Supported Autonomy

by Riola Crawford

As I sit down to prepare a presentation for the 8th International Seminar on the Clubhouse Model, I can't help reflecting back to another conference -- the 5th International Seminar, in St. Louis in 1989. I was preparing a workshop presentation entitled Birth of a Clubhouse. At that time, I had been working with a group of staff and members developing two small rural clubhouses in western Canada. Although I had been specifically hired to develop clubhouses, we had been having tremendous struggles with the local Mental Health Services, whose understanding of the clubhouse model was quite different from ours. After having participated in training at Fountain House, we understood the need to provide a whole clubhouse. We were passionate and committed purists. The mental health agency, however, wanted to provide some components of the model, alter other components, eliminate TEP, and incorporate elements of social skills training into the Day Programme.

Although we were free standing, we had a Board of Directors which was ambivalent about accepting that people who experienced persistent mental illness wanted the opportunity to be involved in meaningful activities, and could handle the responsibility that goes hand in hand with active participation. We in the clubhouse seemed to spend most of our time defending what we were already doing, and fighting to be allowed to do more. We were prevented from sharing financial statements with staff and members, and from taking members out of the country to participate in clubhouse training or attend conferences. Members and staff were not allowed to participate in any clubhouse related meetings called by the Local Mental Health Services; only myself as manager could attend. We were unable to create a dynamic and empowering community that was rich with opportunities for our members because we had neither the support of the funding agency nor of our administrative body. We were unable to fulfill our obligation to our members.

I knew that before I could even think of trying to establish another clubhouse in another community, I had to be able to evaluate that experience, and understand what went wrong and how we could prevent a similar situation from occurring again. I couldn't endure the prospect of having to face a new group of members in another clubhouse community, with unfulfilled promises of meaningful relationships, meaningful work, ownership, and community. I couldn't fail our members again.

In that other experience, in my life before Mosaic Clubhouse, I believe that the Mental Health Services purchased and contracted the clubhouse model without truly understanding it in its entirety. I believe they purchased it because the notion of consumer empowerment was a new one and the Clubhouse philosophy was harmonious with that notion. I believe they purchased clubhouse because deinstitutionalisation and privatization of services was in its infancy and clubhouse was perceived as an inexpensive or cost-effective service. Well, it is cost effective, but it isn't cheap. When we began to move towards developing a pure clubhouse community, with all of the elements of that community, including TEP, the mental health system began to make amendments to our contract. We recognized that the Mental Health Services began to decrease our autonomy through contractual control, and unfortunately our Board of Directors was not invested enough to support us. The

idea of people who were struggling with mental illness being able, interested, and responsible, just seemed too radical a concept for that system to accept. And it produced fear-- fear of care in the community failing, fear of crises, fear of litigation, fear for the safety of patients and community. And perhaps other fears, at which we could only guess. A visiting social worker, who was sympathetic to our plight, said to me one day that everyone at the Mental Health Center thought something very strange was going on at the clubhouse. I asked her what they thought was so strange, and she said, "Everyone there is happy; the staff are happy, and the members are happy. And that is strange." I would agree that this was unusual but I wouldn't have called it strange. But that comment did tell me that there is a generalized fear that occurs when people encounter something that is not the norm, something that they do not understand and have not experienced before. That also is how stigma and prejudice grow.

I am now working in a new country, in a new clubhouse, with a different group of staff and members, and a different auspice agency. Mosaic Clubhouse is under the auspice of the West Lambeth Community Care (NHS) Trust. The Trust is a Health Authority, and for the past year the clubhouse has been operating out of a very small space in a Mental Health Center while we have been working to secure our own building, independent of the Mental Health Center. We remain in that small space while we now wait for that building to be renovated. This is the most unlikely situation for a clubhouse to survive in, and yet Mosaic Clubhouse is not only surviving, it is thriving and growing at a phenomenal rate. Our auspice agency understands the clubhouse model, supports our need for autonomy, and is committed to not allowing the medical model of service to intrude on the clubhouse. No one could be more surprised or pleased by this, than I.

Although I had a tremendous learning experience in developing those two little clubhouses in Canada, we can't take all the credit for our supportive relationship with the West Lambeth Community Care NHS Trust. I think we can learn a lot from looking at the series of events which led to this relationship.

Several years ago, a Professor of Academic Psychiatry within our Trust, Professor Tom Craig, went on a study leave to America. Although he had not planned to visit any clubhouses, he ended up visiting Fountain House and a clubhouse in Nova Scotia, Canada. He was, as most of us are when we discover clubhouse, shaken and amazed at what he saw. He returned to England and began to talk to people within the Trust about starting a clubhouse. Tom's enthusiasm and commitment eventually convinced others, and with the closure of one of our large mental hospitals, money became available to make the dream a reality.

Tom Craig and Gary McNamee, who is a Senior Service Manager within the Trust and who was to become the supervisor to whom the clubhouse would report, took the time to learn and understand the clubhouse model. They wanted to develop the new clubhouse the right way, so they sought advice from the clubhouse community. Marcus Gramps, a clubhouse colleague whom many of you will know, and who was managing a clubhouse in Dartford, Kent, was consulted and was instrumental in establishing the solid framework upon which Mosaic Clubhouse would be built. At Marcus's suggestion, they hired a clubhouse developer who began to work with two members to establish a funding base for the clubhouse and to search for premises.

I was hired six months later. A job description had been developed for me which mandated me to move the clubhouse out to independent, charitable status within three years. This was an ideal situation, which included both a guarantee of funding, and a recognition that clubhouses function best when they are free standing. Additionally, I was assured that the clubhouse would be guaranteed autonomy and support--autonomy from the intrusion of the medical model and support to develop.

I have to be honest, I didn't believe it. My past experience had been that of a patriarchal system that changed its mind once members and staff became empowered and began to challenge the status quo. My work over the next few months was dominated by what I believe was a healthy cynicism. I wanted to believe, but at every corner I expected to be challenged. I knew that there were developmental milestones ahead that would test the commitment of the Trust, and test the strength and commitment of the members and of myself. There were a lot of risky "firsts." There was the first time I arrived at a meeting with member and staff representation from the clubhouse; the first time that we ventured to suggest that some of the Trust's financial procedures prevented members from opportunities that would empower them and strengthen the clubhouse community; the first time we asked the Trust to consider supporting our TEP programme; the first time we printed a controversial article in our Newsletter; the first time a clubhouse member managed petty cash, or drove the vehicle. We knew that these opportunities were critical to the success of the culture we were trying to create, but we were less than optimistic that the Trust would share our views. Well, we passed all those milestones and, eventually, my cynicism changed to belief and trust. The West Lambeth Trust indeed was going to support our clubhouse and ensure that it developed properly.

I could talk at length about the support we receive from our auspice agency. The West Lambeth Trust has altered existing procedures to accommodate the unique way we work in clubhouse. In some cases, particularly financial, they have allowed us to develop new procedures in order to ensure that we retain control over own finances and can involve the clubhouse community in financial decisions and in actual spending. Erville Millar, our Chief Executive, traveled to Glasgow with us to share in a presentation to a group who are interested in starting a clubhouse in that community. And now, he is here sharing this presentation with me. He and the Chairman of the Trust Board, Sir Alan Reay, have attended evening and weekend receptions which we have held at the clubhouse. Our Trust has been visionary in its approach to our development.

I think I am encroaching on Erville's part of this presentation but I must say that we realize that their support has not always been easy. It has meant more work for individuals and sometimes whole departments within the Trust--changing procedures to accommodate the unique way we in clubhouse work, and then justifying the need for that change. Those of us who have worked in clubhouses know that how we work strengthens our members, improves their standard of living, and interrupts the cycle of repeated hospitalizations. Auspice agencies do not always understand or believe this. They often choose to purchase or provide services which are familiar, and in that familiarity, perceived as safe. Our auspice agency took that risk. That takes courage, vision, and commitment.

I knew that if we were to continue to receive support from our auspice agency, we would have to be visible, and the principal players in both our funding structure

and our administrative structure would have to experience the unique "ethos" of our community. I believed that if we could transfer the dynamic and restorative philosophy and principles of clubhouse to our relationship with our auspice agency, we would have a better chance of ongoing support.

Relationship seemed to be the key. Our auspice agency had to become more than distant administrators and funders. They had to become partners. They had to be, and to perceive themselves, as vital partners in the clubhouse community. They had to be wanted, needed, and expected, and they had to have a sense of ownership, just as our members and staff do. They had to be involved and appreciated. It was not difficult to expect support from our auspice agency, nor was it difficult to appreciate them, but we weren't sure that involving them would be an easy task.

We made five major decisions in the first month of our development, which became the foundation for our partnership relationship with our auspice agency. These were:

1. We were committed to developing the best clubhouse community that we possibly could, and that community would be developed following the International Clubhouse Standards. We would not alter or deviate from the Standards. We would be ambitious in our pursuit of excellence, and we needed the support of the Trust in order to achieve this goal.

2. We would, whenever possible, invite key agency people to attend special clubhouse functions. We know that it is the experience of the living, loving, working clubhouse community that satisfies the agency, and binds them to us in commitment. For it is here that they will feel and see our community at work--members talking about how their lives have changed, about their work and their earnings, about feeling valued, needed, and hopeful, and having friends and a place to go to. They will experience staff who are happy, enjoying their participation in the community, and who are also feeling valued and needed. We knew that in experiencing our culture they would learn more about how we work, and understand that their supportive relationship was integral to the development of a healthy and successful clubhouse.

3. We would begin immediately to collect statistics on attendance, earnings, and TEP participation. Feeling satisfied at a human level is not enough for purchasers of service. They also require justification of the expense. We knew that our attendance stats would multiply rapidly and we had to show that to our auspice agency.

4. We would immediately begin to develop our TEP programme. We would not wait until our day programme was perfect or until our location was perfect. We would not use any of the excuses that Margaret Beard outlined in her article entitled "10 Excuses Not to Do TEP and 11 Reasons Why." Not only were we committed to providing TEP for our members, but we felt we could not delay in delivering the entire model of service to our purchasers. TEP stats are as powerful a tool for validating the cost effectiveness of clubhouse to our funders as they are for relaying the message of hope and independence to our members.

5. We decided to publish a weekly Newsletter, and in that Newsletter to share our developmental challenges and successes. This was probably the single most powerful and strengthening decision we made. The publishing of that Newsletter introduced the work ordered day concept to our members, and was the activity that formed the basis for our community. Our Newsletter was circulated to key people in our Trust as well as absent members, new members, potential future funders, other clubhouses, etc. We treated our Newsletter as the public face of our clubhouse. In our commitment to involving our auspice agency as a partner, we wanted to share our development in a way that was reflective of our day-to-day work. We didn't want to submit only statistical data; we wanted our auspice agency to learn about the clubhouse model and to share in our progress, and the Newsletter seemed a good way to do that. At that time we also made a commitment to a Newsletter that was so good that it would change attitudes that people may have about the capabilities of people who suffer from mental illness. Our Newsletter would not contain puzzles or jokes; it would contain news and that news would be current and relevant to the clubhouse community.

Our newest staff member, Brenda Osler, said to us recently that what she thought was different about our clubhouse was that we simply refuse to accept defeat. We do have very clear and very ambitious goals and we are tenacious in the pursuit of those goals. I am not sure that our auspice agency would tell you that those attitudes have helped or hindered our relationship with them; in fact, I'm not sure that those attitudes are recognized beyond the walls of our clubhouse, but they do dominate our planning and sustain us when we encounter a challenge. I actually have never asked our Chief Executive, Erville Millar, or Sir Alan Reay, Chairman of the West Lambeth Trust Board of Directors, or Gary McNamee, whether any of those early decisions that we made have influenced their support of the clubhouse. What I do know is that they have influenced, in a profoundly positive way, the kind of clubhouse community that we have become.

What we strive for in our relationship with our auspice agency is a guarantee of support, autonomy, and protection, and appropriate financial support to maintain that autonomy. We look for the autonomy we need to pursue the Clubhouse Standards, and to seek training and certification through the International Center for Clubhouse Development. We look for autonomy from the agency's established purchasing and financial procedures, which often do not allow clubhouse members to participate. We want the autonomy to make policy decisions which affect our community and culture, and ultimately, the autonomy to pursue independence and develop our own Board of Directors without representation from statutory funders on the Board. That autonomy must be guaranteed and must be actively supported by our auspice agency. Autonomy doesn't mean that the auspice agency can disappear into the corridors of its institutions and forget about us. And it doesn't mean that we can disappear into the clubhouse and forget that we have an agency to whom we are accountable. Our continued visibility will remind the agency that we have needs, and they will remind us that we have obligations. That seems like a win/win situation to me!

We must be guaranteed, and expect, adequate financial support from our auspice agency. Too often clubhouse is thought to be a cheap service and the

expectation is that lower salaries can be paid to clubhouse staff than to professional staff in other rehabilitation services. We expect comparable salaries. We also remember that John Beard, the founder of the clubhouse model, strived very hard to create an environment that was beautifully outfitted with quality furnishings. People who have struggled and suffered with recurrent mental illness have already been subjected to so much that is negative, that the restorative environment in which they will begin to make their recovery must be one that tells them they are important and cared about. That translates into an infusion of money into the start up of the clubhouse, which funders are often not expecting.

While support and autonomy seem to be paradoxical approaches, they represent the combination that will nurture the development of a vibrant and restorative clubhouse community. Yes, nurture. Communities don't develop over night. They start and grow and change and progress, but through it all, they must be founded on a clear vision and commitment on the part of staff and members, and on a strong and supportive relationship with the auspice agency. That's the winning combination! And the result is a clubhouse that everyone can be proud of.

I've noticed that I call the West Lambeth Community Care Trust `our Trust' and I call Erville Millar `our Chief Executive' and so do the members and staff of Mosaic Clubhouse. Perhaps that is the greatest testimonial that we can give to our auspice agency. I hope and I'd like to think that they call Mosaic Clubhouse `our Clubhouse.'

Riola Crawford is the Clubhouse Manager of Mosaic Clubhouse in London, England.