78 Unit I CURRENTTHEORIES& PRACTICE
services to overcome these barriers were not funded
(Mallik et al., 1998).
Clubhouse Model
In 1948, Fountain House pioneered the clubhouse
modelof community-based rehabilitation in New
York City. Currently more than 350 such clubhouses
have been established worldwide (Aquila et al., 1999).
Fountain House is an “intentional community” based
on the belief that men and women with serious and
persistent psychiatric disability can and will achieve
normal life goals when given the opportunity, time,
support, and fellowship. The essence of membership
in the clubhouse is based on the four guaranteed rights
of members:
- A place to come to
- Meaningful work
- Meaningful relationships
- A place to return to (lifetime membership)
The clubhouse provides members with many op-
portunities including daytime work activities focused
on the care, maintenance, and productivity of the club-
house; evening, weekend, and holiday leisure activi-
ties; transitional and independent employment sup-
port and efforts; and housing options. Members are
encouraged and assisted to use psychiatric services,
which are usually local clinics or private practitioners.
The clubhouse model recognizes the physician–
client relationship as a key to successful treatment
and rehabilitation while acknowledging that brief
encounters that focus on symptom management are
not sufficient to promote rehabilitation efforts. The
“rehabilitation alliance” refers to the network of re-
lationships that must develop over time to support
people with psychiatric disabilities. This alliance in-
cludes the client, family, friends, clinicians, and even
landlords, employers, and neighbors. The rehabilita-
tion alliance needs community support, opportuni-
ties for success, coordination of service providers, and
member involvement to maintain a positive focus on
life goals, strengths, creativity, and hope as the mem-
ber pursues recovery. The clubhouse model exists to
promote the rehabilitation alliance as a positive force
in the member’s life.
The clubhouse focus is on health, not illness. Tak-
ing prescribed drugs, for example, is not a condition of
participation in the clubhouse. The member, not the
staff, must ultimately make decisions about treatment
such as whether or not he or she needs hospital ad-
mission. Clubhouse staff support members, help them
to obtain needed assistance, and most of all allow them
to make the decisions that ultimately affect all aspects
of their lives. This approach to psychiatric rehabilita-
tion is the cornerstone and the strength of the club-
house model.Assertive Community Treatment
One of the most effective approaches to community-
based treatment for people with mental illness is as-
sertive community treatment (ACT) (Box 4-5). Marx,Box 4-5
➤ COMPONENTS OF ANACT PROGRAM
- Having a multidisciplinary team that includes a psychiatrist, psychiatric-mental health nurse, vocational reha-
bilitation specialist, and a social worker for each 100 clients (low staff-client ratio) - Identifying a fixed point of responsibility for clients with a primary provider of services
- Ameliorating or eliminating the debilitating symptoms of mental illness
- Improving client functioning in adult social and employment roles and activities
- Decreasing the family’s burden of care by providing opportunities for clients to learn skills in real-life situations
- Implementing an individualized, ongoing treatment program defined by client’s needs
- Involving all needed support systems for holistic treatment of clients
- Promoting mental health through the use of a vast array of resources and treatment modalities
- Emphasizing and promoting client independence
- Using daily team meetings to discuss strategies to improve the care of clients
- Providing services 24 hours a day that would include respite care to deflect unnecessary hospitalization and
crisis intervention to prevent destabilization with unnecessary emergency department visits - Client outcomes are measured on the following aspects: symptomatology; social, psychological, and familial
functioning; gainful employment; client independence; client empowerment; use of ancillary services; client,
family, and societal satisfaction; hospital use; agency use; rehospitalization; quality of life; and costs.
De Cangas, J. (1997). Characteristics of assertive case management systems, http://www.mohan.com/services.html