The International Journal of Psychosocial Rehabilitation
        
Reciprocity in the Clubhouse Context


Kimiko Tanaka, Ph.D.  and Larry Davidson, Ph.D.2

   1 Assistant Professor,
 Marywood University School of Social Work & Administrative Studies,
 2300 Adams Avenue, Scranton, PA 18509; ktanaka@maryu.marywood.edu

2 Professor of Psychiatry, Yale University School of Medicine




Citation:
Tanaka K & Davidson L  (2015)  Reciprocity in the Clubhouse Context.
 International Journal of Psychosocial Rehabilitation. Vol 19(2) 21-33



Abstract

Albeit still limited, the literature has begun to document reciprocity, including service user-provider reciprocity, as key to psychiatric recovery. This article presents a thick description of reciprocity occurring in the mental health clubhouse context, drawing on qualitative interview data from 103 users and 25 staff at five clubhouses in the U.S. and Finland, which was analyzed using a grounded theory approach. We found that receiving and giving support appears to be a part of everyday life at the clubhouse. We also found that this seemed conducive to recovery in that it helped users, through what we identified as clubhouse ways, to experience personhood, thereby transforming their battered sense of existence into a sense of agency and, perhaps more importantly, a sense of self-worth and being part of society. The clubhouse model may represent a viable collective approach to complement current community-based mental health systems of care that emphasize individual support.

Key Words: mental health recovery; reciprocity; clubhouse way; personhood; transformation; community; everyday life



Introduction:
Research on recovery from and in serious mental illnesses conducted over the last 20 or so years has consistently stressed the importance of supportive relationships as a central factor in promoting recovery (e.g., Corrigan & Phelan, 2004; Hendryx, Green, & Perrin, 2009; Ridgway, 2001; Tew et al., 2012; Schön, Denhov, & Topor, 2009), while isolation and the lack of such supports have been identified as factors impeding recovery (e.g., Davidson & Stayner, 1997). Beyond the psychotherapy literature that has identified the “common factors” of empathy, understanding, acceptance, and encouragement as providing the foundation for a relationship that is “therapeutic” (Davidson & Chan, 2014; Wampold, 2013), however, little is known about the active ingredients of supportive relationships, especially outside of the psychotherapy session. At the same time, narrative accounts of persons in recovery have called into question the traditional asymmetrical nature of psychotherapeutic and other clinical relationships, describing such hierarchical forms of human relating as dehumanizing and disempowering, making the person feel “less than” the mental health providers who are supposed to be helping them (Davidson, Stayner, & Haglund, 1998). Especially if, as research suggests (Chiu, Davidson, Lo, Yiu, & Ho, 2013; Davidson & Strauss, 1992), the process of recovery involves the reconstruction of a basic sense of personhood separate from the illness, then criticisms of asymmetrical relationships, in which service users are relegated to relatively passive and receptive roles, must be reconsidered.

Indeed, a recent line of inquiry has begun to show that service users identify “reciprocity” as a key dimension of relationships that they find respectful and helpful (e.g., Eriksen, Arman, Davidson, Sundfør, & Karlsson, 2013; Eriksen, Sundfør, Karlsson, Råholm, & Arman, 2012). By “reciprocity,” we mean to refer to relationships that can be characterized as involving “mutual dependence, action, or influence” (Merriam-Webster’s Collegiate Dictionary, 1993, p. 976) or “mutual give-and-take in social interaction” (Blackwell Dictionary of Sociology, 2000, para 1). Echoing an ethical stance that spans at least from Jane Addams (1910) to Martin Buber (1970), proponents of recovery-oriented practice argue that any relationship between human beings that does not at least allow for, if not actively encourages, reciprocity fails to respect the personhood of one, if not both, of the involved parties (e.g., Davidson, 2011; Davidson & Johnson, 2013; McCarthy-Jones & Davidson, 2012). But accepting such a principle obviously would have profound implications for the ways in which mental health care is conceptualized, delivered, and managed. One need only consider the difficulties the discipline of social work has encountered in striving to be faithful to Addams’ vision of authenticity in relationships to realize that this is far from a straightforward affair.

In the following, we hope to shed some additional light on the nature, role, and impact of reciprocity in the relationships of persons with serious mental illnesses by reporting on data collected as part of a mixed method study of members’ and staff’s experiences of the clubhouse model of psychiatric rehabilitation. We have chosen the clubhouse model as one avenue for exploring reciprocity in relationships as this model places explicit emphasis on the contributions that members are expected to make to the functioning of the clubhouse. That is, the clubhouse model builds on the view of persons with serious mental illnesses as active agents in their own lives and recovery, having long ago departed from the kind of narrowly bounded, asymmetrical relationships that permeate clinical settings. It is perhaps not surprising, then, that previous studies of the clubhouse model have identified reciprocity as an important component of clubhouse life (Coniglio, Hancock, & Ellis, 2012; Karlsson, 2005), with one study finding reciprocity to be a predictor of improved outcomes (Pernice-Duca & Onaga, 2009). Following our description of how reciprocity is experienced within this context, we will then consider the implications these data have for reconceptualizing relationships in other parts of the mental health system as well.

Method
Clubhouses under study were for adults with diagnoses of schizophrenia and its spectrum disorders, mood disorders, or anxiety disorders. The data to be described below derive from a larger qualitative study that the first author conducted in 2009-2013 at five clubhouses certified by Clubhouse International (www.iccd.org), two in the U.S. and three in Finland. This study was approved by the relevant IRBs for each site. Hour-long interviews were conducted using open-ended questions and probes with 103 members (45 for New York [NY], 34 for Ohio [OH], and 24 for Finland) and 1.5-2 hours interview were conducted with 25 staff (11; 10; and 4, respectively). Sixty five percent of the member participants were males. All were age 18-69 with 30% aged 50-59. The demographic patterns did not significantly differ across the three geographic regions. For the staff participants, the OH clubhouse had more females (70%) but the other two had about equal ratios. The first author conducted all interviews except six OH staff interviews led by a colleague. For the Finnish data, a bilingual Finnish research assistant fully interpreted one staff and 10 member interviews; others were led in English. All the member data were analyzed using a grounded theory approach (Charmaz, 2014; Glaser & Strauss, 1967). The first author open-coded the NY data and developed focused codes and then continued constant comparison with the data from other clubhouses to see how the focused codes were trustworthy. The staff interviews and participant observation were used to supplement the member interviews. (More detailed procedures and demographic information were described elsewhere).

Findings
Data analysis in the present study assumed Martin Buber’s (1970) philosophical insight that all human relationships are by definition reciprocal: “Relation is reciprocity. My You acts on me as I act on it” (p. 67). Themes fell along a spectrum of the degree to which the clubhouse member was able to make active contributions in his or her interactions with others. At one end of this spectrum, we find a nascent form of reciprocity in that the member appears to be a relatively passive recipient of support from others in the environment. We describe this as “nascent,” or emerging, form of reciprocity as opposed to passive receptivity, however, because even in interactions at this end of the spectrum the member is being viewed and treated by others as being a contributor to the clubhouse community—as well as an agent in his or her own life—even if only in terms of his or her potentiality. At the other end of the spectrum, interactions and relationships are seen as symmetrical in nature, with the member being an active agent who makes voluntary and spontaneous contributions to the life of the community while at the same time receiving support from others.  

Participants described both receiving and giving a wide range of instrumental and emotional support, as well as collaboration, in their daily interactions at the clubhouse. Receiving support allowed individuals to feel safe and accepted, thereby coming to trust the clubhouse and their own resources to help (a) themselves as well as (b) others—a process representing the transformation of emerging to active reciprocity. Several cultural patterns appeared to facilitate this process, which seemed, in turn, transmitted in the ways staff and members helped each other. Through giving, participants experienced the intrinsic value of helping others, sharing in other people’s success and happiness, and gaining an enhanced sense of self-worth as a result. Most often, participants described collaborative relationships in which they both gave and received support at the same time. All of these experiences offered them a sense of belonging with others and a sense of equality and value as a human being. We describe each of these aspects more fully below.
 
Receiving Support: “Being around people who care.”
Several critical moments or situations emerged in which participants described receiving support from members and staff as very helpful. Some of these situations involved participants feeling vulnerable, such as during their first days at the clubhouse, returning to the clubhouse after a long leave of absence, initiating a new activity, problem-solving, making a mistake or failing to meet expectations, and facing stressful personal life events such as the loss of job. Other, more positive moments involved accomplishing something, making progress, being successful, and making contributions to decision-making or collaboration.

Participants’ descriptions of receiving support in these situations often suggested an evolving sense of trust in their own resources as well as in the clubhouse, based upon which the nascent nature of reciprocity within the clubhouse seemed to transform into an active one. A sense of trust was typically reflected in positive statements, or predictions, about the responses of others in the clubhouse, indicating the ongoing availability and consistency of the support provided. For example, a reassuring remark some members gave to Mike, when he returned to his clubhouse when he lost his job, reflected their sense of trust in the clubhouse: “Glad you’re back at the [clubhouse], they’ll help [you] with this or that.”

Finally, participants’ accounts revealed several cultural patterns that appeared to support the transformative processes. We name the ingredients of the clubhouse cultural milieu “clubhouse ways,” which included: welcoming invitation, accepting, strengths focus, gentle pushing, step by step, side by side, respect for choice and pace, and recognition and appreciation. As described below, each kind of support came at different times and in different ways.

Welcoming.
Entering the clubhouse for the first time, like entering many new settings for the first time, can be stressful. Some people experience more stress than others, and some so much that they never come back. Participants recalled experiencing uncertainty and doubt during their first days at the clubhouse. One member remembered how she was “sick” when she first came to the clubhouse: “I didn’t … schedule an appointment because I figured they’d be faking … and putting on some front [if I did].” She explained how people, like her, often come to clubhouse as “a last straw” after making many other unsuccessful efforts to cope with mental illness. But those who stayed did so primarily because, as one participant said, “being around people who care” gave them hope for a better life.

Participants described experiencing the clubhouse early on as a “welcoming,” “friendly,” and “supportive” milieu. Some described liking “the atmosphere” while others, like Arja, a Finnish member, explained how members were greeted like a “queen or king” during their first days at the clubhouse so that they “don’t feel lonely.” Some participants described being surprised by such a warm welcome that effectively erased or overcame the doubts they had brought with them from previous experiences with mental health services and programs. Mary, in OH, for example, recalled how impressed she was when clubhouse people helped her move into the city to join the clubhouse. Another OH member, Andy, illustrated the way he would approach a new member, explaining, “Stuff [the clubhouse] did to me:”

Maybe start up a conversation, ‘Have you ever made muffins before?’ ‘No, but I’d like to eat it.’ ‘Ok, I’ll give one of the first ones out of the oven, but stick with me, ok … don’t wander off and, …, we can do this together, then it will be our little project’…. You know, try stuff like that.

Accepting.
The welcoming with which participants were met on their first day did not then dissipate over time, as some participants had expected. Rather, participants came to appreciate that the clubhouse was an accepting place overall and over time, they came to experience the “clubhouse way” as “completely opposite” to what they had experienced previously. Participants described a profound sense of relief from at least two sources. First, they felt “relieved” from their prior sense of isolation due to the fact that the other members had mental illnesses also; they were no longer the only one with such a condition, but were, in effect, one among many. Second, they felt relieved by discovering that the clubhouse atmosphere was one in which they did not feel judged, put down, or discriminated against, but instead felt understood and accepted as who they were. Cathy, a member of the NY clubhouse who had only been there for two months at the time of her interview, for example, described her initial sense of feeling safe:
No one’s trying to … no one’s asking me why I’m so quiet. Like, when I work, some people I work with will ask why I’m so quiet, why I don’t talk much. You know, they’ll also ask if everything’s ok. I don’t get that [here]. They kind of just let me be.

Cathy’s statement that “no one’s” pestering her with questions reflected her initial impression of the clubhouse, an impression that then evolved into a deeper and broader sense of trust as she got to know the members and staff better. She continued:
They treat you with respect, they don’t treat you like in a stigmatized way… when I first came in here, I was worried … that I would be treated and talked down to like I was really slow. [I] went to the … unit … in general, just the way the workers talked to you like at first I couldn’t tell who was a worker and who was a member because they just talked to other people like they were, not like they were bossing them around but like they’re working with them.

In this way, she and other participants came to appreciate their relationships within the clubhouse in positive terms as relationships between equals.

Strength focus.
Another clubhouse way that seemed to foster an initial sense of reciprocity between the new member and the clubhouse was its emphasis on strengths rather than on deficits or diagnoses. Their experience of being invited to work from the very first day at the clubhouse was eye-opening to new members who had received persistent explicit and implicit societal reminders about their mental illness that instilled in them an illness-dominated sense of self. As Dan, a NY member, remarked: “[The clubhouse] focuses on work, education, and socialization … more on person’s strength … so I find it helpful … Patients get active right away. And this is an unusual concept for me.” When asked how it was unusual, Dan drew from his previous experiences with mental health services to explain how when he first came to the clubhouse “they didn’t focus on my weakness, weaknesses at all.” In contrast, they told him that “there can be a lot of things to do. That made me feel useful.” “Focusing on strengths” was a “totally new concept” for Dan, one in fact he had “never heard of.” What made it different at this early stage was the message he received that he could do things, that he could contribute, even though at this point he might not yet know how.

Gentle pushing but side by side. Being asked to do new things, take on new responsibilities, can be daunting for someone whose confidence has been undermined by previous failures. The clubhouse ways woven into this process involved breaking activities down into small, manageable tasks and working side-by-side and step-by-step with a reluctant member to engage him or her in taking risks. Members described the way as “less intimidating” and the resulting sense of satisfaction they then derived from seeing themselves accomplish something they didn’t know they could do. Susie, a NY member, explained that the people at the clubhouse “take you from where you are at, right now.” She then described the engagement process as follows:

Two summers ago when I was hospitalized, I came back and there was a new staff member. And she said, ‘Gee, I heard so much about you, I’m glad to have you doing work with me,’ which, was very friendly, and then she said, ‘Do you wanna … clean up the counters?’ And I said no, I’m not feeling well, and she said, ‘How about doing it with me?’ So, I said ok, and two of us started doing cleaning the counters, and, just the physical activity, doing that little thing and doing with someone helped break my mood.
Engagement began with the staff’s “very friendly” welcoming invitation for Susie to take on a small physical task. When Susie said no, the staff respected her decision without judgment or criticism but did not give up on her invitation. She gave instead a “gentle push”—gentle because she joined where Susie was, side-by-side, and offered to do the task with her. Susie responded by going along with the staff, learning in the process that physical activity, doing small chores, and working alongside someone else was a way of improving her mood. At the same time, her work benefitted the clubhouse and gave her a sense of accomplishment. This process, which Susie entered into in a relatively passive way, allowed for an emerging form of reciprocity on a micro level in that the interactive process became two-way, allowing for Susie to take on a more active role in cleaning the counters alongside of the staff.

Mark, a member from OH, described this kind of persistent encouragement as “tough love” or “a little kick” to get a cold engine running. As he said:
Tough love is … care about the person and … the staff cares about the members. We have great staff here. But a staff might say you’re doing a good job … but you’re capable of doing even better things. And they sort of just push, not hard they just give you … sometimes, a little kick to get started and it’s like an engine, in the morning, in the winter time.

Choice and pace.
Another reason participants gave for considering the encouragement they received to be “gentle” was knowing that their participation was considered to be strictly voluntary. With its focus on strengths, the clubhouse milieu is one that expects, and relies on, member participation. Protection of members’ right to self-determination equally is core to the clubhouse model, however (Clubhouse International, 2014). Participants reported trusting this important component of the milieu. As Ron, an OH member, stressed: “Will you help me do this and do that? … They can’t make you do [anything] you don’t want to do … You can leave when you get ready to leave … no mandatory thing.” Maintaining a fine balance between expectations and voluntarism, staff elicit involvement by framing tasks as “situations where members are needed” (David, Staff, NY). Feeling needed, which may be a new experience for some members, offers a welcome counterforce to their reluctance or lack of confidence. As Cathy, a NY member, explains:

I guess I’m sort of feeling like I matter in a group, or have a part. I’m not so invisible. … Like when I’m there, and if I’m just doing nothing, they might ask me, ‘Do you have something to do? Do you want something to do?’ Or, ‘Do you want to help us do this or help us do that?’ So that people are noticing that I’m there.
No one is perfect. Another clubhouse way that seemed to contrast with members’ prior experiences was the lack of blame for problems, mistakes, or failures to meet expectations. As Mark, an OH member, comments “One of the nice things about the [clubhouse] … is that you will get constructive criticism … you’ll never get put down by the staff member here.” The kind of non-judgmental responses reported here may be at the heart of the “accepting place” sensed during members’ first days at the clubhouse. A NY member shared a conflict she faced at her job. She attributed the resolution to a clubhouse staff’s onsite mediation between the member and her supervisor. Pam, a NY staff, shared her experience helping a member experiencing an educational crisis through active listening, empathy, and cognitive reframing, which helped the member calm down:

I just had to listen. Like, you are not making any commitment, we are going to an information session … the worst thing that could happen is you don’t like the information they share. We are going to the building and they are gonna talk about the program they have and, you don’t say one word, you know, you could just come and it’s interesting to see other programs any way even if you don’t end up wanting to go there … She said, ok. I mean, she calmed down.

Pat was authentic enough to be in touch with her limitation and rely on peer support from this member’s peer who Pat also brought to the session, because she had thought this peer “could relate to the member.” The peer member, who turned out to be feeling the same way but was not in panic, joined this member:
She was more like, I’m going for this, but I do have fears and I do have past memories of school and, and so she was with her together and they kind of supported each other and, it’s always good when someone who is in the same boat as you rather than, like me saying, it’s going to be ok.

Pat saw it a success that the member left the information session, “feeling great.” Pat respected the member’s choice not to go to that school. Instead of putting the member down, she shared her process-oriented mindset: “To me, it was a big achievement for her.”

Participants’ typical answer to how people would respond to mistakes was: “You will get a new chance and a new try. … No one is perfect. That’s the spirit of this place” (Arja, Member, Finnish). Members also described how it is “safe to make a mistake” and move on at the clubhouse. Such a safe milieu seems essential for members to explore their potential.

Recognition and appreciation. At the clubhouse, people’s participation, accomplishment, or progress toward their goals often means they are simultaneously making contributions to others. Verbal or nonverbal recognition and acknowledgment on these occasions was another important clubhouse way described by the participants. Jeff, a NY member, found humorous just how much he was praised for the things he did at the clubhouse. At the same time, he implies how his confidence might not have grown without such recognition:

I’ve been praised, like, too much (laugh) … always nice to be praised … for endeavor that I’ve done for [the clubhouse], you know … that’s why I keep coming back … keep creating for them … that’s … the cool part … that’s why I’m not afraid to speak up to help.

Linda, a NY staff, comparing her clubhouse experience with her early career at a residence for teenage girls who had run away from underprivileged homes, explained why she felt something was missing in spite of these girls’ respect she had gained and the good reputation the organization had: “We did everything for these girls. We cooked their food, we cleaned their residence ... [but] zero opportunity for these girls to do anything for themselves … nothing to help with their self-confidence, certainly with their self-esteem.” Whereas these girls’ only opportunity was to expect things from others, clubhouse members are expected and supported to be in charge of their own goals, with their own “littlest success” acknowledged and applauded: “That immediately translates into increased confidence, pride.” Linda then underscored the sincerity or genuineness of the applause and appreciation because the littlest success is needed for the clubhouse community: “You’re also in an honest position for say thank you for doing something helpful. And people know you’re telling the truth, it’s got to be authentic. ... the ringing phone. Somebody’s got to answer it.” Mark, an OH member, found indeed how such “mundane things” as thank you can mean to a member’s personal growth.

Giving Support: “I feel that I am important.”
As if confirming what Linda explained above, Susie shared her insight into her own resources: “I realized that I have input to give and can affect, staff members, well-being or our own good feelings about themselves.” Just as participants appreciated support they received, they acknowledged the intrinsic value inherent in giving support to others. In addition to being a good in itself (i.e., giving to others), participants reported that helping others was rewarded by healing their undermined sense of self-worth. Mary, an OH member, for example, talked about how important she felt when others needed or benefitted from her efforts, and how this improved her relationships with others:
I like [the unit] up there … everything up there is exciting and interesting to me and … how it helps me is I feel that I am important, that somebody actually needs me to help them with something. And I find that my self-esteem is getting better, my communication with people is getting better.

Another OH member, Amy, described how depressed and suicidal she was—“doing nothing and isolated”—when she came to the clubhouse. The “miserable spiral” downward that she had been caught up in, as she continues, “dramatically” changed since then. Now she keeps a journal at home, works part-time on a temporary employment (TE) internship, and volunteers at a hospital. She is active in her clubhouse unit, soliciting donations, making phone calls, and anchoring announcements for the video lab. Amy reported that a staff member had noticed this progress and had given her a “kind of praise [she had] been looking for a long time,” along with a “thank you.” Amy reported feeling “great” as a result, commenting: “I felt more confidence, I felt motivated, I felt less depressed, and less stress … I felt so much better.” She also reported experiencing enhanced senses of self-worth and self-esteem: “You feel worthy and you feel that you have more self-worth about yourself and you feel grateful that you’re doing the best you know how.”

Staff participants also shared their own excitement about members’ progress, to which they felt they had contributed. An OH staff, Judy, for instance, assisted one of her clubhouse members, who had never flown, to arrange his flight to present an award to an employer. Judy and the member also gave a clubhouse conference presentation, during which he told his story: “You know, all dressed up in a suit and tie and just looked so fabulous. So those are the kind of things that just make you, as I would say, fall in love with the model.”

Collaboration.
The bulk of everyday life in the clubhouse involved collaborating on work tasks of clubhouse operation and maintenance. In addition to completing the tasks on which members collaborated, doing so was described as having two related benefits by. First, participants described how collaborating with others gave them a sense of equality. They saw both staff and members making equally important contributions to the overall program, reporting that it enabled them to feel like an equal among equals. Second, participants described the resulting feeling of being a part of something greater than themselves, a sense of belonging to a valued community. Matthew, a NY member, for example, described how “it’s rewarding when everybody kind of meshes together,” continuing on to describe how much he enjoyed eating lunch with his work mates: “yesterday was fun too, we stopped for lunch and uh, the first place we stopped no one liked what they got” (laughing).

From the staff side, Linda, illustrated the joy she experienced working with members on a horrible snow day, when she almost gave up making lunch because no one wanted to help shop for food. This was a moment of her growth, she recalls, when she became “the person on the same ground.” Honing in on her authentic self, she admitted honestly the challenge while asserting the need and importance of the work: “Guys, if we can stick together, we can do it. It’s terrible but let’s do it anyway.”
Um, shopping happened, we had our lunch and actually I learned what the utter joy was, when you have a difficult day … and there are only a few of you working together and the end of the day the utter pleasure of togetherness, of pulling together with the people that work so hard ... double and triple time. And everything got done … pretty good. … what was breathe-taking was how good we felt together, … proud … and unified.

Participants described how mutual help, not only between members but also between members and staff, is part of their everyday life. Members help novice staff just as they do with new members. A Finnish member, Leo, helped a new staff update the TV screen, commenting “That’s the way it goes with this house.” Andy, an OH member, explained helping new staff is “like build[ing] a relationship” because “you never know [when] you might need them.” Such mutual help, he concluded, “makes it such a fine program.”

A NY member, Mike, described how he relishes his ability to “help out” the clubhouse, enjoying the work itself and honing his job skills, all the while feeling like a valued member of the community. When he worked full-time at a company, for example, he covered for the clubhouse, which could not send their staff to the company to fill in a clubhouse member on TE who missed a day:

There were a couple of days where [clubhouse staff were] really swamped … and I would cover for them. I would tell them don’t worry about it, you don’t have to send anybody in to cover, you know, we’ll take care of it.

Mike continues:
[At the clubhouse,] working with [staff], using the computer every day … and just helping out. Even like the stuff which I do when we do the morning meetings, I love to help them out. There’s a lot of stuff like inputting data and doing things which I love to do anyway, and it will help increase my computer skills, you know, so that’s learning and teaching right there, you know, while I’m looking for work. And … helping me with my resume [and] cover letter”
Mike “loves” to help out because he enjoys the work itself, because it increases his chances of getting a job, and because he feels good about being useful to others. It is perhaps in this last reason that we find a core component of reciprocity.

Appreciated similarity as human.
 The depth and authenticity of the sense of equality members experienced can be found reflected in their attitudes toward others’ limitations. That is, while members described appreciating the supportive milieu of the clubhouse, they came to contribute to, and shape, the milieu as well as to benefit from it. Participants remained respectful of others despite whatever shortcomings they might exhibit. They appear to have internalized the strength-based paradigm of the clubhouse and to acknowledge the intrinsic value of each person as an imperfect human being. In this light, limitations were seen as a part of a whole and were often met with a sense of humor that underscored participants’ sense of a shared humanity. Joe, an OH member, for instance, pointed out how differences in level of educational attainment—which might be used to value some people more highly over others—did not diminish a member’s standing in the clubhouse as all of the members, in effect, “do the same work”: 
Some members have been to college, graduated, got their masters … but we are all members and … that doesn’t mean that person is better than a member whose never graduated high school. It just means that they might know more than that member who doesn’t have that knowledge but … we basically here to do the same work.

This acceptance of limitations extended to staff. A Finnish member, Niko, for example, found the staff’s computer skills somewhat lacking, He did not view these shortcomings as serious deficits, however. Rather, he appreciated this recognition that the staff were not perfect or “omnipotent,” as it offered him more of a sense of being their equal:

I feel more … equal with the staff members and nowadays I don’t look them up, as I did previously … It was safe to think that staff members were something very good or every knowing, omnipotent. So [my understanding] improved in that sense that we are [all] human beings.

As a result of this improved understanding, Niko became more responsible for his part of the work at the clubhouse, even making up for staff mistakes as one of their equals:
I take the initiative myself. Not expecting the whole time that what the staff member tells me to do … For example we were counting the money … the staff … didn’t sign the paper. And I just saw that the signature was missing … He had to open the whole package ... to put the signature inside.

Arja, another Finnish member, captured this sense of equality in pointing out how within the clubhouse, everyone has “the same worth.” She finds it “wonderful” that staff acknowledges that they do not know everything and that members can give them advice based on their own strengths and life experiences: 
If you’ve been employed, then you have … the expertise or talent or whatever. You can … use it here. Even though you can’t work at the moment … we are all equal in that sense… We have the same worth. … members will give advice to the staff. (laughter) [Staff] don’t know everything so they need help as well … So that’s wonderful.

Making a difference.
Much of the work involved in maintaining the clubhouse may seem trivial, yet these everyday tasks were experienced by participants as transformative in the sense of moving them from a passive and helpless state to an active and empowered one. Liz, an U.S. member, who joined the clubhouse “very suicidal” and is now employed full-time in a competitive job, attributed this process of transformation to “a unique partnership” between the individual and the clubhouse “Community You”—unique because of “their own individual woes and needs and the respect that the clubhouse gives individuals to reach their best goal.” She recalls how the partnership revolved around what she described as “intrinsic payment”:
What I was getting when I [got] up every morning with a plan to make a difference … The clubhouse could never pay me for what I had got for my time here just like I could never pay the clubhouse for the support that they have given me over the years.

The transformation, at the same time, often meant one’s evolving sense of confidence to give. Amy, also in the U.S., described wanting to become a mental health provider herself so that she can help others to empower themselves in the way staff had done for her. Having been involved in advocacy and now planning to return to school to become a health care professional, Amy said:
I feel powerful, you know, to come to the clubhouse not only to get a job and keep a job but to help other members with mental illness … I can give them tools just like the staff has given me tools to empower myself, you know … to do the things that I want to.
Her story indicated the “tools” for empowerment are the clubhouse ways that made her feel “positive” about herself and being treated as a person “with respect and with dignity.”

Arja, in Finland, shared a story of how she came to feel that she had made a difference in the lives of other people also. By the time of the interview she had retired from working full-time at a restaurant for five years and reported that she had good relationship with her neighbors and went to a gym for exercise. Toward the end of the interview, Arja commented that she took many things from her 10 years of experience at the clubhouse, mentioning in particular that: “Here you learn that we are all useful in our own ways … what kind of abilities do we have, that we are all useful people.” She then showed the researchers a thank you card, saying that she had received it from a nursery she had worked for recently as a volunteer. Children there loved her because she was able to relate to them “as a person”—“being spontaneous and being myself,” the way she learned from the clubhouse. She asked the assistant (interpreter) to tell the researcher that there was such a lovely sentence that made her cry. The card read:
[Arja], you are not just a person who works here, you are an adorable person. It is such a big loss that you left. There are not that many like you. Thanks for all the good moments that we have had together.

Discussion
The purpose of the present study was to describe, from both members’ and staff’s perspectives, experiences of reciprocity in the clubhouse context. Overall, themes that emerged seemed consistent across the clubhouses in different geographic locations, perhaps not surprisingly because all were certified (Coniglio et al., 2010) and in Western countries (e.g., Davidson et al., 2005). Receiving and giving support evolved, as part of its everyday life, from a nascent sense of reciprocity in new or more disabled members, in which the individual is viewed primarily as having the potential to become a contributing member, to a more active form of reciprocity, in which members initiate activities and give and take more equally with others, including staff. The former, albeit nascent, sense of reciprocity sets the ground for the person to take on more active and constructive roles in the community by shoring up his or her compromised sense of self-worth and through the accumulation of what might be described as “micro” successes that help to rebuild the person’s confidence in his or her ability to take charge of his or her own life. This process, if not linear, was fostered by clubhouse ways of supporting members, constituting important ingredients of the milieu: welcoming invitation, accepting or no-one-is-perfect spirit, strengths focus, gentle pushing, chores, step-by-step, side-by-side, and choice and pace, as well as recognition and appreciation of success and contribution.

Data suggested that the clubhouse way as a whole is likely to be experienced as having one’s personhood respected, with members’ self-worth and decision-making capacity restored despite any personal limitations due to illness or to the fact that all humans are imperfect. This emerging sense of personhood then blossomed through a variety of avenues, including feeling safe and accepted to be oneself and to explore one’s potential by trial and error, having one’s values and decisions honored and trusted, and coming to feel more positively about oneself through the accomplishing of goals day-by-day, starting from seemingly trivial chores. At the same time, by virtue of the clubhouse way, members come to trust the clubhouse and their own assets and capabilities—despite inevitable limitations—to give in the very same clubhouse way that they had come to appreciate, constituting a turning point in the nature of members’ involvement in the clubhouse environment. The rewards experienced through giving included happiness, empowerment, and a sense of self-worth members felt by seeing others they helped heal and grow. The reward of work collaboration included a sense of fundamental equality and connection as human and belonging to a community of equals.

These findings offer a “thick description” of reciprocity as it is experienced by persons with serious mental illnesses in one organizational or community context. This description suggests that clubhouses, at their best, can overcome at least two criticisms concerning the “asymmetrical” nature of much of psychiatric care (Davidson et al., 1998). First, the clubhouse seems to offer a different route to some of the same “common factors” that have been found to be the most effective components of psychotherapy; these being the provision of empathy, non- judgmental acceptance, and encouragement (Davidson & Chan, 2014). While within a clubhouse milieu members are more likely to explore and come to value different, previously ignored or unknown aspects of themselves through doing rather than talking, our data would suggest that action can have as transformative an effect as—and lead to—insight. Second, by virtue of viewing, and treating, members as potential contributors to the clubhouse community from their very first day on—regardless of their ability to contribute at the time—staff of the clubhouse foster the evolution of symmetrical and reciprocal relationships. The clubhouse thus adds this “voluntary contributions” component to the other “active ingredients of intentional recovery communit[ies]” identified by Whitley, Harris, Fallot, & Berley (2008, p. 173), these being a place for safety, family surrogate, and socialization. In this sense, our data support the claim that the clubhouse model is at least in part rooted in the same spirit as the settlement house approach originated by Addams as a strength-based and collectivist alternative to individually-focused and deficit-oriented approaches to addressing social issues (Addams, 1910; Davidson, Rakfeldt, & Strauss, 2010; Doyle, Dudek, & Lanior, 2013).

With respect to limitations, our interpretation of findings may call for caution because only one researcher analyzed the data. The study nonetheless achieved data saturation (Glaser & Strauss, 1967) from a large sample obtained from multiple certified clubhouses in the two countries that use this model the most. The generalizability of the findings to other certified clubhouses is, therefore, compelling (Coniglio et al., 2012).

Finally, these findings can inform recovery-oriented community-based mental health practice in two ways. First, the clubhouse way reminds practitioners of the importance of the simple—but not to be taken for granted—principle of reciprocity in their interactions with persons with serious mental illnesses. Regardless of the person’s severity of disability, it remains crucial that he or she be viewed and treated as a person, a human being who is surely imperfect (as are we all) but who has the potential (at least) to make valuable contributions to his or her community and who is to be afforded choices in his or her everyday life. Second, the clubhouse way draws our attention to the central importance of everyday life as providing the context for recovery. Counseling, education, and insight may also be important, but being successful in one’s everyday decision-making and micro actions, no matter how trivial they may appear, seem to provide a kind of backbone or core component of the recovery process. This finding suggests that community-based systems of care may need to complement individually-focused approaches such as supported employment with more use of different models of what Mandiberg (2010, 2012; Mandiberg & Warner, 2013) has described as “enclave communities” that are based on the settlement house principles of equality, collective responsibility, and reciprocity—at least for those persons who either do not want or do not (yet) benefit from the provision of individual in vivo support. Not only would the addition of such models increase the range of choices persons with serious mental illnesses would be able to make, but future studies also might then explore the possibility of how these various approaches may be used to complement each other.

 
Declaration of No Conflict of Interest
Research reported in this study was partially supported by the Fountain House New York Post-Doctoral Research Fellowship (for the initial study at a clubhouse in New York), the Marywood University Research Initiative Funds (for the Ohio study), and the Sidney Baer, Jr., Foundation Research Grant (for the Finland study), with the agreement that the funding would impose no influence on the research findings concerning the clubhouses under study.

Acknowledgement
We would like to express our sincere appreciation of the research partnership provided by the clubhouses under study and the contribution made by all the study participants; and Dr. James M. Mandiberg, Dr. Eric Stein, Ms. Carrie Baxter, Ms. Courtney Connor, Ms. Melody Collins, Ms. Laura Tarkiainen, and Mr. Evan Baer for their collegial assistance during the research administration.


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