside” therapist and other supports in your life.

You are then asked to invest your blind faith in the “staff,” who during your stay will decide when you will wake up, what you will do during the day, who are “appropriate” visitors for you, if any, what medication you will or will not take, and what is or is not appropriate behavior, laughter, or tears.  Neither I nor anybody else goes into a hospital without being extremely vulnerable and shaken as it becomes very easy to slip quickly into full relinquishment of your autonomous, decision-making faculties, while one runs the risk of being labeled a “bad” patient.

I was a “good” patient, and freely allowed the responsibility of my life to slip into the hands of the hospital staff. After 3 months of good behavior, I was discharged to the community, but without the ubiquitous “staff” to dictate my days, I quickly came undone again and was returned to the hospital. For about two years, I found myself tied tightly to the yo-yo string of repeat hospitalizations, because I found myself hankering for the security of the hospital, and more and more dependent on it.

The mental health system, in this regard, can be an addictive system. Patients learn quickly that the way to succeed and gain approval is to be “compliant,” and to allow the merciful staff to unburden them of their conflicts, their decisions, and their onerous autonomy. But once the patient leans into this embrace, he or she begins to lose the ability to function without it. For the patient, the staff became magical, wise, all-knowing, and completely essential beings.

The staff daily secretes themselves behind closed doors to discuss the patient’s intra-psychic reality, and to decide on his or her fate.  As a patient, you quickly learn to hold these judgments in awe, and to believe that behind those closed doors the truth about you is being discussed by those who truly know. You begin to believe that it is only right that they meet in locked and private places, out of your earshot, because the real truth about you is something from which you must at all costs be protected.

You do not miss your sacred sessions with your appointed therapist. If he appears to be distracted, bored, dense or just simply lacking in intelligence, this becomes your problem, for you to express to your therapist, and for your therapist to offer up in holy staff rounds. In staff rounds this piece of yourself will be distilled, understood, and acted upon. The consequence will be issued to you at your next scheduled session, as you do not dare approach your therapist at any other time. You learn from your therapist that the consequence of your negative attitude is that your weekend pass has been suspended. Though this seems to you to have no relationship at all to your feeling that your therapist is bored and dense, you accept that your reality is flawed. You need the all-knowing staff too much to doubt their judgment, so you strive to understand their wisdom.

Being a patient is also very lonely. Staffs are too wise and exalted to count as living, growing human beings who in any way are like ourselves.  Other patients are highly suspect, for as you discover that you as a patient have very little worth, voice or acceptable reality, you must also assume that the other patients are of equally equivocal worth.

What finally allowed me to break out of this destructive addiction to patienthood was a fierce curiosity about what really went on behind those formidable doors that separated us from the staff. And the best way I knew to find out was to infiltrate their ranks. I went back to school to get a Master’s Degree in dance therapy, which would allow me entry into the sacred staff places. I graduated, and got a job as a dance therapist at a small, private psychiatric hospital in upstate New York.

Now I was on staff. I role-modeled myself after the other staff, and learned that I was not to let patients know where I lived, who I was, how I felt or what I thought. I was now invited into staff meetings, where we felt very good about ourselves because we were not “them,” and were safely distanced from them by those wonderful, large doors, and where we made decisions about patient’s lives. We decided, for instance, that we all felt that Joe Brown was giving us signals that he wasn’t ready to go out on his weekend pass to see his girlfriend. His attitudes towards several staff members had been somewhat hostile and secretive. We decided to suspend the pass, and that tolerating this frustration would no doubt be therapeutic for Joe, and in any event this girlfriend didn’t seem to us to be a very suitable partner for Joe.

What I have so far described is not meant in any way as an indictment of individual people, many of whom are obviously genuinely caring and concerned professionals, but of a whole hospital after care system. This system, I think, is built on some very tenuous and, at times, even destructive premises, the central one being, I believe, that people with psychiatric problems are best helped by being relieved of major responsibility for their own lives.

I came to work at Fountain House after several years of working in a traditional hospital setting. I didn’t choose Fountain House for the noble reasons that I now understood the destructive and disabling processes at work where I had been and that I was now looking for a change. The only change I remember having looked for was a shorter commute, and Fountain House was a 10-minute subway ride from my downtown apartment. I applied to Fountain House, was told that I would no longer be doing dance therapy, as “we don’t do therapy here;” and though I wasn’t really told what it was that we do “here,” I accepted the job and began doing it.

For one whole year I was very uncomfortable in my job. There were no closed doors behind which staff could go off and be staff, no offices, no staff rounds, and the one staff meeting we did have, as it turned out, was open to members. I couldn’t keep track of who was who, and least of all who I was. Here when I tried to role model other staff, I found that we were allowed to say where we lived and who we were and what we thought and where we’d been, and that, for me, was problematical at best. For a year I had a constant, gnawing sense of discomfort.

I couldn’t figure out why members would come to this place. In a traditional institution, Joe might be feeling very hostile and angry, and come into his program with the sure knowledge that if he flaunted it, he would immediately be taken up into a net of negative attention and apparent concern. He would be rewarded for being out of control by being flanked by all manner of attentive staff– some to medicate him, some to analyze him, some to protect him, some to chart him.

When Joe came into Fountain House feeling angry and hostile, he might have been asked if he could help a group pull together the monthly statistics which we needed for our funding sources. If Joe picked up the pile of papers and threw them in someone’s face, the group of members and staff who were working on the project would have gotten mildly or seriously miffed (depending on how close it was to the due date for the stats.)  Some of his friends would gather around him and ask him what the hell his problem was, and would give him the option of leaving if he decided not to try to control his behavior. What floored me was that he would usually stay. Then I would see him through my patient’s eyes, and feel cheated for him of the solicitous negative attention and “concern” that I thought he well deserved. I just didn’t see any real treatment plans and patient charts where I could write what I really knew to be the truth about these patients. And that’s when it began to hit me. After spending a year at Fountain House, no matter how obtuse you may be (and I was,) or how addicted to the mental health system, you can’t continue to not see. You simply cannot fail to notice that patients caught up in the traditional mental health system are not growing into more whole and stronger people, but into more compliant and dependent patients.

So I returned (quickly) to Fountain House, and gradually began to be able to see and to personally experience what real rehabilitation can be. I discovered that it has nothing to do with compliance in vocational group therapy sessions, or the ability to press the right staff buttons, or achieving the neatly outlined goals that your staff workers have so carefully plotted out for you and written in your chart. Rehabilitation was Joe, coming to Fountain House because he was being treated respectfully, as an adult.  It was Joe, wanting to work on the monthly statistics because they are important to the community to which he belongs, and therefore to himself. It was Joe, seeing the very real opportunities for meaningful work in which he was invited to engage, because people believed in his health, and in his potential, and because they needed his talents. And it was Joe, not leaving in an infantile fit after throwing the stack of papers, because where else would he go if he walked out on his community of his friends. It was Joe, staying and trying to tell his friends, members and staff, what the “hell his problem was,” because he needed them, and they needed to understand.

The allure of membership in the Clubhouse is the polar opposite to the allure of the traditional mental health institution. Fountain House members and staff come to the club every day because they are immersed in a world of appreciation, of normalcy, and the reflected beauty of other’s newly discovered talents and strengths.  They do not come, as staff, to ‘practice’ their craft on others, to ‘treat’ others, to find a haven from their own pain by closing the staff doors on the “others,” or to feel the snug satisfaction of tucking the quilt of craziness around their unfortunate charges.

Rehabilitation at Fountain House is first and foremost a reprogramming, for all of us, from the disabling addictive system from which most of us come.  The first steps toward rehabilitation come when a member stops trying to recreate the familiar roles of patient and staff, and genuinely begins to crave being together with others as equals, as adults, and as potentially strong, whole human beings.  And to the extent that staff have been deformed by stigma, either by having been labeled themselves or by labeling others, this is equally true for them.

The core of rehabilitation at Fountain House is the de-stigmatization that we all, members and staff, grow through.  By being freed of the role of the omniscient staff member, I have gradually also experienced freedom from the deep stigma of the defeated patient. One is only the flip side of the other, and each requires the other to continue to exert its destructive power. It may seem strange for me as a staff worker to speak about my own rehabilitation process through working in the Clubhouse, but on a deeper level, it should not really be strange at all. The Clubhouse is a world which gradually strengthens its inhabitants by dismantling the illusion that we are all indelibly fixed in certain roles. It is a world that frees us, members and staff alike, to be simply people, each bearing the responsibility for our own lives while also openly depending on one another.

I began by saying that in speaking of the essence of a Clubhouse, it was necessary to focus on attitudes rather than on structure. Having said that though, I must also say that the attitudes that create the healing Clubhouse world are to a large extent dependent on the Clubhouse structure.

The structure of the Clubhouse must revolve around work.  Work is the crucible in which debilitating, stigmatizing roles are radically transformed and in which genuine, mutual relationships become possible.

A Clubhouse needs to be structured so that staff are overwhelmed with work, so that looking to and depending on member’s strengths and assets is not a philosophical nicety, but a necessary means of survival.  Staff need to need members.  They need to be in a position in which they are forced to ferret out every hidden ability, skill and strength in every member.  In order to insure the continued functioning of the Clubhouse, and their own survival in it, staff must experience themselves in a setting in which, working intimately with members, they don’t fear failure and even fail.  It is simply human nature that when people find themselves in a setting in which they have to depend on one another, no matter what stigmas or prejudice they bring to a situation, they are finally able to drop their preconceptions and work toward the common goal.

Fountain House is often accused of being arbitrary and stubborn in its insistence that clinical elements, like therapy groups, or OT, or various ADL classes, have no place in Clubhouse. Obviously, there is no inherent harm in any of those and many of our members benefit tremendously from them, in outside clinical settings.

What we are insisting on is not that these activities have no place, because we know that they do, but that the particular nature of the staff/member relationships that are the heart of rehabilitation in the Clubhouse cannot co-exist with clinical forms. It becomes terribly confusing, and finally false, to expect members and staff to move in and out of all of these various roles in one day and in one setting. Given the opportunity to slip into the known and comfortable roles of clinician and patient, the struggle to truly work together and confront one another as people is too often quickly abandoned, by both members and staff.

Those of us who work in Clubhouse programs, whether we are members or staff, must begin to recognize the enormous power of what we are doing– for ourselves, for our Clubhouses, and for the entire field of mental health.  We have to know that we are part of a movement whose premises are so simply human and true, and whose integrity has the power to offer real hope to the millions of people all around the world who have suffered too much both by their agonizing illness and the debilitating institutionalization to which they have been subjected.  We have to believe in who we are, and that we insist on necessary and meaningful work because it is the instrument that can finally uproot the deeply implanted stigmas that have kept us so separate for so long. We have to keep our Clubhouses clearly focused on the integrity of our relationships, fostered through the sharing of our work, so that more and more of us can have the deeply healing experience of realizing that we are not, in essence, patients, clients, clinicians, or therapists, but people, with the opportunity to help each other to achieve what we want to achieve, and to become whomever we dream of becoming.

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