The Clubhouse: An Environment Where OTs Can Support Recovery

mental health sensory processing

       Occupational therapy’s distinct value in mental health lies in the emphasis on engagement in everyday activities, with the ultimate goal “to enable participation in personally and socially meaningful occupations that support health and well-being (Krupa, Fossey, Anthony, Brown, & Pitts, 2009, p.156). There are many settings within the community-based mental health service system through which occupational therapy has the potential support individuals labeled with serious mental illness (SMI), and a setting that stands out as an excellent fit is the Clubhouse.

          “Clubhouses are intentionally formed, non-clinical, integrated therapeutic working communities composed of adults and young adults diagnosed with SMI (members) and staff who are active in all Clubhouse activities. Clubhouse membership is open to anyone who has a history of mental illness. Membership is voluntary and without time limits. Being a member means that an individual is a critical part of the community and has both shared ownership and shared responsibility for the success of the Clubhouse” (McKay, Nugent, Johnsen, Eaton, & Lidz, 2018, p.29). A key feature of the clubhouse model is the work-ordered day, which refers to the expectation that staff and members work side-by-side, and the temporal flow of the clubhouse paralleling typical business activities and hours of operation of the working community where the clubhouse is located (Stoffel, 2011).

Painted Brain occupational therapy mental health     The clubhouse model implements several basic principles which emphasize individual strengths and potential, teamwork, the belief that work and work-mediated relationships support recovery, and empowerment through choice of activity (McKay et al., 2018, p.29). Clubhouses also provide support for gaining employment in the greater community through transitional employment, supported employment, or independent employment; participating in formal education; and connecting to resources in the community for health, finances, and housing. Also, 193 clubhouses responding to a survey regarding available activities reported offering some type of health promotion programming, including education on health, nutrition, and smoking sessions, and opportunities for exercise (McKay et al., 2018).

        Research has found many benefits to clubhouse participation. A study that compared clubhouse participants to participants in a program for assertive community treatment (PACT) found that “Clubhouse participants were employed more calendar days than PACT participants, worked significantly more hours, earned more during the study, and earned more per hour each week” (McKay et al., 2018, p.36). This same study also found that clubhouse participants reported greater quality of life related to social and financial aspects, and greater self-esteem and service satisfaction than PACT participants (McKay et al., 2018).

        Benefits of clubhouse participation are also found in the areas of physical health, rehospitalization rates, and social participation. A study on a 16-week structured exercise program implemented in a clubhouse called Genesis found that participants had significant improvements in aerobic capacity and perceived mental health, as well as positive changes in the domains of social and physical functioning, physical and emotional roles, vitality, and general health (Pelletier, Nguyen, Bradley, Johnsen, & McKay, 2005). A systematic review found results from 10 published studies that suggest clubhouse participants have lower rehospitalization rates, and the authors reasoned that evidence supported by at least 6 of the included studies suggest that Clubhouse participation may be beneficial in promoting social relationships by increasing social integration and supporting social competence (McKay et al., 2018).

mental health community
Photo courtesy of Fountain House

The first clubhouse, established in New York City in 1948, was known as Fountain House, and offered its members supportive experiences in job training, arts and crafts, and recreational activities; occupational therapists were involved in Fountain House by leading workshops in fabricating small items (Stoffel, 2011). The clubhouse environment presents an ideal setting for occupational therapists to support the recovery of individuals labeled with serious mental illness due to the shared principles between the clubhouse model of psychosocial rehabilitation and the foundational theories of occupational therapy. Occupational therapy is founded on the principle that engagement in meaningful activities provides structure to an individual’s day and purpose to an individual’s life, resulting in improved physical and mental wellbeing, while the clubhouse model implements principles that emphasize structuring participation around the work-ordered day and supporting recovery through engagement in work and work-mediated relationships.

 

       The clubhouse model of psychosocial rehabilitation offers an environment in which individuals labeled with SMI can enter the community and be viewed as having individual strengths and potential to lead personally satisfying lives. Clubhouse participation has been found to be beneficial for individuals labeled with SMI through bolstering employment and educational opportunities, enhancing social participation, and connecting individuals to resources for health promotion. The clubhouse goals of helping individuals engage in meaningful work, supporting the pursuit of employment and formal education, and engaging in culturally relevant social and recreational activities are consistent with the occupational therapy domain of engagement in occupation to support overall health and well-being (Stoffel, 2011). Through innovation and client-centered practice occupational therapists can implement services in clubhouse settings to support the recovery of individuals labeled with serious mental illness and facilitate the realization that all people can be positively contributing members of society.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident

PaintedBrain.org

 

References

Krupa, T., Fossey, E., Anthony, W. A., Brown, C. & Pitts, D. B. (2009). Doing daily life: How occupational therapy can inform psychiatric rehabilitation practice. Psychiatric Rehabilitation Journal, 32(3): 155-161. Doi: 10.2975/32.3.2009.155.161

McKay, C., Nugent, K. L., Johnsen, M., Eaton, W. W., &  Lidz, C. W. (2018). A systematic review of evidence for the clubhouse model of psychosocial rehabilitation. Administrative Policy in Mental Health, 45: 28-47. https://doi.org/10.1007/s10488-016-0760-3

Pelletier, J. R., Nguyen, M., Bradley, K., Johnsen, M., & McKay, C. (2005). A study of a structured exercise program with members of an ICCD certified clubhouse: Program design, benefits, and implications for feasibility. Psychiatric Rehabilitation Journal, 29(2), 89-96. http://dx.doi.org.libproxy1.usc.edu/10.2975/29.2005.89.96

Stoffel, V. C. (2011). Psychosocial Clubhouses. In C. Brown & V. C. Stoffel (Eds.), Occupational therapy in mental health: A vision for participation (Chapter 39, pp. 559–570). Philadelphia, PA: F. A. Davis Company.

 

 

Urban Gardening: A Community-Based Approach to Improving Mental Health

 urban gardening community based mental health       When seeking to creatively foster positive change in the mental health of individuals, a community-based approach may encourage participation of community members in a way that facilitates trust, alleviates discrimination, and promotes insight (Carney et al., 2012). Wakefield et al. (2007) highlight the role that community gardens play in the health and well-being of urban populations, while also emphasizing the interplay between the concepts of space, place, and occupational participation. In developing occupational therapy services in a community-based setting, literature such as this supports the development of client-centered programming that can impact the health and well-being of adults labeled with mental illness in a variety of ways.

       The urban population that served as the setting for the study by Wakefield et al. (2007) was an area of South-East Toronto, Canada; this area is characterized by high rates of poverty and ethnic diversity, and it encompasses Regent Park, Canada’s largest social housing complex. A strength of this study was the investigation of 15 different community gardens, which allowed for a robust inclusion of 68 participants (Wakefield et al., 2007). The researchers also described triangulation of data collection methods via observations, focus groups, and interviews, as well as the use of member checking techniques to increase the credibility of interpretations of participant experiences (Wakefield et al., 2007). Researchers described that they participated with the community gardeners by “planting seeds, carrying water, and shoveling dirt” (p.93), which most likely contributed to the development of trust between the researchers and the participants, and may have allowed for richer description of experiences and feelings regarding the community gardening experience, as well as more in-depth reflection by participants when they were asked to identify research questions and provide insight into the needs of the community.

community gardening mental health occupational therapyDespite the large sample size in this study, the study took place in only one area of one large city, and the number of participants was not great enough to allow for generalization of results. However, the qualitative data presented here does provide insight into the positive health implications of community gardens and illustrates the worry regarding pollution and permanence of such gardens that community members face.

    Important health benefits that were identified through participation in these community gardens were better access to food, improved nutrition, increased physical activity, and improved mental health. Attributes of the gardens that contributed to these health benefits through promotion of stress relief included the opportunity to interact with nature, the gardens conveying “a sense of lushness and abundance” (p.95), and the gardens offering “spaces of retreat within densely populated neighbourhoods” (Wakefield et al., 2007, p.95). This supports Hasselkus’s (2011) position that space and place contribute to health and well-being due to certain aspects of an environment promoting healing and recovery.

      Hasselkus (2011) also describes the ‘transactional unit’ which is comprised of the “dynamic relationship between people and the environments in which they carry out their everyday lives” (p.43) and which results in occupational performance. In the community gardens, the occupational performances of physical activity, social interaction, and growing fresh produce were a result of the interaction between the community members and the gardens. A crucial element in influencing the occupational choices of the community members was that the locations of the gardens were within the neighborhoods where the community members carried out their everyday lives.

FullSizeRender 2 copy         This view of the person-environment interaction also supports Persson & Erlandsson’s (2014) elaboration on the concept of ecology as the “interaction between the eco-system of the doer and the environmental ecosystem” (p.16) and the supposition that this interaction, when examined from a perspective of sustainability, has the potential to contribute to the well-being of the local environment, as well as the well-being of the greater ecosystem. The gardens did promote the well-being of the community members on a personal level, while also promoting well-being on community and environmental levels. Garden-based programming benefitted the community members on an individual level by creating an opportunity to come together to share tools, ideas, food, and culture, which contributed to decreased isolation, increased self-esteem, feelings of empowerment, and skill development (Wakefield et al., 2007).

     The garden-based programs benefitted the “community as a whole, by improving relationships among people, increasing community pride and in some cases by serving as an impetus for broader community improvement and mobilization” (Wakefield et al., 2007, p.97). The presence of the gardens contributed to community pride by enhancing the physical features of the neighborhoods, and working closely with the food that they were to eat, stimulated community members to think about such factors as pesticides, air pollution, and soil contamination.

           While the presence of community gardens provided an opportunity for health benefits on individual, local, and planetary levels, the meaningfulness of these gardens also stimulated concerns by the community members as to the sustainability of the garden plots. Wakefield et al. (2007) allude to the idea that social exclusion and marginalization are prevalent problems in neighborhoods of low socioeconomic status (SES), such as the neighborhoods where this study took place. The community members did express concerns about lack of awareness of the gardens and lack of political will to contribute resources to sustain the gardens, by the greater community and political leaders. These concerns were preempted by the recent initiation of re-development in Regent Park. This contributes to the study of occupational justice by highlighting the importance of the perspective of the community members in determining what is most meaningful and useful for themselves, the community, and the planet.

occupational therapy community gardening       Just as the participation of community members in the study by Wakefield et al. (2007) allowed researchers to understand what was meaningful about community gardens, the participation of community members in decisions about land development would contribute to fair allocation of resources to enable equitable distribution of rights and privileges in terms of occupational participation. However, the current state of Regent Park, with the initiation of re-development without input from those who reside in this housing complex, places the community members at risk for infringement on their freedom to participate in their valued occupation of gardening.

   This situation also contributes to an understanding of how occupational marginalization often “results from informal norms and expectations within a sociocultural infrastructure” (Durocher, 2014, p.422). The greater Toronto society may view residents of low SES neighborhoods to be involved in crime, or to not be concerned with such ideas as access to fresh produce, pollution, and community well-being, and these assumptions may lead political leaders to neglect to examine their expectations of the behavior of the inhabitants of such neighborhoods when making decisions about community development.

gardening mental health occupational therapy          The study of occupational science, which informs occupational therapy, has been developed through the amalgamation of perspectives from various disciplines on the study of factors affecting the participation and engagement of humans in everyday life. Due to the dynamic between the person and the environment, it is imperative that occupational science incorporates knowledge from disciplines that highlight this interaction to truly understand the meaning of occupational choices and the resulting occupational performances, as well as to appropriately promote participation and to address issues of occupational injustice and occupational marginalization. Wakefield et al. (2007), through a health promotion perspective, highlighted the importance of access to natural environments in promoting physical and mental health, contributing to social inclusion, inspiring appreciation for the natural environment, and in stimulating empowerment of community members to address larger social issues. This study also demonstrated the efficacy of a community-based approach in illuminating the client-centered perspective that is the hallmark of the occupational therapy profession.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident

PaintedBrain.org

References

Carney, P.A., Hamada, J.L., Rdesinski, R., Sprager, L., Nichols, K.R., Liu, B.Y. … Shannon, J.       (2012). Impact of a community gardening project on vegetable intake, food security and family relationships: A community-based participatory research study. Journal of Community Health, 37:874-881.

Durocher, E., Gibson, B.E., & Rappolt, S. (2014). Occupational justice: A conceptual review. Journal of Occupational Science, 21(4):418-430.

Hasselkus, B.R. (2011). “Chapter 3: Space and place: Sources of meaning in occupation” In Hasselkus, B.R. (Ed.) The meaning of everyday occupation (2nd ed.) (41-60). Thorofare: NJ: SLACK.

Persson, E. & Erlandsson, L.K. (2014). Ecopation: Connecting sustainability, glocalisation, and well-being. Journal of Occupational Science, 21(1):12-24.

Wakefield, S., Yeudall, F., Taron, C., Reynolds, J., & Skinner, A. (2007). Growing urban health: Community gardening in South-East Toronto. Health Promotion International, 22(2):92-101. doi:10.1093/heapro/dam001

 

Meaningful Activity: A Fundamental Component of Health, Social Inclusion, and Realizing Your Full Potential

 

meaningful activity occupational therapy mental health art cart

               Over the past few weeks I have had an opportunity to lead Painted Brain groups, in various locations around Los Angeles, for adults who will benefit from increased opportunities to socialize and engage in meaningful activities that elicit creative artistic expression. While this component of my position at Painted Brain is not considered ‘occupational therapy’ due to the service not being billed as such, I still approach this work through the lens of an occupational therapist. Thus, I continuously keep at the forefront of my mind the knowledge that adults labeled with mental illness “have been characterized as being at high risk for limited participation in meaningful activities, having few opportunities for emotional fulfillment and personal growth, and experiencing social marginalization” (Edgelow & Krupa, 2011, p.267). My mind also persistently appreciates the knowledge that “human beings define their lives, cultures, values, and worth through activities” (Breines, 1995, p. 3) and that “it is the interactions of everyday life, rather than particular interventions in mental health settings that are the primary medium through which recovery occurs” (Sutton et al., 2012, p. 142).

              In approaching the task of developing an occupational therapy service at Painted Brain, I have been studying the characteristics of being labeled with mental illness, and I have been developing an understanding of how these characteristics lead to lack of participation in meaningful activity and social isolation. Historically, boundaries have persisted that exclude adults who are labeled with mental illness and prevent participation in the everyday activities that lead to community integration, important social roles, and meaningful contribution to self and others; “a well-known example of exclusion for this group has been an historic deprivation from developing their true selves and potential because of being isolated in hospitals or cloistered in homes without something meaningful to do or be…” (Townsend, 2012, p.9). This physical separation from the greater community is exaggerated by lack of opportunity for meaningful doing, holistically being, or potentially becoming anything more than a person labeled with mental illness. Even when adults who are labeled with mental illness discover a means to reside physically within their communities, “community living for some and the deinstitutionalization of supports for others in North America leaves a vulnerable, impoverished group of adults as alienated and marginalized through poverty, drug addiction, stigmatization, abuse from others, isolation from friendships, and persistent, disturbing, disruptive mental symptoms” (Townsend, 2012, p.9). This causes individuals to fall into a cycle of disengagement from meaningful activity, increased time spent in sleep and passive leisure, and decreased productivity, which altogether lead to decreased social interactions, decreased physical activity, and limited community involvement (Krupa et al., 2010).

art cart creative expression social inclusion mental healthA more important realization, however, is that this disengagement and marginalization does not only negatively affect the population of adults who are labeled with mental illness, but universally concerns the health of all of us, because social exclusion is “created by structural determinants and large scale organizational practices, not individual circumstances” (Townsend, 2012, p.14). Therefore, social and occupational justice will advance when we as a civil society “organize universal rights to affiliations that include humans, other species, and control over one’s environment…without occupational marginalization or occupational deprivation” (Townsend, 2012, p.15).

                 What unique contribution then, can I as an occupational therapist make, in addressing the occupational and social needs of adults who are labeled with mental illness? One step is to develop a community-based service that not only provides opportunity for engagement in meaningful activities, but that also facilitates realization and understanding of the benefits to overall health and wellbeing that balanced participation will provide. A step further will be to exchange knowledge and evidence with other mental health providers, organizations, and the general population regarding the significance of engagement in meaningful activities to overall health; the right of all individuals to experience dignity, health, safety, and social inclusion; and the connection between meaningful engagement and social justice.

                The occupational therapy service at Painted Brain will take on a range of forms, including having a presence in Painted Brain’s community center, and by offering a group service that facilitates participation in a variety of and balance between activities of productivity, leisure, sleep, and self-care. Sutton et al. (2012) suggest that the “task of enabling occupation involves creating space for the ‘play’ of doing, that is, to open the interplay of being and world” (p.148).  The Painted Brain community center truly enables this “play of doing” by offering a space where people can freely engage in a variety of activities, make meaning through participation in creative expression, and that supports involvement in everyday life, which as Sutton et al. (2012) advise, should be a “central focus of occupational therapy practice” (p.148). art mental health occupational therapy social inclusion

               The group occupational therapy service is designed to facilitate reflection on current levels of activity, re-imagination of the self to set goals for activity participation, and reintegration into the greater community, such that individuals may break out of their cycles of inertia and resume movement toward realizing their full potential. The focus on the degree to which a person develops balanced patterns of activity and rest, a variety and range of meaningful activities and routines, and the ability to move around in the community and interact socially will be complemented by a group format that encourages active participation, promotes social support, and enhances opportunity for sharing of ideas and experiences (Krupa et al., 2010). Despite evidence that health professionals often have difficulty engaging the general population in behavior change and health-promoting activities, research on an activity-health intervention implemented by occupational therapists with a group of adults with serious mental illness found that this approach is effective in influencing occupational balance by resulting in increased time spent in general activity and decreased time spent in sleep (Edgelow & Krupa, 2011). At Painted Brain, occupational therapy services will soon be implemented, for adults who are labeled with mental illness, to provide increased opportunities to socialize and engage in meaningful activities that elicit creative expression, promote social inclusion and full community participation, and facilitate resumed movement toward realizing one’s full potential.

 

Sharon Vincuilla, OTR, CPDT-KA

Occupational Therapy Doctoral Resident

PaintedBrain.org

 

References

Breines, E. B. (2004). Occupational therapy: Activities for practice and teaching. London: Whurr.

Bullock, A., & Bannigan, K. (2011). Effectiveness of activity-based group work in community mental health: A systematic review. American Journal of Occupational Therapy, 65, 257–266. doi: 10.5014/ajot.2011.001305

Edgelow, M., & Krupa, T. (2011). Randomized controlled pilot study of an occupational time-use intervention for people with serious mental illness. American Journal of Occupational Therapy, 65, 267–276. doi: 10.5014/ajot.2011.001313

Krupa, T., Edgelow, M., Chen, S.-P., Mieras, C., Almas, A., Perry, A., Radloff-Gabriel, D., Jackson, J. & Bransfield, M. (2010). Action over inertia: Addressing the activity-health needs of individuals with serious mental illness. Ottawa, Ontario: CAOT Publications ACE.

Sutton, D.J., Hocking, C.S., & Smythe, L.A. (2012). A phenomenological study of occupational engagement in recovery from mental illness. Canadian Journal of Occupational Therapy, 79, 142-150. doi: 10.2182/cjot.2012.79.3.3

Townsend, E.A. (2012). Boundaries and bridges to adult mental health: Critical occupational and capabilities perspectives of justice. Journal of Occupational Science, 19:1, 8-24, doi: 10.1080/14427591.2011.639723