Programs That Work

Nehemiah Surratt delivers the mail every morning at the Dow Jones office near Times Square in Manhattan. He sorts the incoming mail, transports it to the various departments, and picks up outgoing documents. In the afternoon, Surratt takes classes at Hunter College, where he's a straight-A student majoring in Spanish translation. Soft-spoken and shy, dressed in a rumpled, gray button-down shirt and a white knit cap, Surratt could be any other 26-year-old making his way in the world.

Two years ago, he scraped up all his savings and flew to New York, where he planned to kill himself in a cheap Midtown motel. He'd never been to the city before, he says, and he wanted to see it before he died.

"I stayed for three days, spent all my money," Surratt says. "I ended up changing my mind, because I looked out the window and I saw how beautiful the city was and decided I should get help."

He went to a homeless shelter, and eventually a caseworker there referred him to the state psychiatric hospital, where he stayed for a month and a half. Doctors determined that he suffered from severe depression, which Surratt now says had plagued him since middle school. After being discharged, he bounced between his hometown of Norfolk, Virginia, and homeless shelters in New York, finding and losing jobs, spending time in out-patient treatment centers, and passing from caseworker to caseworker.

As it does for many individuals with severe mental illness, this might have become the story of the rest of Surratt's life -- unemployed, homeless, cut off from others, and trapped in a system that offers few opportunities for exit. Yet, unlike many individuals with severe mental illness, Surratt found his way to Fountain House, an innovative program in Manhattan that helps individuals with severe mental illness transition out of the broken system and back to work, school, and the greater community through a special model of recovery called the Clubhouse program.

The price of the nation's broken mental-health system is high for people like Surratt, and for the nation itself. Each year, 5 million to 6 million Americans aged 16 to 54 lose, fail to seek, or cannot find employment because of a mental illness. At least 200,000 Americans with mental illness are homeless, and another 200,000 are in the criminal-justice system. Those who aren't homeless or institutionalized are often confined to their homes and isolated from society. But Clubhouses, as well as other recovery-oriented, community-based options like Assertive Community Treatment (ACT) programs, offer real promise for individuals with mental illness, while at the same time saving millions of dollars for state and local governments.

Only a generation ago, individuals with mental illness were likely to end up in state psychiatric hospitals. But in recent decades, as lawmakers favored "deinstitutionalization," many such facilities were shuttered and the patients returned to their communities. Funding for community-based mental-health programs was supposed to follow but has been inadequate, leaving many of the mentally ill consigned to nursing homes or, worse, the streets. In addition, tight budgets for mental health and an unwillingness to depart from traditional clinical models have crippled the growth of well-established, community-based programs like Clubhouse and ACT, making them available to only a fraction of people living with mental illness.


Unlike traditional programs for people with severe mental illnesses like schizophrenia, bipolar disorder, and major depression, Fountain House is a voluntary program with the goal of getting people like Surratt out of homeless shelters and hospitals and back into society. Fountain House was founded as the world's first Clubhouse in 1948 by six men who had been discharged from Rockland State Psychiatric Center and sought a place where individuals like them could find a community to support their recovery and help them develop life skills.

Sixty years later, Fountain House serves some 350 people each day, and up to 1,500 visit each month. It now also houses a training program, where people can come to learn how to start Clubhouses in their communities, as well as the International Center for Clubhouse Development (ICCD), an organization that works to promote, train, and support Clubhouses around the world. ICCD has helped the model expand to 326 Clubhouses in 29 countries serving 55,000 people a day, with 220 Clubhouses in the United States alone.

Proponents of the model cast it as a social movement rather than a program or service, and individuals who join the Clubhouse are "members" instead of patients or clients. Clubhouse members select a staff worker who serves as their advocate, working with them to achieve a personalized plan and goals. There are no clinical services offered within the Clubhouse, but staffers refer members to appropriate psychiatric and medical care and housing, employment, and education services. The emphasis within the Clubhouse, though, is not on an individual's illness but on his or her interests and goals.

A high value is placed on equity among members and staff, and all tasks -- from scrubbing toilets to serving on the board of directors -- are shared. Members participate in all the day-to-day operations of the Clubhouse as part of a work unit, which in most Clubhouses includes dining-hall, clerical, education, and employment units. As the largest Clubhouse in the world, Fountain House offers a wider range of work units, and on any given weekday, members tend to the garden in the horticulture unit, write articles for the newsletter in the clerical unit, and help plan classes about managing diabetes in the wellness unit.

In addition to the day's work, most Clubhouse members can also attend classes for things like computing and exercise, as well as evening and weekend social events. Most Clubhouses also offer a subsidized daily lunch and holiday meals. Through work and social engagement, members are able to develop relationships with each other and staff members, who can help them deal with the many challenges of living with mental illness.

"The priority is building strong relationships ? that can empower members and help them pursue their recovery goals," says Joel Corcoran, executive director of the ICCD. "The entire focus is on what you can accomplish, whereas in the traditional medical model the focus is on what your disability is."

Beyond developing coping and social skills, the Clubhouse also helps prepare members for independent employment or education. After securing commitments from local employers, Clubhouse staff go to the job site, learn the job, and then teach the needed skills to a Clubhouse member, who will hold the position for six to nine months. If the member hits a bump in the road, a Clubhouse staffer or colleague will cover for him. The model benefits the businesses because they are guaranteed coverage in an entry-level, high-turnover position. And the arrangement is a win-win for the new worker, allowing him to gain valuable work experience and build a resumé while learning to manage his illness. Members in transitional employment work 12 to 20 hours each week, and earn above minimum wage. Fountain House members are employed in such prominent New York businesses as Dow Jones, McGraw Hill, and the American Stock Exchange, where they work as mail clerks, as messengers, and in food service, for instance. After the initial placement, members can opt for a second transitional post or work with a staff member to secure independent "supported" employment, while others may pursue a GED or a college degree.

By all of these important measures, the Clubhouse model has demonstrated solid success. Though only 15 percent of individuals with severe mental illness are employed nationally, 40 percent of Clubhouse members are in transitional or supported employment at any given time. Over a 30-month period of membership, 60 percent of Clubhouse participants have been employed. And those who aren't in jobs are generally in school or working toward employment. These figures are even more impressive in light of the fact that four in 10 Clubhouse members originally said they had no interest in employment, often because they believed they were unemployable. Within one year of membership, half of that group is engaged in an employment program through the Clubhouse.

"The very way we define ourselves in Western culture is about our productivity," says Pauline Anderson, development director for the ICCD. "Most people living with a serious mental illness, despite what they're told by their physicians or by society, want to be productive citizens, want to be productive members of society, want to go back to work."

In addition to providing opportunities for members, Clubhouses also have proven benefits for the states that support them. Communities spend an average $657 per day of hospitalization for individuals with mental illness, while the costs of Clubhouses total just $27.42 per day. A number of studies have found that the opportunities offered through Clubhouses significantly decrease both hospitalization and incarceration rates for members and increase the number of members living in independent housing rather than shelters or group homes, at a great savings to the states that support them.


Another approach that has proven highly successful for people with serious mental illness is the Program of Assertive Community Treatment, also known as PACT or ACT. Much like the Clubhouse model, ACT programs are intended to help individuals re-enter society through housing, education, and employment. ACT was designed by a team of doctors at Mendota State Hospital in Madison, Wisconsin, in the 1960s as a way to provide treatment for individuals with mental illness within their own community.

ACT services are deployed through a mobile, multidisciplinary team of 10 to 12 trained professionals. Many teams also include a substance-abuse counselor and a "peer support" specialist -- someone who has experienced mental illness first-hand and can provide advocacy and guidance. In more traditional models of outpatient care, individuals are assigned to separate case managers, psychiatrists, medical doctors, and housing and employment services, which often creates a fragmented and unstable system of care. But an ACT team consists of professionals in each of those areas who can provide services 24 hours a day, 365 days a year.

The model is intended to flex to the needs of individual users, often called "consumers" or "clients." Team members collaborate to create a treatment plan and coordinate with each other to ensure that the consumer's needs are being met. If the client is facing a mental-health crisis, a team member will accompany him to the hospital. If he decides to seek a job, the team's vocational counselor will work with him to achieve that goal as well.

"It helps people live independently who might have their life much more controlled in institutions," says Elizabeth Edgar, a senior policy analyst at the National Alliance on Mental Illness (NAMI), which supports the development of ACT programs. Like Clubhouses, the goal of ACT is to help individuals with severe mental illness acclimate to life in the community and be able to access the range of opportunities available to everyone else. "It's a way for a person to reclaim things that they may have given up on, like going back to college, working, or living [on their own]," Edgar says.

Because of its mobility and flexibility, ACT is also a model that can reach those who are most disabled by mental illness, or who are homeless or even incarcerated. The approach allows for individualized, person-centered care, says Cheri Sixbey, executive director of the Assertive Community Treatment Association (ACTA), an organization that provides support and training for ACT teams. It also allows individuals with mental illness to recover within their own community, among relatives, friends, and neighbors. "It's honoring community and seeing people as more than a mental-health patient," says Sixbey, who is a former ACT program manager from Livingston, Michigan.

ACT teams are in place in at least 35 states, though they are more widely available and better funded in some places than in others. Michigan alone has 100 teams, and other states, like New Jersey, Indiana, and Oklahoma have increased their investment in these programs over recent years. Fifteen states, however, have no ACT program at all.

Like the Clubhouse model, the ACT approach has a proven record of success. National surveys found that ACT participants spent 78 percent fewer days in the hospital than individuals in other outpatient programs, while other research found an 83 percent reduction in the number of days spent in jail by program participants. In Georgia alone, reduced hospitalization and incarceration of individuals receiving ACT services saved the state $1.1 million in a single year. Nationally, ACT participants were also much more likely to be employed; within 30 months of joining, 74 percent of them had secured a job.


Cost-effectiveness aside, community-based programs like ACT and Clubhouse should be supported because they are more socially just than traditional medical-care models, says Robert Bernstein, executive director of the David L. Bazelon Center for Mental Health Law, an organization that advocates for the rights of individuals with mental illness. "These are fellow citizens who have disabilities and who have quite a bit to offer society," Bernstein says. "People want to have a job, they want to own something, to have a life, and not just simply be treated as a former mental patient."

Within the consumer-rights movement, some argue that programs like ACT and Clubhouse don't go far enough in being recovery-based and self-determined. According to Dan Fisher, executive director of the National Empowerment Center, a coalition of consumer-advocacy groups, these programs still involve an over-reliance on professional staff and medical treatment. There should be a wider range of opportunities available to individuals living with mental illness, and more peer-driven programs. Fisher points to states like Florida and Oregon, where individuals with mental illness can select from a range of community-based options, and the funding follows.

But securing funding to develop and sustain even model initiatives like ACT or Clubhouse is often difficult, says NAMI executive director Michael Fitzpatrick. "The tragedy in America is if you look at our mental-health system, in most states and counties there's really ? a lack of political will to fund these very innovative, effective programs."

Many policy-makers simply assume that traditional institutional or clinical care models are cheaper, despite the demonstrable cost savings that the government accrues from programs like ACT and Clubhouse. Making the case for these models is also hampered by the absence of studies that quantify the full costs of untreated or mistreated mental illness across the whole system?from hospitalization and incarceration to the cost of dispatching police officers to deal with mental-health emergencies or transport homeless individuals.

The structure of the funding system for mental health in this country also works against programs like Clubhouse and ACT. Sixty percent of funding for mental-health programs comes from state and county governments, and it is often difficult to convince legislators or health departments to fund new programs, especially in states where budgets are already tight. In some states, like Illinois, individuals with mental illness are often assigned to nursing homes, and legislative efforts to shift funding from those nursing homes to community-based care programs have met stiff resistance from the nursing-home industry and other entrenched interests.

"There are vested interests in the status quo," says Robert Bernstein, who also cites the influence of the nursing-home industry. The result is a system that throws all of its money at crisis situations rather than investing in long-term, recovery-based programs. "We really do have the [knowledge] to help people" with severe mental illness, Bernstein notes. "We're just not doing it for political reasons."