Treatment Model

From 1948 until the recent unavailing of “The Working Community”as the new descriptive name for the Fountain House treatment program, Fountain House has been known as a day program, a psychosocial program, a psychiatric rehabilitation program and a clubhouse program. Although politically and professionally in tune with the changing times, these labels do not reflect the real changes in the treatment approach that Fountain House has made over the years. This article is an effort to elucidate the differences in theory and practice that were consistent with a “Family Model” practiced from 1948 to 1975, a Community Model” practiced until 2009 and the new” Working Community Model”.

The Family Model 1948-1975

Since the family was the place that children were socialized and learned how to successfully function in society, Fountain House was conceptualized as a large extended family made up of staff in a respectful parental role and members who were brothers and sisters in need of re socialization because of the ravages of the illness, the stigma and the institutionalization. As such the immediate goal of staff was to develop a relationship with a member in which they were seen as parental figures who though the relationship could help the member function in the Fountain House family and ultimately be re socialized into the general community. In this model all of the decision making was done by staff with input from members. In this respect most work projects were conceived and developed by staff in private meetings and presented to members for execution. This is not to say that staff did not work side by side with members, they did, and the work was real and necessary for the stability and growth of the family. Also, then as it is now members were needed to help staff who were responsible to the family for the satisfactory completion of all work, although at that time each activity area had only one staff person which made the need staff had for members to assist in the work palpable. Since the primary role of staff was the re socialization of members, the work of the family was primarily conceptualized as a mechanism or a tool for relationship building and secondarily as necessary for family stability and growth. As a matter of fact all of the program elements were thought of as tools for helping staff develop a parental type relationship with a member, which is why each staff worker was given the power of controlling, in addition to a basic activity area, some number of, apartments and some number of transitional employment placements Like a parent each staff worker had the power to select a member for different opportunities in transitional employment or in the apartments that they controlled when they felt, that the need was there, the member was ready and or the experience would be therapeutic. A member could request an apartment or a transitional employment placement and would probably, based on the request alone get it, but it was still the staff worker who had the ultimate decision making power. Consistent with a parental role, this power, it was believed, could enable a staff worker to more easily develop an influential relationship with a member and with that relationship and the workers therapeutic use of interpersonal reward help the member in their re socializing efforts. The development of this dependent type relationship with a member although strident to the ears in todays psychology was then considered an appropriate therapeutic goal. As matter of fact many believed that to be a therapeutic agent required a dependent relationship with a client since it was the influence the worker had in such a relationship that would lead to the clients re socialization and independent functioning. The phrase used at that time was “independence is the result of a healthy dependent relationship”as in the parent child relationship in families. It is clear to me that although the idea of a parent child relationship between two adults is in retrospect abhorrent and disrespectful it did focus staff on the importance of providing members with a basic acceptance and a caring that is implied in the parental relationship. The disrespect that is implied in the parental type relationship between adults was mitigated in the Fountain House environment because staff needed the help and support from members which was generally forth coming and which created in staff a deeply felt respect and gratitude. Also, the overwhelming obstacles that most members had to overcome in an time where community support was minimal, created in most staff, an awe for those members who never the less maintained their active participation. The emphasis on relationship building in the family model was supported by the idea that people with serious mental illness had severe motivational issues that where only resolvable in the context of a strong persuasive influence. Ergo the parental type of dependent relationship which also gave staff a clear therapeutic and professional role and identity. An identity that was necessary for some staff who had difficulty understanding why they were cleaning bathrooms and serving lunches. Also since a lack of motivation was seen as a major negative, for many with serious mental illness the staff worker with assistance from members was not only responsible for reaching out to members on his case load, but also to members still in the intake process. Again, it was believed the reaching out to a perspective member was a good way to establish the initial caring relationship. Finally, another major therapeutic tool used by staff to facilitate re socialization in the family model was the extensive use of strategic modeling of the members who were doing well. These members like older siblings were asked to speak about their experiences at the transitional employment meetings or in one on one situations with a member who was fearful of trying something new. These members who were called member leaders were known to the staff leadership and took on major responsibilities in transitional employment coverage, as tour guides and in reaching out to perspective members still in the process of intake.
Also like most good families, regardless of independent status, a member would always belong and could always count on Fountain House for support and a place to report good and bad news and expect a helpful response.

The Community Model 1975-2009

In 1975, Fountain House became known as a Clubhouse program and was deeply involved with replicating its model. Then with the arrival of Rudyard Probst as the director of training a series of declarative statements were developed to offer guidelines to the developing clubhouse programs and to protect the rights of their memberships. These standards gave members, the right to choose their staff worker, be present in all meetings, have access to all spaces, choose the programs they wanted to participate in and be involved in all decisions affecting them or the community. In so doing Fountain House went from being a family model to being a community model and the therapeutic punch went from the staff- member relationship to the members relationship to the community, a community that offered a shared emotional connection and a sense of belonging, that fights stigma, that works to satisfy the basic and secondary needs of its membership, that creates opportunities for relationships that offers choice in all things and an active voice in all decisions. The goals for the membership in the community model included a sense of community ownership and empowerment, personal investment in the community, development of an intrinsic motivation and ultimately self actualization. The staff member relationship went from parental to collegial and the staff role went from therapeutic to leadership. This is not to say that close relationships between staff and members did not develop, they did, since staff and members were still working closely together. Given this change from a family model to a community model members became an essential presence in all groups, committees and forums, on all levels in which community decisions were made. In this model being a member of the community required that the goals, values and practices of the community, as represented by the standards, be understood by the membership so that they could properly exercise their rights in the community. The idea being that excising ones rights had the therapeutic function of empowering and motivating participation while reducing some of the negative effects of self stigma. The activities in the community model were no longer thought of as tools for relationship building but as work that helped the membership in their quest for recovery and community integration and work that helped the community grow and prosper. The treatment goal in the community model was not re socialization it was improvement in the self efficacy of members, the reduction of self stigma and the improvement of autonomy which was accomplished by creating an environment in which members could make their own decisions, feel wanted and needed be supported in their efforts, have the opportunity to develop relationships and experience interpersonal and task successes. The rewards members enjoyed were intrinsically based on completion of tasks and the concomitant experience of mastery, although extrinsic interpersonal reward as part of a significant relationship had its place and is still a motivating factor.

The Working Community Model 2009-Present

The new Working Community designation maintains the community model with its emphasis on collegiality, intrinsic motivation, empowerment, self efficacy and adherence to the standards but with it re emphasizes the idea that staff need to develop what is being called a significant relationship with members; a significant relationship being defined as authentic, mutual and having influential capacity. Authenticity (realness) relates to being without professional facade, being yourself, and allowing others to know you. It facilitates relationships by establishing a relaxed acceptance of, and a rapport with, another. Influential capacity (the ability to help others reassess beliefs and behaviors) relates to the likelihood that feedback will be heard and heeded. Mutuality (shared affectivity) relates to the idea that the member and the staff worker allow each other into their lives and are comfortable sharing factual and emotional aspects of who they are. In conclusion, regardless of the model being practiced, the fact that the staff role includes case management, shared values and beliefs between members and staff and a real need for member assistance in the activities of the program, means staff and members will inevitable develop meaningful relationships. Recognizing significant relationships as a key factor in helping members reach their full potential and merging this idea with all of the therapeutic benefits of the community model makes the Working Community model holistic and complete.