Clubhouse Staff's Support for Psychiatric Recovery: A Paradoxical Agent Role for Transformation

Background: With signs that early interventions for severe mental illness (e.g., Bertelsen, et al., 2008; Craig et al., 2004) have at best only a modest impact on longer term outcome (e.g., Gafoor, Craig, Garety, Power, & McGuire, 2009), a need for a long term care and support system that facilitates recovery while not producing institutionalization or dependency (Nordenntoft et al., 2014) is resurfacing (e.g., Craig, 2014). Systematic research, however, has yet to define long-term care programs, such as the clubhouse model, despite their long existence internationally. The purpose of this study was to describe the clubhouse model, with its specific focus on the staff’s part of support for recovery.

Method: The study drew on qualitative interview data collected through open-ended questions and probes in 2009-2013 from a purposive sample of 105 service users and 25 staff from 6 clubhouses located in geographically different areas (2 in the U.S. and 4 in Finland. Data were analyzed using a grounded theory approach (Charmaz; 2014; Glaser & Strauss, 1967). The initial data (45 users) from one U.S. clubhouse were first open-coded and then, with 10 selected transcripts, line-by-line coding was iterated to develop focused codes, based on which constant comparison was continued for trustworthiness with the remaining transcripts within the initial data set as well as those from the other data sets.

Results: Recurrent patterns of transformative life changes emerged. Users, peers, and staff alike, described gradual processes in which their incremental involvement in the core program paralleled their gaining or regaining sense of self-confidence and self-worth thereby “getting a life back” and coming to feel “part of society.” Participants attributed the transformation in essence to staff guiding users to voluntary work participation whereby users came to trust the staff as a person, who, as part of everyday life, encourages, respects, and recognizes with appreciation users’ own part and contribution to the whole—long-term experiences that accumulated into coming to trust themselves, others, who became a “friend” in the sense of a trusted colleague with whom they share work camaraderie, and people outside. The transformational processes appeared to entail common core elements, being equal as a human with a value despite limitations and the right to choice, which were experienced as turning points toward healing and growth; a principle that seemed paradoxical in that the elements operate when and only when received as genuine.

Conclusions: The clubhouse staff at their best appear to play a paradoxical role in creating a milieu that facilitates transformational processes through working together as a colleague, rather than staff, who, also as a person, shares humanity that genuinely supports fundamental human rights as part of everyday life. The clubhouse model should be re-evaluated as suggesting what constitute essential elements for sustaining social network that promotes recovery.