Expanding the clubhouse model and community based therapy

Clubhouses in the mental health space are a form of community-based therapy. The model was introduced in the 1930s and 1940s as a form of psychosocial rehabilitation. Clubhouses focus on providing services to people with serious mental illness. The goal is to rehabilitate members back into society where they can thrive and be healthy. 

Fountain House, a New York City nonprofit which has pioneered the clubhouse model, focuses on providing free, safe, and diverse spaces for its 2,000 members. The voluntary organization encourages members to help design and lead activities. Members also, through participation in the program, saw their Medicaid costs drop 21%, according to an NYU study. "Among individuals who used Fountain House services, we see a reduction in medical costs of $637 per month from the 12-month period before enrollment to the 12-month period after enrollment," said James Knickman and Claudia Solís-Román, the lead researchers on the study. 

The program has locations in Manhattan and the Bronx and is now looking to expand into Los Angeles. Fountain House CEO Ken Zimmerman has been a vocal advocate in the movement to expand and make accessible community based therapy for people with serious mental illness. City & State caught up with Zimmerman to talk about Fountain House's mission, recent policy and advocacy successes.

This interview has been edited for length and clarity

What does it mean and/or look like to have health-led responses to mental health crises? 

With regard to mental health crises, there's really two critical things to mention. First, is just the recognition that mental health crises don't need to lead to many of the outcomes they currently do. So if we invested, not just in Fountain House, but in many of the other things that would prevent mental health crises from ever occurring, we would be addressing many of the things that lead to very high profile types of issues. We reduce mental health crises by 40% among our members. It’s because people are in a community. If somebody is having a problem, they can be seen, observed and addressed much earlier. So it's really critical to start with that.

The second piece (in terms of health-centered crisis response) is a recognition that if one just asks people with mental health conditions what they want and need, it's a critical part of designing the right kind of system. The new 988 [Suicide and Crisis Lifeline] number that is being used widely is a step in the right direction because it actually supports some of the city's efforts to ensure that we can lead with mental health professionals as opposed to leading with law enforcement. You'll also find lots of agreement about the value in peers.

What are the biggest challenges facing Fountain House this year and how are you working to address them?

There's a set of challenges. I think the broader social environment contributes to people with serious mental health conditions (and leads to complicated situations). So, the shortage of affordable housing, just like everybody else, contributes mightily to the challenges that people with serious mental health conditions face. The mental health workforce shortage is something that, again, for the kinds of support that some people need. And those are all the broader challenges that in order to create the kind of system that supports and enables people with serious mental health conditions to thrive, which is what we think the end goal should be. They need to be part of the conversation.

There is growing attention to clubhouses, which means there's more and more people who seek the support that we provide. We are having unprecedented numbers of people coming to join our community. And that's going to lead to what we are so excited about, which is the city's expansion of clubhouses. They put out a request for proposals to triple the resources, almost double the number of people to be served by clubhouses going forward. So we are focused on providing the level of resources needed to ensure that the clubhouses of the future are high quality and attentive to the transition that needs to take place. So the first area of challenge is really the increased demand and ensuring the resources to meet that demand. 

I think the second challenge is improving the coordination and partnership between different key elements of the systems and sectors support. To us, growing those partnerships with affordable housing providers, community mental health providers and an array of organizations that serve unsheltered people is key. 

Mayor Adams has been pushing for a bill in Albany to make it easier to admit people with mentally illness to be hospitalized involuntarily, what are Fountain House's thoughts?

I think first and foremost, our fundamental belief is that involuntary treatment is the last resort and not the default that we have. And our deepest concern when you talk to our members is that it means investing upfront in all the things we know that work (to avoid the last resort). It’s reinforced by unfortunate histories, especially involving people of color who frequently have been targeted when there is undisciplined resort to involuntary treatment. We believe that the call for investment in community based approaches to supporting people with serious mental health conditions is even more important than it's ever been. If done right, and with a coordinated approach, you can truly minimize and ensure that any involuntary approach is truly a last resort and that we understand the implications of doing that.

Can you elaborate on your support for the (Certified Community Behavioral Health Clinic Expansion Act) introduced by Rep. Ritchie Torres last month? How will this legislation benefit Fountain House members?

The good news is that the national attention being paid to people with serious mental illness is leading to a number of positive reforms and changes. One of them is served by community behavioral health centers and the funding at the federal level that they provide. I mean, an additional $9 - $10 billion of federal funding to make CCBHC a model of value-based payment of coordinated care and support is a positive development. The bill that you're referencing, which Congressman Torres introduced, says that the CCBHC can be strengthened by incorporating intentional community as a therapeutic intervention. While there is some language in the authorizing statute CCBHC that mentions the value of psychosocial rehabilitation currently, we believe that this legislation could do more by stating that intentional community should be built in as a therapeutic intervention. And specifically thinking about how you can expand partnerships between CCBHC and clubhouses like Fountain House.  

What are some recent Fountain House successes?

Let me just say that the successes I start with are individual people who have gone through enormous ups and downs. And one of them is somebody who was hospitalized 15-20 times before he became 20-years-old and found Fountain House. Over the course of five years, he has graduated from college, served on our board and has a job at one of the elite mental health consulting firms nationally. 

We continue to see our success charting a course for individuals that allows them to break the stereotypes that suggest people with serious mental illness cannot live full and complete lives. We are fortunate to see that happen over and over and over. With that said, Fountain House itself is enormously gratified by the increased attention on clubhouses and the people's ask of us to do more. The situation in Los Angeles, where they've invited us to create a Fountain House in their city, and the creation of a state of the art clubhouse and supportive housing in the Bronx are concrete manifestations of what we see as critical momentum being built. We are beginning to articulate through policy reports and policy change. 

In the Medicaid waivers that are in New York and California, we're starting to see openings for new forms of public funding that take place. Beyond that the economic modeling report that's on our website is making a stir because it illustrates why this is not just a good thing to do, but an economically sensible thing to do. So those are a few of the many really good things that we see happening. And the last thing I'd say is that we're deeply gratified by the level of support (we have received) from both the public sector and from private individuals, funders and foundations. We see that as a reflection, that this momentum is something many people would like to see built and become expanded.

Can you tell me more about Fountain House United and what are the long term goals for the program?

Fountain House United is one of the mechanisms that we have set up to take this momentum and increase the attension and enable it to benefit communities across the country. What it represents is a set of clubhouses that are leading examples of what clubhouses can do, and are able to become a proof point in multiple communities across the country. And in doing so, help advance the case that clubhouses can and should be part of the national mental health infrastructure. Specifically, there are partners of ours who collectively further advocacy about public funding streams and represent in different states new ways of getting public dollars. In Ohio, for example, Gov. DeWine has invested money into clubhouses out of the state budget. We're advancing research together, including data sharing, and have a fairly sophisticated way where we can actually show how the data illustrates the positive impact of clubhouses. And then partly what we're doing is sharing the profile and enhancement of these types of leading clubhouses to further the national case about what is possible.