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I DATE DUE DATE DUE DATE DUE Lin 1:5 309“ 6101 cJCIRC/DatoDuepes-sz THE CLUBHOUSE MODEL IN MICHIGAN: A PRELIMINARY EXAMINATION 0F INDIVIDUAL AND ORGANIZATIONAL CHARACTERISTICS ASSOCIATED WITH EMPLOYMENT OUTCOMES By Chandra M. Donnell A DISSERTATION Submitted to Michigan State University in partial fulfillment of requirements for the degree of DOCTOR OF PHILOSOPHY Department of Counseling, Educational Psychology and Special Education 2001 ABSTRACT THE CLUBHOUSE MODEL IN MICHIGAN: A PRELIMINARY EXAMINATION OF INDIVIDUAL AND ORGANIZATIONAL CHARACTERISTICS ASSOCIATED WITH EMPLOYMENT OUTCOMES By Chandra M. Donnell Persons with severe mental illness experience high rates of unemployment and underemployment. Both the state-federal rehabilitation program and the mental health community have tried to address this issue. However, in spite of program initiatives and innovative approaches to employment placement, the statistics for employment outcomes within this population remain grim. Psychosocial rehabilitation, and more specifically, the clubhouse model, has gained increased attention in regard to employment outcomes. The literature shows that the combination of empowering persons with severe mental illness, strong social supports, full integration in the community and a key focus on vocational success, has made the clubhouse model successful in assisting persons with severe mental illness to attain employment. The values of recovery, choice and control, fostering and encouraging hope, and improving vocational outcomes for persons with severe mental illness are core to the philosophy of psychosocial rehabilitation. The clubhouse model of psychosocial rehabilitation is but one means by which to express these values. Hence, the purpose of this stmly was to I) examine the relationship between member characteristics (i.e., sense of recovery and community) and employment success for club members, and 2) to gain an understanding of the organizational characteristics of the clubhouse that contribute to successfill employment outcomes. An ex-post facto descriptive design was utilized to conduct this study. A combination of quantitative survey research and a qualitative interview addressed the research questions. Subjects were recruited from a pool of persons with severe mental illness participating in the Flinn Project research study. The Flinn Project research study was a joint effort of the Michigan Department of Community Mental Health and Michigan State University, designed to examine: 1) elements of the clubhouse model that represent best practice; 2) the degree to which existing clubhouse programs conform to the clubhouse best practice model; and 3) the effectiveness of clubhouse elements and overall program in improving the psychological functioning, vocational outcomes and quality of life for persons with severe mental illness. In order to gauge which personal and organizational characteristics best predict an employment outcome, results of this study were analyzed using discriminant function analysis. Although this analysis did not produce significant results, a great deal was learned in the process of completing this research. The sense of recovery variable consistently yielded high values toward employment, which may be indicative of a variable that could perhaps enhance employment outcomes for club members. A similar effect was noted for sense of community and it’s association with unemployment. These results prompted discussion on the implications of promoting recovery and community within the clubhouse model. Implications for practice education and further research are also discussed. Copyright by Chandra M. Donnell 2001 Progress is not so much a statement of what we have achieved, as it is a signpost of where we need to go. - Chandra M. Donnell ACKNOWLEDGEMENTS First and foremost, I give all honor to my Lord and Saviour, Jesus Christ. His guidance and strength have allowed me to accomplish even the most difficult tasks. Without His wonderful grace and mercy, I know that none of this would have been possible. Secondly, it is most important that I express my sincere thanks and appreciation to my mentor, dissertation chair and major advisor, Dr. Michael Leahy. His faith in my ability, his unrelenting encouragement and support, provided me with strength and perseverance to complete this awesome task. His wisdom and continued dedication to upholding the professionalism and standards of our field have been a true inspiration for me. To know that he was always there for me and willing to share his time with me, was a true blessing. I could not have designed a better person, a better educator, or a better rehabilitation counseling professional to learn from and work with. In addition, I must thank the principal investigators and research team members of the Flinn Project. This study would not have been possible without their support. A special thank you goes to Dr. Sandra Herman and Dr. Esther Onaga for providing me the opportunity to participate in such an important research project, their assistance with reviewing and editing this document, and their insight into the issues therein. Special thanks also go to my colleague Francesca Pernice-Duca, for her “open door” and listening ear. Much appreciation is also extended to those persons with severe mental illness who allowed me the privilege of speaking with them and entering their lives. I would also like to thank other members of my dissertation committee, Dr. Nancy Crewe and Dr. Mark Reckase for their extreme patience, guidance and support. I would like to further thank Dr. Reckase for his time and effort and for sharing his knowledge with me, as well as for helping me to appreciate some of the disappointments of statistical analysis. To that end, I must also acknowledge Dr. Oren Christmas, and thank him for an excellent learning opportunity, sharing his wisdom and fostering my statistical ability. I would also thank my many friends and inspirations that I have met these past four years, those who have finished the journey and those still making their way. Sincere thanks go to Dr. Alfiee Breland, my mentor and friend, for taking the time to know me and for “passing the torch” through sharing her experiences with me. A warm and heartfelt thanks also to my wonderful family and friends who supported me through prayer and encouraged me through their words. My journey through lifecand this chapter of my life, would not have been possible without my mother, Patricia Donnell, my sister, Tonya Donnell-Boston and my wonderful friends Melita Mitchell, LaConyea Pitts-Thomas, Nicole Musenga, Janae Lockett, and John Jackson, Ph.D. I sincerely hope that I have made them as proud of me, as I am to know them. vii TABLE OF CONTENTS LIST OF TABLES ..................................................................................... x CHAPTER INTRODUCTION ..................................................................................... 1 Statement and significance of problem ............................................................ 3 Purpose of the study ................................................................................... 5 Definition of terms ............................................................................... 6 Assumptions and limitations .................................................................. 10 CHAPTER 2 LITERATURE REVIEW .......................................................................... 13 Psychosocial Rehabilitation .................................................................... 13 Principles Goals and Philosophy of Psychosocial Rehabilitation ......................... 14 The Clubhouse Model of Psychosocial Rehabilitation ..................................... 16 Empowerment ........................................................................... 16 Vocational Aspects of the Clubhouse ................................................ 18 Clubhouse Governance ................................................................ 20 Employment ..................................................................................... 21 Employment Outcomes for Persons with Severe Mental Illness ................. 22 Employment Outcomes for the Clubhouse Approach of PSR .................... 23 Factors Associated with Employment Outcomes .................................. 24 Personal Characteristics ............................................................... 28 Organizational Characteristics ........................................................ 30 CHAPTER 3 METHODOLOGY .................................................................................. 33 Participants ....................................................................................... 34 Description of Sample ................................................................. 34 Instrumentation .................................................................................. 36 Club Participation Interview .......................................................... 37 Employment Member Interview ..................................................... 40 Corrigan Recovery Scale ............................................................. 41 Sense of Community .................................................................. 43 Demographic Questionnaire .......................................................... 46 Program Assessment Survey ......................................................... 46 Procedures ....................................................................................... 48 Design ................................................................................... 52 Data Analysis ........................................................................... 53 CHAPTER 4 RESULTS ............................................................................................. 56 Sample Characteristics ............................................................... 56 Discriminant Analysis ................................................................ 60 viii Summary of Hypotheses ............................................................. 68 CHAPTER 5 DISCUSSION ........................................................................................ 71 Summary of Results ................................................................... 71 Assumption and Limitations ......................................................... 77 Implication of Findings ........................................................................ 81 Implications for Practice ............................................................. 81 Implications for Education ........................................................... 82 Implications for Further Research .................................................. 83 Conclusions ..................................................................................... 84 APPENDICES .................................................................................. 86 REFERENCES .................................................................................... 172 ix LIST OF TABLES I. Table of Participation Variables Scoring ............................................... 38 2. Table of Sense of Community Item Reliability Analysis ............................. 45 3. Table of Reliability Analysis of Composite Variables ................................ 48 4. Table of Demographic Characteristics of Sample ..................................... 57 5. Table of Educational Characteristics of Sample ........................................ 59 6. Table of Characteristics of Clubhouse Participation .................................. 60 7. Table of Classification Results of Employment Status ................................ 61 8. Table of Standardized Canonical Discriminant Function Coefficients ............. 62 9. Table of Tests of Equality of Group Means ............................................ 63 10. Table of Structure Matrix ................................................................. 64 11. Table of Structure Matrix for Individual Characteristic Hypothesis ................. 65 12. Table of Structure Matrix for Organizational Variable Hypotheses ................. 66 13. Table of Structure Matrix for 2"‘1 Discriminant Analysis ............................. 67 14. Table of Classification of Analysis 11 ................................................... 68 CHAPTER I INTRODUCTION Employment and the nature of work are important, if not essential, to the lives of most people. Work is also an important facet through which we experience social contact and a sense of belonging in our communities and in society. Borgen, Weiss, Tinsley, Dawis & Lofquist (1968) contend that work is a major source of identity and self-esteem. Even more, it has been asserted that work is the “key to self-sufficiency and the backbone of a strong American society” (Noble, Honberg, Hall & Flynn, 1997, p. 10). However, this key element and means through which social contact occurs is one that has not been prevalent in the lives of persons with severe mental illness. The National Institute on Disability and Rehabilitation Research (NIDRR, I993) contends that there are more than 40 million people in the United States that have psychiatric disabilities. According to the National Institute for Mental Health (NTMH, 2001), approximately “22.1% of Americans ages 18 and older - which translates to l in 5 adults — suffer from a diagnosable mental disorder in a given year”. When this figure is translated over to the 1998 U. S. Census residential estimate, they approximate to 44.3 million people with diagnosable mental illness (Narrow, 1998). Of the persons that comprise this large group, approximately half are adults between the ages of 25 —- 44 (Manderscheid & Sonnerschein, 1992), which represents a significant portion of the working age in the United States. Even more disturbing are recent estimates, which illustrate that of the four to five million persons who have severe psychiatric disabilities, 70% to 90% are unemployed (Rutrnan, 1994). In fact, for those that are employed, the competitive and transitional employment rates remain relatively low, ranging from 11.7% to 30% (Rogers, Anthony, Toole and Brown, 1991). Subsequently, the unemployment and under-employment rates among this population are overwhelmingly large. Rogers et al. (1991) contend that persons with severe mental illness have full competitive employment figures below 15 %. This is a startling low rate of employment. It is also suggested that, “despite the advent of new program technologies, such as supported employment, community and psychosocial rehabilitation, programs have not increased their effectiveness in achieving successful employment outcomes for this population” (Fabian, 1999, p.6). Researchers and professionals in the field have taken note of these disparities and have attempted to address them through a number of studies. The National Alliance for the Mentally III (N AMI, 1997) published a report regarding the low employment rates and sought to understand the many dimensions that effect successful employment outcomes. However, NAMI (1997) purports that the “high unemployment rate belies a growing body of research which documents that treatment and specific rehabilitation interventions for people with severe mental illnesses can significantly improve employment outcomes” (p.10). Their compilation of research reiterates the reality of low employment rates for this population. It also validates past research efforts, which suggest that persons with severe mental illness experience less success at becoming vocationally rehabilitated than most other persons with disabilities (Roger et. al, 1991). Unfortunately, notwithstanding recent increases in psychiatric and vocational rehabilitation literature on employment outcomes and overall quality of life for persons with severe mental illness, there still exists the challenge to improve the quality and consistency of employment outcomes for this population. Statement and Sigg'ficance of the Problem Mental health and vocational rehabilitation service systems have a poor history of success in achieving positive employment outcomes for persons with psychiatric disabilities (Andrews, Barker, Pittman, Mars, Streuning & LaRocca, 1992). Time-limited funding and service provision as well as durational limitations of the state-federal vocational rehabilitation system traditionally have not been in harmony with the needs of persons with severe mental illness. The discord between this populations’ dependence upon long-term supports and on-going follow-up and the linear nature of state- federal vocational rehabilitation program services has been one of the contributing factors to unsuccessful employment outcomes. Psychiatric rehabilitation, synonymously referred to as psychosocial rehabilitation, has also addressed the issue of unemployment for persons with severe mental illness. Psychiatric rehabilitation differs from vocational rehabilitation in service delivery, scope of service, and philosophy of needs. Anthony (1980) developed a functional approach to diagnosing the rehabilitation needs of persons with psychiatric disabilities. What he recommended was an approach that analyzes the persons’ physical, intellectual and emotional strengths and potential limitations as they interact with the demands of living, learning and working across environments. The International Association of Psychosocial rehabilitation Services (IAPSRS, 1997) offers a similar description of psychiatric rehabilitation. IAPSRS contends that psychiatric rehabilitation entails a set of “treatment interventions designed to work with the whole person: mind, body and spirit; to improve individual functioning; improve the individual’s own management of his/her illness; and facilitate the recovery of the individual” (p2). Psychiatric rehabilitation programs, while diverse in nature, have experienced inconsistent trends in outcomes for persons with severe mental illness as well. The 1950’s clubhouse model, a more traditional approach to psychiatric rehabilitation, has addressed the dismal employment outlook for persons with severe mental illness. The key vocational concepts introduced in the clubhouse approach of a work-ordered day and transitional employment, have come to be seen as necessary elements of psychiatric rehabilitation (Beard, Propst, & Malamud, 1982). A chronological review of experimental research involving the clubhouse model in psychiatric rehabilitation (Dion & Anthony, 1987) yielded positive, though inconsistent, employment outcomes for persons with severe mental illness. More recently, Bond, Drake, Becker and Mueser (1999) reviewed the employment outcomes at clubhouses as well and asserted that definite conclusions on clubhouse’s vocational effectiveness could not be drawn due to the lack of rigorous research. While the reason behind this lack of research has yet to be specifically examined, Bond et al. contend that a specific methodology to assist members in gaining employment is not explicitly spelled out in the clubhouse standards. It could be this lack of specificity, which permits various interpretations of the standards that may contribute to the inconsistency within the literature. The need for further research in this area is clearly apparent. In the past two decades, psychiatric rehabilitation has received much attention in the literature. However, this approach, which is more consistent with the cyclical nature of the disability and the need for empowerment of the consumer still requires more extensive examination so that we may understand what specific characteristics appear to be associated with employment outcomes for this population. While there have been several studies that have examined predictors of employment outcomes for persons with severe mental illness, research that looks specifically at the potential influence the values of the clubhouse model and psychosocial rehabilitation (i.e., recovery and empowerment) may have on individual and organizational characteristics in relation to employment outcomes, is scarce. Purpose of the Study The purpose of the present study is to I) examine the relationship between member characteristics (i.e., sense of recovery and community) and employment success for club members, and 2) to gain an understanding of the organizational characteristics of the clubhouse which contribute to successful employment outcomes. The ultimate desire for this research is to inform the field of what individual factors can be further enhanced by the clubhouse model and how these factors, in conjunction with organizational characteristics, can enhance employment outcomes for clubhouse members. The results have implications for clubhouse staff training and further understanding the impact of clubhouse philosophy on member employment outcomes. Participants in this study were engaged in an hour-long structured interview to gather information regarding their present employment status and their experiences and supports received while a member of the clubhouse. They were also queried on how they perceived their supports and the clubhouses’ role in their recovery process. Participants responded to structured questions and select responses for the majority of the interview. Participants in the study were volunteers who participated in the Flinn Project In-Depth interview. In order to investigate the aforementioned interests, the following research questions were addressed: 1) Is there a relationship between participant characteristics and employment outcomes? The characteristics examined were: a) length of clubhouse membership b) level of clubhouse participation c) sense of recovery d) sense of community e) previous work history 2) Are there features of the clubhouse organizational structure that are related to employment status? The organizational features examined were: a) staff training b) type of employment programs available such as: transitional employment and supported employment c) existence of relationships with external employment programs/organizations. Definition of Terms Sever: mental illness: Psychiatric disorders such as schizophrenia, bipolar disorder (manic-depressive), obsessive-compulsive disorder, and panic disorder (Noble et al., 1999). For the purposes of this study, major depressive disorder, severe personality disorder, any major psychotic disorder, or any dual diagnosis of the above disorders will be considered. Psychosocial rehabilitation: Psychosocial rehabilitation, also referred to as psychiatric rehabilitation (psychosocial rehabilitation) is a “community-based model of mental health and rehabilitation service delivery for persons with severe and persistent mental illness” (Cook and Hoffschmidt, 1993, p.81). Clubhouse: Clubhouse is the psychosocial rehabilitation model based on Fountain House (Beard, et al., 1982), which is a central meeting place for “members” to socialize. The clubhouse has two key vocational components: a work-ordered day and transitional employment (Bond, Drake, Becker & Mueser, 1999). Clubhouses are typically classified as either a Fountain House clubhouse or a hybrid model certified by the International Center for Clubhouse Development (ICCD). There also exist self- ascribed clubhouses that have not received certification from ICCD. m Anyone with a psychiatric disability who attends the clubhouse at least once at any time. Clubhoug micipation: Attendance at the clubhouse and engagement in clubhouse goal-oriented activities, which orients members to conditions that exist within the world apart fi'om the clubhouse (Mastboom, 1992). In accordance with clubhouse standards (Propst, 1992), level of participation was viewed in two parts: social participation which included activities specific to social activities and labor/work focused participation which includes participation in activities related to work and the work- ordered day. The length of participation was defined either as, short-term (0-11 months), intermediate (1-5 years) or long-term (5 years or more). Commtitive emploment: A job on the open labor market for minimum wage or above with employment supports as needed (Cook and Razzano, 1995). For the principles of the current study, “employ ” versus “unemployed” status was grouped by those persons who responded as being cunently employed in any capacity at the time of the interview. Sense of Recovery: The perception of a person with severe mental illness’ process of living a satisfying life within the constraints of one’s mental illness (Anthony, 1993; Deegan, 1988, 1996; Leete, 1989; Unzicker, 1989; as seen in Corrigan, Giffort, Rashid, Leary, and Okeke, 1999). Sense of Communig: A community may be viewed as a group of people in a shared environment and in a social relationship (Webster’s Dictionary, 1992). Within community psychology literature, “psychological sense of community” is one of three concepts of cohesion. This concept refers to the “sense of belongingness, fellowship, ‘weness’, identity, etc., experienced in the context of a functional (group) or geographically based collective” (Buckner, 1988, p. 773). Transitional emploment: A series of time-limited placements, typically part- time positions, during which time members acquire a work history, various job skills, and confidence to perform in employment environments (Cook and Hoffschmidt, 1993). Traditionally, clubhouse stafi' workers negotiate these positions. Suppgrted employment: An employment model authorized by the 1986 Amendments to the Rehabilitation Act (PL 99-506). The model applies a “place and train” philosophy with on going, on-site training and supports provided for the client throughout placement. The model is most often utilized with persons with the most significant disabilities (Maki & Riggar, 1997). Previous work histog: Any past employment experience in the job market. International Center for Clubhog Development (ICCD) Training; The international body that regulates the standards for clubhouse development. They also administer training on the values and philosophy of psychosocial rehabilitation, as well as training to staff members within clubhouses on their roles in the environment and how to effectively run clubhouse programs. Clubhouse traim'ng: Training provided to clubhouse staff on club values and specific emphasis and training on transitional employment. Pachiatric diagnosis: The psychiatric diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). , Flinn Project: A joint research study conducted by the Michigan Department of Community Mental Health and Dr. Esther Onaga at Michigan State University. The project will evaluate clubhouses in the State of Michigan that: 1) are Medicaid enrolled and 2) have an effective date for Medicaid billing no later than June 30, 1998. Three objectives guided the Flinn Project inquiry: 1) to identify elements of the clubhouse model that represent best practice; 2) to assess the degree to which existing clubhouse programs conform to the clubhouse best practice model; and 3) to measure the effectiveness of clubhouse elements and overall program in improving the psychological functioning, vocational outcomes, and quality of life for persons with serious mental illness. The Flinn Project will retrieve this information from both clubhouse staff and members through an interview with clubhouse director on operations, innovation and reinvention, observational study, individual interviews with members and staff, and a staff survey. In-depth consumer interviews with members will examine: 1) member outcomes; 2) member characteristics; 3) the clubhouse experience; 4) employment; 5) other outcomes (i.e., psycho-educational); and 6) hospitalization. Michigan Demrtment of Career Development —— Rehabilitation Services (MDCD- _R_S_)_: The public, state—federal vocational rehabilitation agency in the State of Michigan. Assumptions and Limitations It is assumed, for the purposes of this study, that self-report is a valid and reliable method by which to collect information on clubhouse and member characteristics and their relationship to employment outcomes. According to Heppner, Kivlighan and Wampold (1992), self-reports are useful not only in accessing private thoughts and cognitions, but also in gaining information regarding hypothetical situations. Self-report allows access to Cognitions and perceptions that are ofien beyond the observation of the researcher. The interview format employed during this study, typically allows for greater control and depth of information obtained (Kerlinger, 1986 as cited in Heppner et al., 1992). The aforementioned advantage to utilizing self-report and the benefit of the interview format provide a counterbalance to several disadvantages that are also limitations to the present study. Self-reports become vulnerable due to the phenomena of distortions on the part of the subject (Heppner et al., 1992). These authors assert that self-report allows the opportunity for subjects to project themselves in a biased manner, either in a more positive light; in a socially desirable way; or one that makes them appear more distressed than is the case. Self-reports in the case of this study are even more vulnerable due to the psychiatric diagnosis of the subjects. The potential weakness of the self-report is increased due to symptomatology of the diagnosis classified as “severe 10 mental illness”, which most often involve some delusional thoughts or distorted thinking processes. The underlying purpose of this study is to investigate the characteristics of the clubhouse model that may influence employment success through the examination of the participants’ experiences and perceptions. The interview format, allows for structure and points of clarification, if the subject is unclear of the meaning behind any given question. Subsequently, it is maintained that self-report will yield the most accurate perceptions of the subjects. The sampling procedure to be utilized within this study also presents itself as a limitation. Traditionally, random sampling is seen as the most critical element in allowing for generalization to the representative population (Serlin, 1987 as cited in Heppner et al., (1992). Nevertheless, most often in rehabilitation research, the utilization of “available samples” or “convenience samples”, provide a more realistic method by which to conduct research. A ‘purposeful’ sample was utilized in this study. The clubhouses where the interviews were conducted included those that both, completed the program assessment surveys and were site-visited. Of the 40 clubhouses in Michigan, a representative sample of 17 clubhouses were chosen to conduct member interviews, based on a selective criteria developed by Flinn researchers. The members of those clubhouses that participated in the study did volunteer and were compensated for their participation. Since this study wishes to investigate the impact of clubhouse membership and the subsequent personal and organizational characteristics that may influence employment outcomes, demographic information was examined from the entire 11 clubhouse population in Michigan. These figures illustrated the similarity between the entire population and the sample population from this study in age, ethnicity, and educational backgrounds. While it is appropriate to assume that the results of this study will generalize to other clubhouse members within the state of Michigan, the generalizability of the results to clubhouse members throughout the United States, serves as another limitation to the study. However, it is assumed that the current study of examining persons with severe mental illnesses who access clubhouses, is representative of other persons who access these services throughout Michigan. While it is understood that the self-report method will not reveal a “pure relationship”, it does give information regarding the perception of the members. This will allow for the knowledge and experience of members to be directly honored and valued (Denzin & Lincoln, 1994). It is relevant to note that, as with all disabilities, severe mental illness interacts with each person in very different ways. The experiences of persons with psychiatric disabilities will vary. The information gathered from this study should make a significant contribution to the literature and practice regarding employment, staff training and clinical treatment effects on clubhouse members of the clubhouse model of psychosocial rehabilitation. 12 CHAPTER 2 LITERATURE REVIEW The following review of the literature will address major focal points of this inquiry. The present study is interested in the impact of clubhouse membership on personal characteristics, their relation to organizational characteristics and how these factors might influence employment outcomes. The literature review will examine psychosocial rehabilitation and the philosophy and goals that support it. The development and evolution of the clubhouse model will also be reviewed. Aspects and specific components of the clubhouse model will be addressed, as well as research related to the impact of the model in the lives of persons with severe mental illness. Constructs such as sense of recovery and sense of community will be explored. As the underlying theme of this inquiry, employment outcomes for persons with severe mental illness will be reviewed. Prevalent barriers to the successful employment of persons with severe mental illness will also be explored. Psychosocial rehabilitation Over recent years, it has become evident that an integration of rehabilitation and mental health yields the most positive outlook for improving the outcomes of persons with severe mental illness (F lexer & Solomon, 1993). The result of this integration produced what is referred to as “psychosocial rehabilitation” or “psychiatric rehabilitation” (PSR). Flexer & Solomon contend that what PSR has become is a 13 combination of various interventions, which concentrate on modifying the skills and environmental supports of the individual with severe mental illness. Principles, Goals and Philosophy of Psychosocial rehabilitation Psychiatric rehabilitation initially based its philosophy of service on the medical model. However, Anthony (1980) revised the definition to take a more functional approach to diagnosing the rehabilitation needs of persons with severe mental illness. Psychosocial rehabilitation also went through a period of modification. Psychosocial rehabilitation was traditionally based on a social model, which excluded medical management. It soon became evident that medical management was also an integral part of the rehabilitation process (Flexer & Solomon, 1993). Soon thereafter, F lexer and Solomon reported that the terms “psychosocial rehabilitation” and “psychiatric rehabilitation” became interchangeable as their philosophical differences became minimized during implementation. The labeling issues that exist within this population, are similar to language issues experienced by other populations of persons with various disabilities. However, the semantics of the terms have not detracted from the goals, philosophy or successful outcomes achieved by this rehabilitative approach. “Finding ways to enable persons with severe mental illness to live more satisfying lives has been a difficult goal to achieve” (F arkas, Anthony, & Cohen, 1989, p. 1). The goals of psychosocial rehabilitation have kept this notion in the forefront and worked to alleviate the difficulty that exists. F arkas, Anthony and Cohen describe the psychosocial rehabilitation approach as one that is comprised of values, principles, process and a conceptual model. They also assert that the clinical practice of psychosocial rehabilitation is comprised of two interventions: 1) client skill development, and 2) l4 environmental support development. The overall concept of PSR is essentially guided by the basic philosophy of rehabilitation, which entails enhancing skills and environmental supports to assist persons with disabilities engage in the demands of daily living, learning, social and working environments. While psychosocial rehabilitation has several fundamental goals, a more central goal is to assist persons with severe mental illness with the skills that will enable a productive community-oriented life. A basic theme behind psychosocial rehabilitation is that programs for persons with severe mental illness are client-centered. For example, within the clubhouse model, clients are referred to as “members”. Versus “attending” various programs, members “belong” to them. This form of empowerment engages the member in the services they receive, which is another theme within psychosocial rehabilitation. In fact, Beard, Propst & Malamud (1982) assert that empowerment permeates throughout the psychosocial rehabilitation philosophy. There are also several core principles that can have been conceptualized differently across various implementations of psychosocial rehabilitation, but that are fundamental to the overall psychosocial rehabilitation process. Cook and Hoffschmidt (1993) identified several of these core principles as the following: 1) client choice; 2) situational assessment; 3) comprehensive rehabilitation service planning; 4) a biopsychosocial approach; 5) emphasis on strength and wellness; 6) empowerment of consumers; 7) family involvement and psycho-educational; 8) community based services, integrated settings, and natural supports; 9) ongoing services; 10) evaluation of services and member outcomes; and 11) staff commitment and involvement. Consequently, psychosocial rehabilitation offers a comprehensive model 15 that encourages empowerment, client involvement, community integration and ongoing supports. Anthony et al., (1990) contended that at a very base level, psychiatric rehabilitation focuses on improving the competencies of persons with psychiatric disabilities. Therefore it can be asserted that this model supports the cyclical nature of severe mental illness and offers continual support in the environments in which the persons live, work and socialize. The Clubhouse Model of Psychosocial rehabilitation Dincin (1975) describes the 1950’s approach to psychosocial rehabilitation that assisted persons with severe mental illness adjust to community life. The clubhouse, which was originally developed as a meeting place for persons with severe mental illness to socialize soon took on a more elaborate role in psychosocial rehabilitation, with the birth of Fountain House in New York City. Fountain House maintains and follows the clubhouse pattern. In an examination of 40 Fountain House/ICCD certified clubhouses, Mastboom (1992), surveyed clubhouses in the United States in order to get a general idea of the state of affairs in psychiatric clubhouses in America. While Mastboom’s findings are the most comprehensive to date, other studies have sought to understand the guiding force behind the clubhouse model - the concept of empowerment. Emmwermgnt. It would be an oversight to discuss the principles of psychosocial rehabilitation and the values and philosophy of the clubhouse model, without first introducing a distinct core concept that embodies the client-centered focus of psychosocial rehabilitation and that which is inherent in the clubhouse model. As previously mentioned, psychosocial rehabilitation promotes and encourages empowerment. The term “empowerment”, like many significant psychological terms is 16 one that has yet to be clearly defined, yet, has been shown to be key in the minds of persons with SMI and to those persons who work with them (Chamberlin, 1997). During a research project at the Center for Psychiatric Rehabilitation, Chamberlin, along with an Advisory Board of leading US. consumer/survivor self-help practitioners worked at providing a distinctive definition of this concept. The group developed several qualities of empowerment and ultimately recognized it as a process one experiences, versus an event. Fifteen qualities were developed by the group: 1) Having decision making power, 2) having access to information and resources, 3) having a range of options from which to make choices, 4) assertiveness, 5) being hopeful, 6) learning to think critically: a) using your voice, b) redefining what you can do, and c) redefining relationships with institutionalized power, 7) learning about and expressing anger, 8) feeling part of a group, 9) understanding that you have rights, 10) effecting change in your life and community, 11) learning skills that you define as important, 12) changing others perceptions’ of competence and capacity to act, 13) “coming out”: revealing your identity and thereby displaying self-confidence, l4) self-initiated and on-going growth and change, and 15) increasing self-image and overcoming stigma Though this research only worked to produce a “working definition” of empowerment, it does illustrate the power of the term to consumers and the impact to the overall recovery process. To empower can be to uplift, to encourage, to support, and to promote a belief in one’s self or simply to “invest a power” (Webster’s Dictionary, 1986). It is this concept of empowerment that fuels the success of the clubhouse model. This term is relevant to the clubhouse model of psychosocial rehabilitation because it also promotes independence and autonomy (Chamberlin, 1997). As a concept, empowerment l7 upholds the concept of “ownership” that is core to the clubhouse model. Chamberlin also asserted that the shift in roles that occurs when “clients begin to control their own lives and become partners in their treatment yields a true and positive transformation in the lives of clients” (p. 46). A strong sense of empowerment has been linked to factors such as employment (Kirsh, 2000) and recovery (Beale & Lambric, 1995; Young & Ensing, 1999). Its relevance to the clubhouse model as a foundational and theoretical base to the model is apparent. With this in mind, it is imperative that the concept of empowerment pervade every aspect of the clubhouse model. Vocational Asgts of the Clubhouse. The clubhouse pattern, according to Mastboom’s (1992) findings, is one where the “club is managed by the members who are counseled by a small staff of paid workers and volunteers” (p. 10). Fountain House also helped to introduce and maintain what has become another guiding principle of psychosocial rehabilitation, employment. The development of two key vocational aspects: the work-ordered day and transitional employment modified the identity of the clubhouse model, yet brought more fidelity to the overall principles of psychosocial rehabilitation. The work-ordered day consists of “work-units” that exist within the clubhouse (Beard et al., 1982). Members are responsible for the day-to-day operations of the clubhouse (i.e., preparing meals, clerical duties, cleaning the building, operating in- house businesses). This responsibility and participation allows the members to experience ownership over the club, and therefore allowing for a sense of empowerment. Whereas the “work-units” exist within the clubhouse, transitional employment allows for employment opportunities in the commrmity. 18 Transitional employment consists of competitive employment, in the community, at minimum wage or above, and with or without on-going supports (Cook and Razzano, 1995). These temporary, part-time positions are consonant with the stamina and stress tolerance for members, therefore providing an atmosphere to gain employment experience without the symptomatology of severe mental illness presenting itself as a barrier. Macias, Kinney & Rodican (1995) studied an evaluative description of transitional employment placements for Fountain House members who had attendance at the club between January 1988 and September 1994. Their sample consisted of 295 individuals. The characteristics of members indicated that they typically had high levels of education, a diagnosis of a severe mental illness and over 90% had been hospitalized at least once. One of Macias et al. more significant findings was that length of tenure in transitional employment was significantly correlated to time spent in clubhouse activities, specifically the work ordered day. Macias et al. purport that these positions increase the self-confidence of members while helping them become accustomed to the culture and nature of work. It is hopeful that these experiences (i.e., work-ordered day and transitional employment) will assist members to eventually achieve competitive employment. The goal of participation in the clubhouse and in clubhouse activities is to prepare members for higher levels of independence, which includes the possibility of competitive employment (Mastboom, 1992). Mastboom also reports that the most important aspect of any given clubhouse is the culture of the clubhouse. This culture will be the core of what draws and more importantly maintains membership with the clubhouse. Mastboom found that the clubhouse culture is guided by “the provision of safety and protection, 19 volunteerism and freedom, equality and participation, bonding and individual responsibility, mutual support and involvement and an optimistic perspective” (p. 13). This dimension of “culture” is closely related to the theme of cohesiveness and community, which have been shown to influence outcomes such as recovery (Buckner, 1988). Clubhouse governance. The clubhouse model is governed by the Standards for Clubhouse Programs and the International Center for Clubhouse Development (ICCD). Mastboom (1992) asserts that a “clubhouse with just a coffee shop and a living room in which to engage in conversation or games is not a Fountain House clubhouse. Neither is a clubhouse where activities are based purely on the theme of labor rehabilitation” (p. 14). The growing emergence of the clubhouse community prompted the need for a system that could maintain quality assurance and govern the practices of the clubhouses. Propst (1992) describes the process through which the Standards for Clubhouse Programs were developed. The charge for developing these standards was mostly handled by the Faculty of Clubhouse Development, which consists of a group of 50 members and staff of clubhouse programs, representatives of family and consumer groups and other mental health professionals. It was desired that the clubhouse community as a whole, be as involved as possible in this process. At the F ifih International Seminar on the Clubhouse Model, members and staff were asked to submit proposals for standards (Propst, 1992). The standards were organized into thematic groups and accepted as a first draft. The draft was then sent to the international clubhouse community for revisions. The standards, which were perceived as a living document that should be reviewed every 2 years, was accepted in December, 1990. Propst asserts that the standards are “highly 20 prescriptive in nature and intent” (p. 26). The Standards for Clubhouse Programs consists of 35 total provisions and guidelines within the following topical areas: 1) membership; 2) relationships; 3) space; 4) work-ordered day; 5) employment; 6) transitional employment; 7) independent employment; 8) functions of the house; and 9) funding, governance, and administration. Employment Relatively low rates of unemployment are not unfamiliar to persons with disabilities. The U. S. Bureau of the Census (1993, as cited in Menz, 1997) paints an extremely grim picture of employment for persons with disabilities. According to the Census, there are 16.9 million adults with disabilities considered working-age. Of those 16.9 million, 11.4 million are unemployed and seeking work. Menz contends that “rates of employment among working-age adults without disabilities who are working are three- times those of persons with disabilities and ten-times the rate for persons with severe disabilities” (p. 17). These facts are staggering. While it would seem that these figures would improve with greater acceptance of persons with disabilities and the passing of the Americans with Disabilities Act (1990), the trends remain dismal especially for those considered to have severe disabilities. Fabian (1999) asserts that income gaps between individuals with disabilities who are employed and persons without disabilities who are employed have indeed widened. Reports from the U. S. Dept. of Labor ( 1997, as cited in Fabian, 1999) indicate that men with severe disabilities earn approximately 58% less than their male counterparts without disabilities in relation to monthly salaries. Equally disturbing trends exist for women. Women with severe disabilities earn only 68% of what females without disabilities earn. It is increasingly apparent that although 21 employment opportunities for persons with disabilities and those with severe disabilities appeared to have improved, there still exists a need to further investigate the barriers that prevent successful employment outcomes. Employment Outcomes for Persons with Severe Mental Illness “Work is an important part of life” (Mowbray, Bybee, Harris & McCrohan, 1995, p. 17). Yet for persons with severe mental illness, the employment outlook is as disconcerting, if not more so, than it is for persons with significant disabilities in general. As stated earlier, Rutrnan (1994) illustrated recent estimates of the four to five million persons who have severe psychiatric disabilities, with 70% to 90% who are unemployed. For that relative few that are employed, the competitive and transitional employment rates remain relatively low, (Rogers, Anthony, Toole and Brown, 1991). Rogers et al. (1991) contend that persons with severe mental illness have firll competitive employment figures below 15 %. NAMI (1999) contends that the state-federal public rehabilitation program has failed, through their service delivery program to increase these figures. Anthony (1992, as cited in McCrohan, Mowbray, Bybee, & Harris, 1994) asserts that the mental health service model practitioners have also done little to exact change on the phenomena McCrohan et al. (1994) examined several studies that indicated overall percentages of persons with severe mental illness who were working. Overall, the employment rate, which is consistent with other findings (Rogers et. al., 1991) was approximately 15 % or less for persons with severe mental illness. Several methods of employment practices have been implemented to help to increase the employment rate of persons with severe mental illness and to decrease the 22 substantial unemployment rates for this population. The psychosocial rehabilitation approach to rehabilitation has been receiving increased attention in the literature and thus will be discussed in order to review employment outcomes for persons who participate in this form of rehabilitation. Employr_nent Outcomes for the Clubhouse Approach of PSR Bond et al. (1999) assert that some research has revealed a competitive employment rate for persons with severe mental illness of 40% for clubhouse members. A 1985 survey of 95 agencies that provided transitional employment estimated that approximately 35% of those persons who participated in transitional employment were competitively employed 6 months following their placement (Rutrnan and Armstrong, 1985, as cited in Bond et al., 1999). These percentages present a more positive outlook for employment outcomes for persons with severe mental illness. A major study of 40 clubhouses by Mastboom (1992) yielded similar positive outcomes for persons with severe mental illness. His inquiry found that a total of 33 clubhouses had placed 521 members, which translates to approximately one out of every four members. While employment outcomes for persons with severe mental illness who belong to clubhouses appear to be more successful than other approaches of employment, the clubhouse model is also plagued by issues that prevent the model from fully serving the needs of members. One of the largest issues facing clubhouses is securing and maintaining funding (Mastboom, 1992). Traditionally Medicare and Medicaid funding sources did not perceive clubhouse membership as a legitimate service. Often this prevented clubhouses from running programs consistent with the clubhouse philosophy as well as providing services necessary to the well being of the members. In recent years 23 however, that has changed. While this change has been a positive event for clubhouses, it has not alleviated other issues that they face. Clubhouses, similar to other mental health programs, face high staff turnover (Mastboom, 1992). This issue is especially critical in relation to the Employment Specialist staff position. Persons not properly trained in job development, could potentially disrupt the vocational balance of the clubhouse. Macias, Kinney and Rodican (1995) describe transitional employment as the “cornerstone of the clubhouse model of psychiatric rehabilitation” (p. 151). These transitional employment placements for members, are often negotiated by clubhouse staff and more specifically the Employment Specialist. This poignantly exposes yet another major concern for clubhouse practices. Bond et al. (1999) purport that the most difficult issue that clubhouses face is the lack of rigorous research to validate their effectiveness in facilitating successful employment outcomes. It is assumed that information gathered from the present study will help to add to the growing body of research that exists and perhaps fill some of the gaps in outcome research that exist for clubhouses and persons with severe mental illness. Factors Associated with Employment Outcomes Recently, the literature discussing persons with severe mental illness and employment outcomes was replete with information regarding predictors of employment success (Anthony, 1994;N1DRR, 1992; Anthony, Cohen & F arkas, 1990). These studies have typically focused on consumer demographic characteristics such as: previous employment history, psychiatric diagnoses, ethnicity, gender, marital status, living arrangements, and recidivism. Prior work history, which involves any previous experience in a competitive work setting, has been identified as a predictor as well. 24 While employment for persons with psychiatric disabilities is typically in low paying, low status positions with high turnover rates (Cook, 1991), this prior work history has been shown to work to the benefit of the consumer. NIDRR (1992) also maintains that the most prevalent predictor of employment outcomes is past employment history. Also, Anthony, Cohen and Farkas (1990) identified employment history as the variable most predictive of future success. People with more work experience seem to benefit more from vocational programs than people with little or no work experience (Bond, 1992). This theory, in fact, is supported in the very nature of transitional employment placements of the clubhouse model, which allow members to experience various types of employment experiences and allow for a diverse employment history. The number of previous hospitalizations, length of the last hospitalization, marital status, race, and occupational level have also typically been very relevant in predicting employment outcomes. More recently, gender, and age have also been found to be correlated variables (Anthony, 1994). While this new information would seem to present more difficulty, on the contrary, it better arms researchers, educators and practitioners to effectively deal with the barriers that exist. The task now is to identify successful rehabilitation programs and those central characteristics that contribute to initial employment success. While some strides have been made, a constant flow of research is needed in order to improve the overall quality of life for this population. The difficulty that individuals with severe mental illness experience in attaining employment far surpass the extent of barriers faced by other groups of persons with significant disabilities. In 1992, The National Institute on Disability and Rehabilitation Research (N IDRR) sponsored a 25 conference to specifically focus on strategies to help secure and retain employment for this population (NIDRR, 1992). This conference consisted of the presentation of papers on various issues concerning employment and testimonies from persons with mental illness. The conclusions drawn were similar to the problems that Rutrnan (1994), has identified. Rutrnan (1994) defined psychiatric disabilities as an enigma: a force that can be dealt with and at best, contained when possible. However, this being the case, there is much discussion in the literature on the barriers to employment. Rutrnan (1994) identified nine barriers that are inherent to the disability itself, the process of receiving VR services and the influence of the stigma on societal views that have a negative effect on employment outcomes. However, despite existing barriers, there remains evidence that concentrated programs and extensive on-going supports are conducive to positive outcomes and persons with psychiatric disabilities can successfirlly maintain employment and assume productive roles in society. Other studies have reached consensus on several factors that are predictive of employment attainment. Within the clubhouse approach of psychosocial rehabilitation, Macias et al. (1995) examined members who participated in transitional employment at Fountain House in New York from 1988 through 1994. The authors found that 58% of the placements were maintained over a 3-month period and approximately 35% of the placements were held for over 6 months. While these figures may not represent large increases in employment tenure for persons with severe mental illness, they do present the opportunity to examine employment and factors that may contribute to maintaining placements. 26 Similarly, a study previously mentioned, that was conducted by Macias, Kinney & Rodican (1995) also illustrated support for clubhouse members’ participation in transitional employment, an activity that can also be viewed as “prevocational training”. Historically, research has shown that “prevocational training” or ‘Wvork-readiness” does not effectively prepare persons with disabilities for competitive work opportunities (Dwyre & Trach, 1996). Previous research specific to persons with severe mental illness also reveal that immediate job placement is more effective in securing competitive employment and increasing job tenure than prevocational work settings (Bond, in press; Drake et al., 1994; Gervey & Bedell, 1993 as seen in Macias, Kinney & Rodican, 1995). However, Macias et al., maintain that these finding may not fit within the clubhouse framework. Because the work that is performed at the clubhouse is less of a “rehabilitative” nature and more so a necessity to maintain the function of the clubhouse, it not only contributes to the members’ self-esteem, but also enhances their sense of community and ownership, which may then enhance their sense of empowerment. Transitional employment opportunities are also viewed differently because they promote financial responsibility to the club to help retain the contract. In addition, the contracts that are held are most likely with community-based businesses. This provides the realism and necessity to the “prevocational work” that may not be promoted in other “prevocational settings”. These results which provided support for the contention that “prevocational work” or time spent at the clubhouse involved in the work-ordered day, also provides a grounding for examining participation in work units within the current study. 27 Personal Characteristics that Influence Emploment Outcomes One concept that has received much attention in recent literature is recovery. However, similar to the concept of empowerment, little consensus has been reached regarding a definite understanding of the construct. Young and Ensing (1999) contend that this concept is not a new development and has existed since the self-help period of the 1970’s. These authors conducted a qualitative interview of eighteen people with psychiatric disabilities in order to explore the perception of the concept according to the consumers. Much like empowerment, recovery is not an event, it is more so a process; one which travels its own unique path for each person (Anthony, 1993). Through evaluation of the focus group data, five categories emerged. Overcoming “stuckness”, discovering and fostering selfoempowerment, learning and self-redefinition, returning to basic firnctioning and improving all over quality of life were identified as being key to the recovery process. Again, mirroring the evaluation of the importance of empowerment, Miller (2000) purports that “recovery is now being recognized as holding the key to transformation for persons with serious mental disability” (p. 342). While there is still debate over whether or not recovery can occur (Ralph, 2000), it is agreed that it is a personal characteristic based on consumer perception, perhaps the most valuable tool of research. Evaluating this person-level characteristic may be imperative in helping to explain the variance among clubhouse outcomes. Anthony (1994) asserts that understanding the personal characteristics of persons with severe mental illness is imperative to understanding the dynamics that will facilitate successful entry into competitive employment (i.e., stress tolerance). What this calls for across rehabilitation models, is the need for attention to individual needs and concerns as 28 well as an understanding of their perception of the benefit of the services. Understanding the nature of these factors could potentially yield valuable information toward interventions that may increase employment outcomes for persons with severe mental illness. More recently, Kirsh (2000) asserted that individual characteristics have been examined, but overall have failed to report any conclusive findings on predictors of employment. The amount of research on various predictors that fail to provide any consistent findings is perhaps indicative of the need to explore other variables and their predictive value of employment outcomes. The need seems to indicate an examination of both individual and organizational characteristics and their predictive value in regard to employment. Kirsh (2000) answered this call in a study of 36 mental health consumers. The purpose of this study was to evaluate how individual and environmental issues impact the process of work integration. Kirsh sought to include factors such as empowerment, perceived social support, the climate and culture of the work environment and the person/environment “fit” in that investigation of factors related to employment outcomes. Kirsh administered the Interpersonal Support Evaluation List, the Empowerment Scale, the Workplace Climate Scale and the Organizational Culture Profile in order to gauge member perceptions. The 36 participants were placed in one of two groups: 1) competitively employed for at least 6 months and 2) persons who left competitive employment at least 6 months prior to recruitment. Descriptive analyses were provided for scores on the four instruments and t-tests were utilized to examine differences between the two groups on the dimensions of empowerment, perceived social support, organizational climate and person/environment fit. While Kirsh did not find any 29 significant results for empowerment or perceived social support, there were significant differences for organizational climate and person/environment fit. Organizational Characteristics that Influence Emploment Outcomes It is pertinent when discussing perceptions of the members and their comfort within the clubhouse setting, that you also address staff at the clubhouse. The staff, while not the focus of the clubhouse model, are integral to the clubhouse framework. The interpersonal interactions that exist between them and the members can have a strong impact on the atmosphere of the club, the values promoted at the club and more importantly on the members’ process of recovery. Russinova (199) reviewed the staff’s influence on psychiatric rehabilitation outcomes. While Russinova looked specifically at the staff’s ability to promote hope, the relationship drawn between staff training, hope, and member recovery were relevant to the current study. Russinova maintains that the staff/practitioners have the ability to promote hope in the recovery process, but also to provide resources and supports to assist with facilitating this process. This review inferred that professional qualifications were relevant in assessing whether or not professionals would be effective at providing resources to the member/client (e.g., job training, coping skills and resilience). Russinova (1999) also maintains that practitioners and staff have the responsibility to develop and provide needed resources. Without adequate training, it would be difficult to adequately perform these duties. Paralleling Russinova’s (1999) ideas on the importance of training and competence, Coursey, Curtis, Marsh, Campbell, Harding, Spaniol, Lucksted, McKenna, Kelley, Paulson, & Zahniser, 2000) echoed the call for specific competencies for staff. Coursey et al., first attempted to draw a distinction between competency and standards. 30 They maintain that standards provide guides for interventions, sets requirements and provide standardized procedures. While theses are important, they contend that competency is an individual level attribute that "entails proficiencies that are acquired and developed through study, training and experience” (p. 370). Again, in congruence with Russinova (1999) this indicates the personal responsibility staff must take in their role as stafl‘. From their effort, twelve competencies were agreed upon that were indicative of efficient staff training. Two of the competencies that stand out and are also relevant to the current study focus on collaborative relationships with external employment agencies and the knowledge to successfully implement programs core to the service model (e.g., employment). In an executive summary of a report on vocational options for persons with sever mental illness, Noble et al., (1999) explored the relationship between psychosocial rehabilitation and public vocational rehabilitation programs and suggested in order to provide optimal services to persons with severe mental illness, a strong partnership needed to emerge. Within the same report, Cook (1999) also alludes to the fact that a sincere collaboration needs to take place. Psychosocial rehabilitation and the vocational rehabilitation system need to gain an understanding of each others’ programs, so that the clients may be adequately served with the optimal available resources. Drawing on information from the aforementioned studies, it seems logical to surmise that there is a need for further research that exarrrines the relationship between the personal characteristics of persons with severe mental illness and employment outcomes. There exists a dearth of this information in the general literature and even less that looks at specific models with employment as a specific program outcome (i.e., the 31 clubhouse model). It is imperative within a service model that is client-centered to not ignore the consumer’s subjective views (Lustig & Crowder, 2000) regarding the impact of the services they receive. It is hoped that this study will not only point to factors that can be indicative of employment success, but also that the responses of participants will inform the field of what is conducive to their success, from their own point of view. This consumer perspective may necessitate a shift in focus on employment outcomes or it may identify factors that need to be reinforced in order to assist consumers with continuity in relation to employment. 32 CHAPTER 3 METHODOLOGY The purpose of this study was to determine which personal and organizational characteristics might contribute to successful employment outcomes. It was hypothesized that the high levels of participation in clubhouse activities, the members’ perception of their recovery and the nature of the clubhouse commmrity would facilitate successfirl employment outcomes. It was also anticipated that this study would further inform the field regarding employment outcomes for persons with severe mental illness; with a central focus on the specific aspects of the individual and the clubhouse that foster successful outcomes. This information, based on the member perceptions can greatly enhance planned services and target specific areas that may enrich the members’ perception of themselves and the clubhouse community. This chapter will provide information regarding subjects, instrumentation, procedures and the data analysis utilized in the study. The research questions addressed are: I 1) Is there a relationship between participant characteristics and employment outcomes? The characteristics examined are: a) length of clubhouse membership b) level of clubhouse participation 0) sense of recovery d) sense of community e) previous work history 33 2) Are there features of the clubhouse organizational structure that are related to employment status? The organizational features examined were: a) staff training b) type of employment programs available such as: transitional employment and supported employment c) relationship with external employment programs (MDCD-MRS) The design utilized in this study was developed to help answer the above questions and to evaluate the following hypotheses: 1) A combination of high clubhouse participation, a strong sense of recovery, and a strong sense of community will be related to employment outcomes of clubhouse members. 2) Specific organizational characteristics of the clubhouse including staff training, availability of specific employment programs at the clubhouse and external relationships with MRS will be related to clubhouse members’ employment outcomes. 3) A combination of both personal characteristics and organizational charac- teristics will yield the most predictive value of employment outcomes. Participants Description of Sample The sample for this study consisted of volunteers gathered from individuals who are members of a clubhouse and who participated in the Flinn Project, ln-depth 34 Consumer Interviews. The Flinn Project is a study conducted by Community Mental Health in conjunction with Dr. Esther Onaga of Michigan State University, which examined 40 clubhouses in Michigan. The criteria for the 17 clubhouses included in the Flinn Project In-depth Consumer Interview were that they: 1) were Medicaid enrolled; 2) had an effective date for Medicaid billing no later than June 30, 1998; 3) voluntarily completed a program assessment developed by Flinn Project researchers; and 4) were site-visited by Flinn Project researchers. Following the site-visits by Flinn Project researchers, all clubhouses that qualified for and received site-visits were contacted regarding individual interviews for members. Clubhouse managers voluntarily completed consent forms for the interviews to be conducted on-site and were to notify members and solicit volunteers. Each volunteer was compensated twenty dollars by the Flinn Project for their time and each clubhouse that consented received one hundred dollars. Once the Flinn Project was notified of the interest of volunteers to participate, the researchers set dates to again visit each club and interview approximately 15 members per club. A total of 17 clubhouses consented to holding individual interviews on-site. Two hundred and forty-five participants completed the Flinn Project In-Depth Interview. Each participant responded to several structured interview forms and scales as well as a series of open-ended qualitative questions. A power analysis (Cohen, 1992) was conducted with alpha at .05, conventional power at .80, a medium effect size (.30) and 8 predictor variables, indicated a minimum need of 107 participants. The final number of participants in the Flinn Project was 245 persons, with 91 (3 7%) of those persons reporting that they were currently employed. Subjects were those participants in the Flinn Project In-depth Consumer Interview. Data 35 for the initial Flinn Project In-depth Consumer Interviews were collected from August, 2000 through January, 2001. Instrumentation The instruments used in the Flinn Project In-depth Consumer Interview are a combination of established survey instruments and questionnaires developed by the Flinn Project researchers. An extensive review of the literature regarding the psychosocial rehabilitation model, clubhouses, other social and psychological literature, employment issues and employment outcomes for persons with severe mental illness yielded several research instruments that combined to form the Flinn Project In-depth Consumer Interview instrument. The structured in-person interview was comprised of the following content areas: 1) clubhouse participation, 2) relationships with staff and members, 3) employment, 4) social support networks, 5) health & medications, 6) history of mental illness, 7) mental health service use, 8) extent of daily functioning, and 9) demographic information. Segments of the structured interview contained standardized measures to assess specific constructs related to sense of community, relationships with clubhouse staff, and recovery from mental illness. The purpose of this study is to focus on employment outcomes and relationships between individual and organizational characteristics for persons with severe mental illness that are members of the clubhouse. With this in mind, for the present study, focus will be given to four specific instruments utilized with the Flinn Project, in addition to the demographic questionnaire. These instruments addressed clubhouse participation, employment, sense of recovery, and sense of community. 36 In order to assess organizational and operational characteristics of the clubhouse environment, program assessment surveys were also developed. Three measures comprised the program assessment survey: 1) organizational and operational structure of the clubhouse, 2) program level outcomes and 3) demographic information. The information to complete these survey instruments was gathered in three separate mailings to clubhouse managers and staff. Each clubhouse was required to return all three surveys in order to conduct individual member interviews at that location. Information gathered from the program assessment surveys involving staff training, employment programs available and connections to MDCD - MRS were all relevant to the present study. Together, data from these 4 person-level measures and 3 organizational characteristic measures provided the necessary information to evaluate the hypothesis of the present study. Each of these instruments, as well as the remainder of the In-depth Consumer Interview that will not be examined in this study were piloted on a group of voluntary consumers with severe mental illness who participate in a centrally located clubhouse. Their responses were not included in the follow-up data set. The pilot study allowed for a validity check on the clarity of questions and on the usage of appropriate prompts from the interviewers. The following section will give a description of each of the instruments used in the study for data collection. Club Em'cipatiop Iptgm’ew The Club Participation Interview (CP) was developed by the Flinn Project research team (see Appendix A). This structured interview protocol gathered pertinent information from the members regarding their participation in the clubhouse. The protocol queries frequency of attendance at the clubhouse, the length of time a member 37 has belonged to the clubhouse, how the member becomes involved at the clubhouse, what work-units they participate in while at the clubhouse and what, if any, leadership positions they have held at the clubhouse. This instrument gathered information from the participant on the level of participation (i.e., attending daily vs. attending once per month; leadership roles in the clubhouse vs. individual activity), the length of participation in the clubhouse and their overall satisfaction with the clubhouse. Data collected with this instrument addressed research questions one and two, as well as defining the independent variables: “length of participation” and “level of participation”. Length of participation was gauged by asking members: “How long have you been coming to the clubhouse?”. Members responded either in number of months or years. For data entry, any responses given in years were converted to months. The overall distribution of months was then broken into three categories: short-term (0-11 months), intermediate (12-60 months) and long-term (61 months and higher.) Table 1 illustrates the assigned score for this variable. Table 1 Participation Variables Scoring Participation Score Interval Time Frame Category Short-term l 0 - 11 months Intermediate 2 12 — 60 months Long-term 3 61 months and more Level of participation was a much more complex variable to devise, therefore it was broken into two parts. Mastboom (1992) describes clubhouse participation as, “the preparation for a higher degree of independence” (p. 12). Work is an essential function 38 of the clubhouse philosophy, however, membership within the clubhouse also allows for the building and sustaining of social networks. However, these two central factors are explicitly separate domains within the clubhouse program standards (Propst, 1992). It is for this reason that these two constructs were separated for this study. Level of participation was evaluated through “work participation” and “social participation”. Work participation is defined by participation in the work units that operate the clubhouse. These work units, which comprise the “work-ordered day”, allow members to take a stronger ownership over the club by maintaining the daily operations, while also providing an atmosphere for goal-oriented interactions with other members and staff. Typically members are placed within a specific work unit for a prescribed amount of time and then access other units for variety of experience and best match. Eventually members will settle within a unit that is most appropriate for them. It is important to note, however, there were local administrative differences to the implementation of this framework. For the purposes of this study, the units were grouped and scored according to four categories: 1) zero unit activity (0 units), 2) stable unit activity (1-2 units), 3) medium unit activity (3-6 units) and 4) high unit activity (7-9 units). The Club Participation instrument also provided valuable information regarding the social participation of members within the clubhouse. It not only accessed actual measures of participation (e.g., have you led a house meeting; are you a member of any clubhouse committees; and do you participate in any club social activities), but addressed social acuity (e.g., do you consider yourself a leader in the club) as well. The responses from these four questions were summed to create the social participation variable. A 39 score of ‘0’ equaled low social participation, a ‘1’ equaled medium participation and a score of ‘2’ equaled a high level of social participation. Emploupent Member Interview The Employment Member interview (EMP) was developed by Flinn Project researchers (Appendix B). Combining questions from the researchers’ extensive knowledge of employment outcomes and information gathered from the literature, the EMP is a structured interview protocol that consists of 46 questions. The EMP gathers information on current employment, employment history, length of time each position was held, hours worked per week, pay range for the position, what supports were received while in the position, who provided the supports and what accommodations, if any, were given. The information gathered from this instrument will give general background information on employment history, participation in transitional employment and length of employment terms (tenure or retention). Responses received fi'om this instrument (i.e., “are you currently working?”) will operationalize the dichotomous dependent variable: “employment” for the purposes of data analysis. This dependent variable measures whether or not members reported being employed at the time of the interview, and were scored ‘1’ if so and ‘0’ if not. Employment was scored ‘1’ regardless of whether it was competitive employment or not. This scoring for employment status was found to be acceptable by project researchers due to the “point-in-time” trait of the majority of the research instruments. It provides information on the current situation in which the member exists. Altogether, 37% of the participants in the sample (n = 245) held the “employ ” status. 40 Corriga_n Recoveg Scale The Recovery Assessment Scale will be used to assess recovery (Appendix C). The Recovery Scale is a 41-item, S-point Likert scale instrument designed to assess how people sometimes feel about themselves and their lives. A 1999 study conducted by Corrigan et al., reviewed the psychometric properties of a measure of the psychological construct of recovery. The Recovery scale resulted from an analysis of four narratives of persons with severe mental illness and their recovery process. The narratives yielded 39 items representing the construct. The items were then reviewed by a lZ-member group of consumers and ultimately a 41 -item measure was constructed. In order to determine the construct validity of the scale, a variety of psychosocial variables were selected. Measures of psychiatric symptoms and global ftmctioning ratings were utilized to assess the psychosocial impact of disability. The constructs of quality of life, self-esteem and empowerment were also utilized as positive measures of successful living. The Recovery Scale yielded test-retest reliability at r = .88 and Cronbach’s alpha showed that the test had stable internal consistency with alpha = .93. In regard to concurrent validity, recovery was associated with five of the psychosocial variables (e. g., empowerment, quality of life, social support, self-esteem, and psychiatric symptomatology), with four of the five meeting the Bonferroni Criterion for significance. Overall, the authors found that the construct of recovery is described by a complicated network of associations with other psychosocial concepts (Conigan, Giffort, Rashid, Leary, & Okeke, 1999). Despite examining recovery according to these various psychological constructs, Corrigan et al. neglected to develop solid subscales to their 41 overall recovery scale. Due to the complexity of this concept and the lack of general consensus in the literature regarding the nature of the phenomenon (Young & Ensing, 1999), the Flinn research team collectively examined the instrument and in congruence with the literature (Young & Ensing, 1999; Ralph, 2000; Harding & Zahniser, 1994), developed five subscales of empowerment. Managing illness, hopefulness, self-efficacy, purpose in life and social support are the five subscales that evolved from the Flinn analysis. Reliability analyses were run for each subscale. Managing illness consisted of thirteen items involving questions that gauge the members’ able to effectively understand and deal with their mental illness (e.g. “I understand how to control the symptoms of MI”), and had an alpha of .88. The Hopefulness scale included seven items that reviewed the member’s perception of hope and belief in themselves. This scale had an alpha of .85. Eleven items comprised the Self-efficacy subscale. This scale, with an alpha of .87, was comprised of items such as: “if I keep trying, I will continue to get better”. The Purpose in life scale included 6 items. Statements like: “I have a desire to succeed” comprised this subscale, which had an alpha of .81. The final subscale, Social Support, referred to the outside network of support and consisted of 4 items. Combined questions like: “I have people I can count on”, had an alpha of .74. For the purposes of the current study, in order to determine the overall recovery of each member, the individual item scores were combined into a total score. Based on this continuum, persons with higher scores equated to those with a stronger sense of recovery. 42 Sense of Community Sense of community, or the social network that evolves fi'om it, is a core factor within psychosocial rehabilitation and inherent to the clubhouse model. A community may be viewed as a group of people in a shared environment and in a social relationship (Webster’s Dictionary, 1992). Sense of community is one of three concepts of cohesion. Buckner (1988) sought to find a high sense of community based on factors such as “the existence of a common goal, clear criteria for who belongs to the group, ...and a shared set of values” (p. 773). This goal was consistent with the Flinn project’s goal of understanding what the ‘clubhouse community’ means for each member. The Flinn research team also believes that a strong sense of community within the clubhouse can be expected to influence a number of outcomes such as: recovery, and quality of life. The original version “Neighborhood Cohesion Instrument” (NCI) (Buckner, 1988) consisted of three rationally derived scales measuring attraction to neighborhood (10 items), neighboring (15 items) and psychological sense of community (15 items). Thirty-nine discriminating items resulted from the first analysis across neighborhoods. Of those, two were discarded for low test-retest reliability. The average test-retest for the remaining thirty-seven was r = .80. The scale was found to have high intercorrelations with other scales and so one common scale comprised of the sense of community, attraction-to- neighborhood, and the degree of neighboring was adopted and termed at the individual level construct of “sense of community/cohesion”. Internal consistency for this unidirnensional scale had an alpha level of .97. For the purposes of the Flinn project, nine items from the Buckner scale were used and eleven items (Appendix D) were developed through concept mapping by the 43 research team. Together these twenty items (Table 2) had an internal consistency of .91 , a mean score of 4.31 and a standard deviation of .78. A total score was computed to give a sense of community score for each member. The higher the total score, the stronger sense of community the member reported. Table 2 Sem pf Community Items Variable Item *SOCI I feel like I belong to this clubhouse *SOC2 Friendships mean a lot to me *SOC3 If people in my club were planning something, I’d think of it as what we’re doing rather than what they’re doing SOC4 I could go to someone in the clubhouse for advice *SOCS I agree with most in the club about what is important in life SOC6 I feel loyal to members in the club *SOC7 I feel loyal to staff in the club *SOC8 I’m willing to work with others to improve the club SOC9 I plan to remain a member for years *SOC10 I like to think of myself as similar to others in the clubhouse SOCII A feeling of fellowship runs deep between me and staff *SOCIZ A feeling of fellowship runs deep between me and members *SOC13 Being a part of club gives me sense of community SOC14 Being part of club helps me deal with MI SOC15 Being part of club helps me have hope for the future SOC16 Belorging to club reduces m SOC17 Being a member gives me a place to o SOC18 Being a member help me learn new skills SOC19 Being a member gives me chance to find paid work SOC20 Being a member gives me something meaningful to do Note: "' indicate items fi'om Buckner (1988) scale 45 Demographic M'onnaire The demographic questionnaire (Appendix E), which was also developed by Flinn Project Researchers, was completed during the In-depth Consumer Interview. The questionnaire was administered following the administration of the remainder of the interview protocol. The questionnaire gathers information on the participants’ diagnosis, age, gender, ethnicity, religion and spirituality, and level of education. This information was utilized in order to provide comparison information to clubs throughout the state of Michigan as well as throughout the United States. These comparisons allow for the ability to cautiously generalize the results to the SMI population who accesses clubhouses in the state of MI (Appendix F). ngzarp Assessment Qr_r_estionnaire The program assessment questionnaire (Appendix G), which was developed by Flinn Project researchers, was administered to clubhouse managers. This questionnaire was compiled based on information regarding the criteria for ICCD standards for clubhouses as well as Medicaid/Medicare requirements for clubhouses in the state of Michigan. The total questionnaire consisted of three forms that addressed: 1) clubhouse administration and operations, 2) program level outcomes, and 3) demographic information on members who access the clubhouse. From Survey I: Clubhouse Administration and Operations, information regarding the variable determining a relationship with MDCD-MRS was gathered. Clubhouses responded to the questions: a) is there a cash match agreement established between MRS and Community Mental Health (CMH) and b) were there agreements for fee-for-service contracts. The responses (0 = no and l=yes) for these two questions were summed to 46 create the ‘MRS relationship’ variable. Clubhouse scores on this variable were categorized as: 0 = no relationship, 1=some involvement and 2=strong relationship. The overall clubhouse scores were then assigned to each individual member in the corresponding clubhouse. From Survey I]: Program Level Outcomes, information on the availability of employment programs supported at the clubhouse was collected. From the program assessment Survey II, each clubhouse staff was asked to respond to the number of transitional employment slots they owned, the number of persons enrolled in supported employment and the number of persons competitively working. Any number from 1 through the highest on each of these questions was coded as ‘1 = program present’ and 0’s were recorded as ‘0 = no program present’. The score from each category was summed to become the final score for the clubhouse. These total scores were ‘0’ for minimal employment offerings, ‘1’ for average amount of employment offerings and ‘2’ for an optimal amount of employment offerings. Again, the overall clubhouse scores were then assigned to each individual member in the corresponding clubhouse. Program Assessment Survey HI: Demographic Questionnaire provided information regarding staff training. A count was taken for each club of how many full time staff were at the club. Questions from Survey III regarding staff participation in clubhouse training and ICCD training were totaled to create the “staff training” variable. These scores ranged from 1 -—3 with ‘1’ representing a low level of training (i.e., not having received either training), ‘2’ representing an average level of training (i.e., having received at least one of the trainings) and ‘3’ representing having received both trainings 47 (i.e., a high level of training). These clubhouse scores were assigned to each individual member in the corresponding clubhouse. Several of the previous variables described, are composite variables, which represent combined items from the various instruments. The following table (T able 3) illustrates the reliability values for the composite variables: sense of community, sense of recovery, social participation, clubhouse participation, and MRS relationship. Table 3. Reliability Analysis of Comp_osite Variables Composite Variable Number of Cases Number of Items Alpha Sense of Community 223 21 .8840 Sense of Recovery , 199 41 .9538 Social Participation 239 4 .0116 Clubhouse Participation 236 3 .3211 (work participation, social participation, length of participation) MRS Relationship 13 (out of 17 clubhouses) 2 -.0625 Procedures The Flinn Project received initial approval and funding through the Department of Community Mental Health in the State of Michigan in order to examine the practices of clubhouses in Michigan. A partnership was forged between Michigan State University Professor Esther Onaga, Ph.D. and the principal researchers from the Department of Community Mental Health. The results received from the study will be utilized to observe and understand the best practices of Michigan clubhouses to inform the ICCD 48 clubhouse standards as well as to potentially improve practices of clubhouses in Michigan. Due to the nature of this study and the involvement of hmnan subjects, an application was submitted to the University Committee on Research Involving Human Subjects (U CRIHS) for approval. Approval to initiate the research study was received in September of 1999, with the most recent approval received December 2000 (Appendix H). Upon receiving approval of UCRIHS, the data collection process was initiated. Each Medicaid enrolled clubhouse in Michigan was offered the opportunity to participate in the project by completing a three-part clubhouse survey which covered administrative aspects of the club as well as a description about the activities and membership of the clubhouse. In return for completing the survey, the clubhouse was paid $100. Thirty-five clubhouses completed the survey and volunteered to be site visited by the research team. Since it was not financially feasible to visit all 35 clubhouses, the research team developed a method to select a representative sample of Michigan clubhouses. The first step was to rank the clubhouses by their organizational score on a ‘Values Survey’ that was completed by administrators, staff, and members of the clubhouse. A mean score was derived to rank the clubhouses on the extent that people within the club valued core principles of the clubhouse. Using this score, a representative sample was identified across the continuum of clubhouse values. In addition several variables from the program assessment were considered. They included: age of clubhouse program; urban vs. rural; % of members working; size of the clubhouse and whether they had sent staff to ICCD training. 49 Seventeen clubhouses who met the following criteria were included in the data collection: 1) were Medicaid enrolled; 2) had an effective date for Medicaid billing no later than June 30, 1998; 3) voluntarily completed a program assessment developed by Flinn Project researchers; and 4) were site-visited by Flinn Project researchers during an earlier phase of research. Each Flinn team member participated in a training that reviewed the interview questions and discussed appropriate prompts for further information, and prior to data collection, a pilot of the survey instrument was conducted with 6 members of a local clubhouse. Following those interviews, interviewers requested that respondents give information regarding the clarity of questions and other feedback information. Researchers collectively reviewed these suggestions and their feedback regarding the process and collectively made revisions to the instrument. These revisions were submitted to UCRIHS for review and were approved. The data collection for the In- depth Consumer Interviews proceeded as follows. Each clubhouse that received a site- visit was contacted regarding the opportunity to have members participate in individual interviews. A packet (Appendix I) was mailed to the clubhouse managers and the entire clubhouse membership briefly describing the nature of the project and the content of the in-depth interviews. The clubhouses interested in participating notified the research team to coordinate the on-site interviews. Once notification of interest was obtained, (Appendix J) clubhouses were provided flyers advertising the project, and “consent to contact” sign-up forms for members. A letter describing the project, the nature of the interviews, and right to 50 confidentiality was attached to a “consent to contact” form. Volunteers were asked to return the “consent to contact” form to the research office. Once the research office received the ‘consent to contact’ forms, members were scheduled for an interview according to available times. A maximum of 15 interviews were allocated for each clubhouse. Therefore volunteers were selected on a ‘first-come, first-serve basis.’ A waiting list with alternates was used in case scheduled interviewees failed to show for an interview. A reminder letter about the interview date and time was mailed to the clubhouse of each scheduled participant. In addition, participants with legal guardians were required to obtain consent (Appendix K) prior to scheduling an interview with the research team. A maximum of 15 structured interviews were scheduled for the one-day on-site interviews. Four to five research team members conducted interviews at each participating clubhouse. One on one interviews were conducted in a private area at the clubhouse or at a nearby facility. Consent fiom each member was obtained prior to the start of the interview (Appendix L). Each interview was approximately one hour in length. Interviewees were paid $20 for each completed interview and the clubhouse was paid $100 for hosting the on-site interviews for the day. The structured in-person interview was a combination of standardized measures and instruments designed by the research team. It comprised the following content areas: 1) clubhouse participation, 2) relationships with staff and members, 3) employment, 4) social support networks, 5) health and medications, 6) history of mental illness, 7) mental health service use, 8) extent of daily functioning and 9) demographic information. 51 Participants’ confidentiality was protected with the utilization of an identification number that would correspond to their clubhouse. The identification number was utilized on all instruments instead of names to maintain confidentiality. Only the primary researchers as well as the Flinn Project research team would be privy to the specific contact and demographic information of participants. Data for this study were collected from August 2000 through January 2001. Throughout the interview process, interviewers kept notes of questions that arose during the interview. Prior to data entry, these questions were reviewed and consensus was reached amongst the group on how to appropriately score responses for data entry. DLsiIru The present inquiry falls within the definition of a descriptive design. According to Heppner et al. (1992), the relationships that exist between or amongst variables can be examined through descriptive research. Qualitative and various modes of quantitative research fall within this category. For the purposes of this study, survey research was utilized to examine the relationship among several variables. While descriptive designs have traditionally received less than favorable attention, due to the lack of “experimental conditions”, various conditions have enhanced the strength of this study. One such factor that strengthens the descriptive design of the present study is the “face-to-face interview” mode of data collection. One of the largest disadvantages to descriptive designs and more specifically survey research is the low return rate of mailed questionnaires, which typically yield a 30% return rate (Heppner et al., 1992). While mailed questionnaires present the least expensive option, the low rates of return often compromise the generalizability of the research findings. Data collection 52 for this study was conducted face to face. This mode of data collection was also most helpfirl for the population examined. It is assumed that the information that was gathered will be illustrative in showing the impact of clubhouse membership and the organizational structure on employment outcomes. Finally, the combination of qualitative and quantitative methods increase the modes through which information is obtained and thus provides stronger evidence for the validity of results produced The independent variables to be included in this inquiry are: 1) length of clubhouse membership; 2) level of clubhouse participation; 3) sense of recovery; 4) sense of community; 5) previous work history; 6) staff training; 7) the availability of employment programs; and 8) external employment supports. The dichotomous dependent variable included in this investigation is: 1) employment status: employed/unemployed. Data Analysis Descriptive statistics were computed for each predictor and outcome measure, as well as on demographic information received. This information helped to provide general descriptions of the participants in the study as well as allowed for comparisons to statewide data Frequency calculations for each of the predictor variables were also conducted in order to reveal any patterns in the data. What was needed in order to statistically analyze the data, was a technique that would classify clubhouse members into mutually exclusive/exhaustive groups based on a set of individual variables. Hence, in order to address the research questions, discriminant function analysis was utilized. Williams (1992) asserted that, “discriminant analysis helps determine how a linear combination of multiple variables might differentiate individuals into some given group of categories” (p. 195). There are 53 typically two applications of discriminant analysis. The first being, determining the degree to which persons who belong to different groups can be categorized according to various discriminator variables (for example, employed members compared with unemployed members in terms of work history, sense of recovery, etc.). The other use is to group individuals into groups, given the results of previous analyses of an existing relationship between the discriminating variables and the groups (for example, predicting whether members are likely to be employed or unemployed). By using this method, what is essentially being asked is: “What is the maximum linear relationship or relationships of a cluster of variables with a variable that is divided into categories” (Williams, 1992, p.200). In this particular study, the cluster of variables that were more likely to give a maximum relationship in relation to employment status, were examined. According to Dillon and Goldstein (1984), the correct classification of individuals into groups is an important performance measure of discriminant analysis. This statistic fit most with attempting to correctly classify clubhouse members as being employed or unemployed at the time of the interview. Within discriminant analysis there is an option for the function to equally weigh the cases or to select the weight based on the actual proportion of persons employed within the sample. The selection of the a priori defined groups based on the actual proportion within the sample works to improve the rate of accurate classification (Dillon and Goldstein, 1984). In addition to this, there is also a desire to understand on which dimensions or how the two groups differ. Again, this analysis was most helpful in trying to address the hypotheses about personal characteristics and organizational characteristics and their ability to correctly classify members. Thus, in discriminant analysis and more 54 importantly, in relation to the current study on employment outcomes of clubhouse members, discriminant analysis allowed for both prediction and explanation (Dillon and Goldstein, 1984). Additional discriminant analyses were conducted in order to provide better classification rates, using standardized z-scores of the continuous variables and other tests of correlation to understand the relationship between the predictor variables selected and the outcome variable of employment status. Lastly, the .05 level of statistical significance will be used as the minimum level of rejection throughout all statistical analyses. 55 CHAPTER 4 RESULTS Sample Characteristics The 245 persons from the 17 clubhouses in the Flinn Project sample, who participated in the member interviews, were collected as a convenience sample. There were four persons who declined to participate in the study; they did not differ from the research sample in demographic or other background characteristics. The clubhouse members participated in hour-long interviews between August 2000 and January 2001. All 17 clubhouses provided consent for the Flinn Project to conduct interviews on-site at the clubhouses. The clubhouse staff posted flyers from the project that assisted with the recruitment of volunteers. Each clubhouse was compensated $100 for the usage of the club during interviews and each club member was paid $20 for participating in the Flinn study. The sample was comprised of approximately an equal number of men and women. One hundred and eighteen men (48.6%) and 125 women (51.4%) participated in the research. The participants ranged in age from 18 years of age to 66 years of age (M = 43 years). The interview sample is characterized by a large number of Caucasian members (200 at 82%). Afiican Americans comprised the second largest group with 23 members participating (9.4%). Eight Native Americans participated (3.3%), 10 persons who identified themselves as Multi-racial (4.1%), one person that identified as Latino (.4%) and one person who identified as Arab American (.4%). See Table 4 for 56 demographic characteristics. It is relevant to note that the sample population was not comprised of similar proportions to statewide data on ethnic minority involvement in the clubhouse. Statewide data on clubhouse participation for FY2000, indicated a smaller percentage of Native Americans (7%), and persons who reported being Multi-racial (.5%), but the state population does report a higher percentage of African Americans (13%) represented. The state population does indicate a representation of Asian American/ Pacific Islanders at .7%, which was not represented in the Flinn sample. Table 4 Demographic Chmcteristics of Sample Variable Number of Percentage of Sample Cases Gender Males 1 18 48.6% Females 125 5 1 .4% Total 243 Ethnicity African- 23 9.4% American Arab American 1 .4% Caucasian 200 82% Latino 1 .4% Multi-Racial 10 4.1% Native American 8 3.3% Other 1 .4% Total 244 Employment Employed 91 37% Unemployed 1 54 63% Total 245 57 Table 5 illustrates the level of education across participants. The educational status of clubhouse members interviewed varied, but was equally distributed throughout the sample. Approximately 37% of the sample had received a high school diploma or equivalent, and nearly 30% have had some college education. Thirteen percent were enrolled in an educational program at the time of the interview. Approximately 3% were preparing for the GED and 4.6% were attending college. A small number of respondents were participating in supported education (1.6%), and close to 4% were involved in some form of continuing education. Less than 1% reported being involved in a vocational training program. In addition, while the majority of respondents (87%) were not currently enrolled in an educational program, more than half of the sample indicated that they would like to continue their education at some point. 58 Table 5 Educational Characteristics of Sample Variable Number of Percentage of Sample Cases Educational Status No formal education 1 .4% 1st - 8‘“ grade 7 2.9% 90: — 12th grade completed, less 39 16% high school diploma High school diploma 77 31.6% GED 13 5.3% Some college, less than degree 65 26.6% Professional degree or educational 11 4.5% certificate Associate Degree 12 4.9% Bachelor Degree 16 6.6% Master Degree 3 1.2% Members reported membership ranging from 0 months to the outlier of 336 months at the clubhouse (M = 46, approximately 4 years). Again, the length of time members participated in clubhouse activities was divided into 3 categories: short-term, 59 intermediate, and long-term. Of the 245 persons who agreed to participate, the majority of persons were in the intermediate category, which spans from 1 to 5 years. Table 6 Characteristics of Clubhouse Participation Classification Number of Cases Percentage of Sample Short-term 46 19% Intermediate 13 1 53.5% Long-term 68 28% Discriminant Function Analysis A Discriminant function analysis was performed using ten variables as predictors of employment status. Sense of community, sense of recovery, previous work history, length of membership at the clubhouse and level of participation at the clubhouse (defined by two variables: work participation and social participation), level of staff training, relationship with MRS, and employment program availability. The dichotomous employment grouping (employed/unemployed) was the outcome variable evaluated. The Discriminant function analysis of employment status with this group of variables did not reach statistical significance (x2 = 7.453, p = .682), and also had a low canonical correlation of .21. The lack of correlation between all variables did not support 60 the hypothesis that a combination of individual and organizational characteristics would provide the best linear combination to allow for classification of employment status. This prediction was based on previous research reporting the significance of both individual and organizational characteristics being the best predictors of improved employment outcomes (Kirsh, 2000; Russinova; 1999). The combination of the current variables yielded an overall 63.7% correct classification of persons who are employed or unemployed (Table 7). However, only 12.1% (n=1 1) of the persons employed were correctly classified. Table 7 Classification Results of Emploment Status Employment Status Observed Count Predicted Count Employed 91 ll Unemployed 1 54 145 Clearly there is error preventing the correct classification of the employed group. This combination of variables did not adequame discriminate (Table 7). These standardized figures are indicative of variables that would be better predictors of employment. Table 8 illustrates that sense of recovery has the largest value and thus can be assumed to be a better predictor (canonical coefficient = .667). Whereas a lower value of .158 (coeflicient for previous work history) would have less predictive value and would lessen the overall ability to adequately discriminate between the two groups. 61 Table 8 Standardizfi Canonical Discriminant Function Coefficients Variables Measured Function Coefficient Sense of recovery .667 Work participation (a measure of .594 level of participation) Staff training .391 Weekly attendance(a measure of -.335 level of participation) Availability of employment .302 programs Relationship with MRS .198 Length of participation -.180 Previous work history .158 Sense of community -.162 Social participation (a measure of -.109 level of participation) Table 9 represents the tests of equality of group means. The large values for Wilk’s lambda are also indicative of the lack of distinction between the two groups ~ (employed/unemployed). 62 Table 9 Tes of i of Grou Means Variables Measured Wilk’s Lambda F dfl d0 Significance Sense of recovery .990 1.794 1 178 .182 Work participation (a .989 1.922 1 I78 .167 measure of level of participation) Staff training .992 1.412 1 178 .236 Weekly attendance(a .995 .819 l 178 .367 measure of level of participation) Availability of .998 .307 1 178 .580 employment programs Relationship with MRS 1.000 .001 l 178 .969 Length of participation .998 .274 1 178 .602 Previous work history .999 .245 l 178 .621 Sense of community 1.000 .027 1 178 .870 Social participation (3 1.000 .002 l 178 .963 measure of level of participation) The loading matrix, Table 10 illustrates which of the variables would be best at discriminating between the employed and unemployed group. These values however should be interpreted cautiously, as none of the values carried any significance. 63 Table 10 Structure Matrix Variables Measured Function Work participation (a .495 measure of level of participation) Sense of recovery .478 Staff training .424 Weekly attendance(a -.323 measure of level of participation) Availability of .198 employment programs Length of participation -.187 Previous work history .177 Sense of community .059 Social participation (a .017 measure of level of participation) Relationship with MRS .014 According to the structure matrix, two predictor variables (participation in work units and sense of recovery) have loadings near .50, which separates employed members from unemployed members. Typically, however, loadings less than .50 are not interpreted (Tabachnick & Fidell, 1983). Another analysis was run to evaluate the hypotheses that sense of recovery, participation and sense of community would better classify persons who were employed. Again, the discriminant firnction analysis of employment status with this group of variables did not reach statistical significance (x2 = 4.608, p = .203), and had a low canonical correlation of .138. Table 11 illustrates the structure matrix with the loadings of the individual variables. Here again, sense of recovery has a high weight toward predicting employment. Table 11 Structure Matrix for Individual Characteristic Hymthesis Variable Measured Function Sense of recovery .998 Sense of community .405 Length of Participation .1 l6 Despite this high correlation of the sense of recovery scale with the discriminant function, the classification rate correctly identifying persons who were employed was at 0% and 100% for persons who were unemployed. In addition, in order to evaluate the hypothesis that organizational characteristics of the clubhouse would assist in the classification of persons who were employed, yet another discriminant analysis was conducted. This analysis yielded similar results. The structure matrix again indicates variables with significant loading value on the discriminant function (Table 12). The discrinrinant function analysis of employment status with this group of organizational variables did not reach statistical significance (X2 = 2.301, p = .511), and also had a low canonical correlation of .111 and a large Wilk’s lambda of .988, which again illustrates the difficulty in discriminating between the dichotomous variable. The lack of correlation between these variables did not support the hypothesis that a combination of organizational characteristics would provide a linear combination that would be predictive of employment status. 65 Table 12 Structure Matrix for Organizational Variable Hypotheses Variable Measured Function Staff Training .793 Availability of employment .222 programs Relationship with MRS .214 Of the original 245 cases, 65 were dropped from analysis because of missing data. One hundred and eighty cases were evaluated. Missing data seemed to be primarily concentrated amongst the organizational characteristics (staff training, relationship with MRS andemployment program availability) (Appendix L). Due to this large number of dropped cases, as well as the low loadings among the organizational characteristics and other variables, (specifically relationship with MRS and availability of employment programs), these variables were dropped and a second discriminant analysis was conducted. Previous work history, despite it’s low value in the first analysis was retained for the second due to previous research linking work history to successful employment outcomes (Rogers, Anthony, Toole & Brown, 1991; Anthony, 1994; Mowbray, Bybee, Harris & McCrohan, 1995). The second discriminant analysis yielded non-significant results as well. The sense of recovery predictor variable, consistently (throughout the variation of variables) has a loading in excess of .50 on the discriminant firnction. Also throughout the various analyses, the sense of community variable has had a consistent negative loading (negative according to the group centroids) toward unemployment. While the loading for this 66 variable does not exceed .50 and thus according to Tabachnick and F idell (1983) should not be considered, it has consistently had a negative value which is indicative of a prediction for unemployment. Table 13 illustrates the structure matrix loadings for the second discriminant analysis. Table 13 Structure Matrix for 2'“I Discriminant mixes Variable Measured Function Sense of recovery .749 Previous work history .438 Work participation .389 Staff training .268 Sense of community -.O31 * values are standardized The overall significance for all of the variables was alpha = .297, with a low canonical correlation of .162. Similar to the first analysis, the test of equality for group means, yield a significant score for sense of recovery at p <.05, where F (l, 231) = 3.850. Despite these consistent significant findings for sense of recovery and it’s predictive weight of employment, the classification table produced a lower rate of prediction than did the initial analysis. Three point four percent of the persons working were correctly classified. 67 Table 14 Classification Table of Analysis II Employment Status Observed Count Predicted Count Employed 85 4 Unemployed 148 143 Summgy of Hyp_otheses In order to summarize the findings of this research study, the research hypotheses will be restated. Hypothesis 1: A combination of high clubhouse participation, a strong sense of recovery, and a strong sense of community will be related to employment outcomes of clubhouse members. Results of discriminant analysis of these specific variables showed no significance (p S .203) in their ability to correctly classify clubhouse members who were employed or unemployed. Although sense of recovery did illustrate significance (p 5 .05) and had a strong loading toward employment (.998), which indicates the strength of its correlation to the flmction, there was no accurate classification (0%) for persons who were employed. Hence, the analysis did not provide support for the hypothesis that this combination of variables would supply the best linear combination in order to correctly Pmdict employment classifications. HYpothesis 2: Specific organizational characteristics of the clubhouse including staff training, availability of specific employment programs at the clubhouse 68 and external relationships with MRS will be related to clubhouse members’ employment outcomes. Discriminant analysis did not show significance (p S .551). The correlation between these variables was low at .111. The level of staff training did have a strong loading on the Discriminant function, however, unlike sense of recovery it was not significant (p _<_ .226). The rate of accurate classification for employment outcomes again, was 0% for persons who were employed. This analysis did not provide support for these variables’ to correctly distinguish between employment and unemployment. Hypothesis 3: A combination of both personal characteristics and organizational characteristics will yield the most predictive value of employment outcomes. Both initial and secondary discriminant analyses for the combination of these variables yielded insignificant results. The discriminant analysis for the first analysis yielded a X2 = 7.458 (p =.682) and a canonical correlation of .205. The score for the second discriminant analysis, which looked only at variables with strong weights from the first analysis, yielded a X2 = 6.094 (p =.297) and a canonical correlation of .162. The classification rate for the first analysis for persons employed was 12.1%, which was the highest classification rate received. Even for the second analysis, which focused on those variables with stronger weights, only 4.7% of the people who were employed were correctly classified. Thus again, it stands to reason that the analysis conducted does not 69 provide support for this hypothesis and the strength of this group of variables to discriminate between employed and unemployed clubhouse members. 70 CHAPTER 5 DISCUSSION S_um_m_arv of Results The main purpose of this study was to I) examine the relationship between member characteristics (i.e., sense of recovery and community) and employment success for club members, and 2) to gain an understanding of the organizational characteristics of the clubhouse, which contribute to successfirl employment outcomes. This was accomplished through evaluating the ability of these variables to correctly predict the employment group membership of clubhouse members. The ultimate desire for this research was to inform the field of what individual factors can be further enhanced by the clubhouse model and how these factors in conj unction with organizational characteristics can enhance employment outcomes for clubhouse members. The discussion of these results will focus on the following research questions: Is there a relationship between participant characteristics and employment outcomes? The characteristics examined were: a) length of clubhouse membership b) level of clubhouse participation c) sense of recovery d) sense of community e) previous work history 71 CHAPTER 5 DISCUSSION Mary of Results The main purpose of this study was to I) examine the relationship between member characteristics (i.e., sense of recovery and community) and employment success for club members, and 2) to gain an understanding of the organizational characteristics of the clubhouse, which contribute to successful employment outcomes. This was accomplished through evaluating the ability of these variables to correctly predict the employment group membership of clubhouse members. The ultimate desire for this research was to inform the field of what individual factors can be further enhanced by the clubhouse model and how these factors in conjunction with organizational characteristics can enhance employment outcomes for clubhouse members. The discussion of these results will focus on the following research questions: Is there a relationship between participant characteristics and employment outcomes? The characteristics examined were: a) length of clubhouse membership b) level of clubhouse participation c) sense of recovery d) sense of community e) previous work history 72 Are there features of the clubhouse organizational structure that are related to employment status? The organizational features examined were: a) type of employment programs available such as: transitional employment and supported employment b) existence of relationships with external employment programs/organizations. c) staff training The methodology utilized to evaluate these questions involved administering interviews to clubhouse members throughout the state of Michigan. The interview instrument contained several standardized measurements on sense of recovery and sense of community as well as measures developed by the Flinn project research team. Information regarding the level and length of participation, prior work history and the members’ perception of their sense of community and recovery were gathered from those interviews. Organizational information regarding the clubhouses training was gathered from the Program Assessment Surveys, which were mailed to clubhouse managers and staff to complete. Together information from these instruments was utilized to evaluate the questions of this study and to help examine the strength of the hypotheses. The first question looked specifically at individual characteristics. Although prior work history and type of involvement in the club were also pertinent to the study, an earlier review of the literature sparked an interest in these specific concepts. The results of the analysis did not reveal significant differences in the prediction of employment based on these variables. The inability of the SPSS program to distinguish between the a 73 a stronger predictor of employment classification than together with other variables with weaker discriminant loadings. If you look at recovery as an on-going process of change, growth and discovery (Stocks, 1995) as suggested by some survivor/consumers, then it might be usefirl to also examine readiness to change and change behavior before examining other individual characteristics in regard to employment outcomes. Ralph (2000) revealed an interesting point to understanding the impact of recovery. She questions whether or not it is a concept that can be measured, and if so, what are the consequences. This is thought provoking, specifically since recovery is such an individual process, how can service providers work to increase it? What will the training entail in order to help them foster it and maintain it? In regard to the second hypothesis, similar issues arise. There were no significant findings of the discriminant analysis, which would indicate that the organizational characteristics of staff training, availability of employment programs, or relationships with vocationally based organization (e.g., MRS), were good predictors of employment outcomes. Specifically in regard to these variables, when examining possible reasons for the lack of significance, it is pertinent to reflect on the construction of these variables. Each of these variables were taken from the Program Assessment Surveys and were constructed based on like items and item sums. It is possible that the construction of the variables were unreliable and hence made them unreliable predictors. Another important consideration is to further explore the meaning behind the variables. While the general hypothesis regarding staff participation in clubhouse, ICCD training, clubhouse employment offerings (TE and SE) or club relationship with MRS was explored, there is 74 no way to gauge the depth of these connections or the extent to which they may influence employment outcomes. Staff training was also found to have a higher correlation to the discriminant function, although it was not found to be significant. This may reflect the inability of the variable that gauges whether or not staff has received training to directly impact employment outcomes of members, without understanding the impact of the training on the staff. If as a result of training, staff’s ideology or adherence to the psychosocial rehabilitation philosophy is changed from participating in training, this would appear to be a better indicator of impact on member outcomes. Russinova (1999) maintains, that staff must have the understanding and knowledge of how to interact with clients in order to be able to effectively serve them. Perhaps for future research the better question in regard to this hypothesis is not so much if the staff has been trained, but what was the impact of them receiving that training. The final hypothesis that looks at the combination of personal characteristics and organizational characteristics also did not have any significant predictive value. This hypothesis served as a combination of the previous two hypothesis to look at the total impact in a person X environment manner. Kirsh (2000) examined the impact of demographic variables and found little significance as well of their predictive value. She contends that her study implies that a further look into the perception of the member in the moment and that the culture and the climate of the place of employment or in this instance, the clubhouse, are as imperative to predicting outcomes. Chatrnan (1989) also reported that the congruence between personal and workplace values is an important feature which impacts work for the general population. This is also true for persons with 75 severe mental illness. Unfortunately, within the confines of this research study, the individual and organizational characteristics examined held no predictive value of employment outcomes. There was no statistical support for this hypothesis. Again, the most obvious reason for this discrepancy with the literature appears to be the reliability of several of the composite predictor variables (refer to Table 3). One other important issue to consider, is the potential limitations created by the criterion variable. The overarching interest within this study was for general employment outcomes. Employment status was measured as “currently employed” in any capacity or “not currently employed’. For that reason, specific types of employment (SE, TE, or CE) were not separately examined during data analysis. A specific examination of these employment characteristics would have significantly decreased the sample size of the study, and therefore was not conducted. However, it is plausible that probing into these various types of employment might have yielded different outcomes and varying levels of significance of the criterion variable on the predictor variables utilized. The employment opportunities available in each community that houses the clubhouse can also be regarded as a potential limitation to this study. Clubhouses are entities that exist within the community. Community employment for clubhouse members is not only desired, but a key element of clubhouse standards (Propst, 1992). Consequently, the employment trends within the community are also relevant to the success of the employment of clubhouse members. Throughout this examination, these community trends were not examined. However, the impact of community employment trends and the community setting (urban vs. rural) can be relevant to the success of the clubhouse programs. Appendix N illustrates general employment rates for the various 76 areas/regions where clubhouses reviewed in this study are located. In future examinations, it would be relevant to examine these trends and their confounding impact on the employment success of clubhouses. The following section will address other limitations that existed within this research project. Limitations The results and conclusions yielded from this study should be interpreted with an awareness of the study’s limitations. The first limitation that needs to be noted is the possible effect of the “purposeful” sample. The limited selection criteria of the 17 clubhouses that participated in the project may have affected the amount of variability among clubhouses and may have influenced the overall nature of the sample. Again, this selection was based on a rank of the clubhouses by their organizational score on the ‘Values Survey’ that was completed by administrators, staff, and members of the clubhouse. From this variety of clubhouses, members volunteered to participate. The most prevalent concern here is in regard to the lack of variance within the sample. While the sample does represent the population of the state of Michigan, it still appears to be a somewhat homogeneous group. There could be several reasons for this. Possibly, members replied in a socially desirable manner perhaps as a “perceived” obligation for being compensated. It is feasible that the clubhouse staff encouraged certain members to participate in the study and it is also possible that the group of persons who access the club most regularly are a somewhat homogenous group and they are the ones most likely to be involved in activities such as research studies. This could also be a function of the state selection criteria of who qualifies to participate in the 77 program. In addition, it is also likely that while this particular study sought to examine employment outcomes, the persons who were employed are likely not those who heavily utilize the clubhouse and could have been inadvertently excluded from the sample. While the Flinn Project sample was similar in demographics with all of the clubhouses in Michigan, however, the lack of variance amongst predictors should caution interpretation of these results. Additionally, there were multiple interviewers at each clubhouse site. Although a prior training and pilot interviews were conducted, the impact that this could have on the variability of responses from each member should not be overlooked. Data Collection As previously mentioned, it was assumed, for the purposes of this study, that self- report was a valid and reliable method by which to collect information on clubhouse and member characteristics and their relationship to employment outcomes. Heppner, Kivlighan and Wampold (1992), purport that self-reports are useful not only in accessing private thoughts and cognitions, but also in gaining information regarding hypothetical situations. Self-report allows access to cognitions and perceptions that are often beyond the observation of the researcher. The interview format employed during this study, typically allows for greater control and depth of information obtained (Kerlinger, 1986 as cited in Heppner et al., 1992). The advantage to utilizing self-report and the benefit of the interview format provide a counterbalance to several related disadvantages that are also limitations to the present study. Self-reports become vulnerable due to the phenomena of distortions on the part of the subject (Heppner et al., 1992). In this particular case, self-reports may have 78 been more vulnerable due to the psychiatric diagnosis of the subjects. There is potential weakness of the self-report due to symptomatology of the diagnosis classified as “severe mental illness”, which can involve some delusional thoughts or distorted thinking processes. Although the participants in the Flinn study did not represent the most severe cases of mental illness, this is still an important consideration. In addition, the Flinn project research team did take several measures to insure clarity while conducting interviews. First of all, the research team secured written consent from each member, to gather information regarding employment for the employment specialist. This assisted with verifying current employment status and type of employment for members. Clubhouse records were also checked against clubhouse members’ length of participation. If there were any participants with what appeared to be extreme responses, the team collectively decided to remove those from the final sample. Instrumentation Several of the measures utilized in the study were standardized measures with high internal consistencies, where as other individual characteristics were compiled of variables within the instrument, did not uphold a similar amount of internal consistency. However, it is also important to recognize the difference in reliability between instrument scales could open the analysis up to error and may have contributed in providing the limited correct classifications that were received. Another potential limitation of this study was that the instruments measured the perceptions of the members at a “point-in-time” and that member perceptions were of utmost importance to the research team. As Honey (2000) stated, more “person-focused research is needed. . .understanding each person’s perceptions of vocational issues is of 79 vital importance and is congruent with a philosophy of empowerment” (p. 277). While it is understood that the interview format will not reveal a “pure relationship”, it does give information regarding the perception of the members. This will allow for the knowledge and experience of members to be directly honored and valued (Denzin & Lincoln, 1994). The Flinn project sought to uphold psychosocial rehabilitation values as well as empowerment and recovery throughout the research project. Generalizabilitv of Results The sampling procedure utilized within this study also presents itself as a limitation. Traditionally, random sampling is seen as the most critical element in allowing for generalization to the representative population (Serlin, 1987 as cited in Heppner et al., (1992). Nevertheless, most often in rehabilitation research, the utilization of “available samples” or “convenience samples”, provide a more realistic method by which to conduct research. The sample population utilized in this study was however, a purposeful one. Since this study wished to investigate the impact of clubhouse membership and the subsequent personal and organizational characteristics that may influence employment outcomes, demographic information were examined from the entire clubhouse population in Michigan. These figures illustrated the similarity between the entire population and the sample population from this study in age, ethnicity, and educational backgrounds. It is appropriate to assume that the results of this study will generalize to other clubhouse members within the state of Michigan. Since this study sought to examine member outcomes in the state of Michigan, it is not expected that these results will generalize to clubhouse members throughout the United States. Hence, 80 it is assumed that the current study examining persons with severe mental illnesses who access clubhouses, is representative of other persons who access these services throughout Michigan. Implications of Findings Implications for practice. This research provides specific information regarding practice within the clubhouse model of psychosocial rehabilitation. It points out the need for practitioners to be more keenly and clinically aware of their role in facilitating recovery for club members. It points out the need for specific training that will enable these staff to become not only familiar with the definitions of key terms such as recovery and empowerment, but one that will also provide specific information on how to help facilitate, encourage and maintain progress through these processes for persons with SMI. The descriptive statistics of this population and the percentage of persons who were working in the sample (3 7%), while congruent with literature on employment within clubhouses, also reiterate the need for clubhouse standards to explicitly define appropriate methods to help facilitate, encourage and promote independent employment for clubhouse members (Bond et al., 1999). Bond et al. contend that an asset of the clubhouse model is that the approach is well understood by practitioners and members. While this may be true of the approach, perhaps a more concerted review needs to be given to the theory behind the phIIOSOphy and to concepts like recovery. One other implication for psychosocial rehabilitation, is the distinct and obvious need for serious collaborations between psychosocial rehabilitation and vocational rehabilitation programs. One that goes beyond cash-match agreements and really 81 involves implementing and understanding each other’s service models. Accomplishing this partnership would definitely be a step in a direction that could improve the rate of employment for persons with severe mental illness, which is suffering in both fields. Psychosocial rehabilitation also needs to reexamine its’ philosophy and review in further detail the potential for dependency that may unintentionally develop within this “safe” atmosphere that may be preventing growth and change for it’s members. Wang, Macias and Jackson (1999) began an initial step to measure and assess the fidelity of mental health programs to the clubhouse model. These authors assert that a “good clubhouse is a paradox within community support theory. Offering a cohesive, supportive, and protective community, the clubhouse simultaneously encourages member independence and individual accomplishment outside this community” (p. 295). This illustrates the difficulty that exists in maintaining clubhouse standards, and provides additional information as to why the results of this study were not statistically significant. The authors concluded that there is a strong need for a measure of fidelity to the Standards for Clubhouse programs. A concerted effort toward fidelity to the core of the clubhouse ' model and clubhouse standards may increase successful outcomes for clubhouse members. A focus on training in the area of these psychological, individual-level constructs may not only help to increase successful employment outcomes, but other phenomena, (e.g., drop-out) as well. Implications for education. This study also has implications for Rehabilitation Counselor Education. As of late, there has been attention in rehabilitation research that addresses training needs for rehabilitation counselors interested in servicing persons with severe mental illness. However, rehabilitation counselors typically are not equipped with 82 the specific knowledge needed to effectively work with this population (Kress-Shull, 2000). Again, there exists a specific need for collaboration between rehabilitation counseling programs and community mental health or psychosocial rehabilitation focused programs so that there is a cross-section of knowledge received. Rehabilitation counselor programs, which typically operate on a generalist model, should make strides to involve students interested in this population in internships and practicum opportunities within this field. The relationships that grow from this involvement will not only increase the strength and opportunities for collaboration across the disciplines, but will also work in the direction of improving employment outcomes for persons with severe mental illness. _ Implications for further research. The lack of significance with this study definitely indicates the need for further research to examine characteristics that not only predict employment outcomes, but that also influence successful employment outcomes. Replicating this study, while necessary, may be difficult. It is suggested that in replication, standardized measures be substituted wherever possible. Perhaps even utilizing an alternate recovery scale with established subscales would be useful to examine the various qualities of recovery. It is also suggested that the face-to-face interview be maintained because of its empowering value to the clubhouse members. Replication of this study should definitely focus on ways to access clubhouse members who may be working, that aren’t accessing the clubhouse at the same rate. This will perhaps add much needed variance in the sample and will allow for better interpretation of the results. Follow-up studies are encouraged. One specific recommendation for future study is related to sample size. For the current study a power analysis (Cohen, 1992) was 83 conducted with alpha at .05, conventional power at .80, a medium effect size (.30) and 8 predictor variables, indicating a minimum need of 107 participants. The overall effect of the predictor variables was in fact small. Hence, perhaps calculating with a small effect size (.05), and thus increasing the sample size (294), could produce significant relationships and yield stronger findings. These studies should focus on employment retention and tenure as well as a longitudinal look at recovery and sense of community. This will perhaps provide valuable input into the “change” that occurs within the members’ lives and how this change affects their member-level characteristics. Conclusions The purpose of the present study is to I) examine the relationship between member characteristics (i.e., sense of recovery and community) and employment success for club members, and 2) to gain an understanding of the organizational characteristics of the clubhouse, which contribute to successful employment outcomes. Specifically, this study examined the predictive value of personal characteristics and organizational characteristics on employment outcomes. Although there were no major statistically significant findings, and none of the variables held any significant predictive value, a great deal was learned in the process of completing this research. Information on the predictive value of the recovery process and the relevance of recovery to employment outcomes consistently yielded high loading values within the results. This may speak to a bigger issue of a concept that might be overlooked that could perhaps enhance employment outcomes for club members. Another interesting point that arose from the analysis was the linkage of sense of community to unemployment. It not only points to the power of this concept, but also 84 provides a possible explanations of the difficulty that employment specialists experience when attempting to engage club members in employment. If the sense of community can truly be shown to be a deterrent to leaving the club to become employed, then a closer look at the values the clubhouse promotes and the significance it places on employment needs to occur. Overall, it appears to be most relevant to continue to research individual characteristics and their specific impact on employment outcomes. Situations where recovery is stressed and community is broadened to include the “world of wor ” may not only provide a stronger adherence to the clubhouse model, but may also add to the consistency of employment outcomes for this population. 85 APPENDICES 86 APPENDIX A 87 APPENDIX A CLUBHOUSE PARTICIPATION (0’) Now I would like to ask you about being a clubhouse member. History CPI. How long have you been coming to the clubhouse? months years CPZ. On average, how often do you come to the clubhouse in a week? (How many days a week?) days a week CP2a. If less than once a week ask, how often do you come to the club each month? times per month CPB. When you come to the clubhouse, how long do you usually stay? hours 6P4. Do you participate in the work-ordered day D Yes (1)121 No (0) 88 gm If member lists specific units check below. If member lists specific tasks write in space provided below. M: WMabmm/brdowlmywmerofinchbm? Orrin? tasksdoywdoaspa'rofthem-mdday? CPS. UNITS Item Unit Yes (1) No (0) CP5a. kitchen I! D CPfib. maintenance D D CP5c. snack bar D D CPSd. employment unit D I: CPSe. clerical D D CP5f. member services U D CPSg. thrift shop D D CPSh. environmental services (lawn maintenance) D D 05. recreational unit D D 6P5]. member bank D D CP5k reception E El CP5I. other, C! D 0%. _total # of units m If member lists specific activities check below. If member lists specific things write in space provided below. CP5i. Tasks: 89 CPb. Aside from the work-ordered day, can you briefly tell me what you generally do when you come to the clubhouse house? CP7. Do you participate in any of the social activities (with the clubhouse)? D No (0) Cl Yes (1) If yes, How many times a month do you participate in social activities? CP7a times per month CP7a. Has anyone at the clubhouse asked you if you would be interested in employment or work? [I] Yes Cl No CP7b. Who would you go to about getting a job? . Name of person Relationship to persorL D clubhouse staff El employment specialist C] no one CPS. Describe three main reasons why you come to the clubhouse. Give me your top reason first. Code CPBa. CPBb. CPBc. (codes: 1 = friendship, 2 = learning new skills, 3 = employment opportunities, 4 = something to do, 5 = my case manager/group home provider says to attend, 6 = social activities, 7 = other) Leadership Role CP9. Do you consider yourself a leader in the clubhouse or unit? I: No (0) D Yes (1) CPIO. Have you led house meetings, unit meetings, or community meetings? 0 No (0) D Yes (1) CP11. Are you a member of any clubhouse committees? D No (0) D Yes (1) CPlZ. Have you represented the clubhouse in any manner to the larger community? (for example, by participating on a speakers bureau, participating on community mental health board, or doing public education or speaking on behalf of the clubhouse in other settings?) I: No (0) D Yes (1) 91 APPENDIX B 92 APPENDIX B YM MP W: Nowlwouldukewukyouabomwork. First, I’llask aboutyourcurraujobsaudmen l’llaskaboutyourpastjobs. ’°" a! NowIwouId I foaskywabwtmcm'entemploymarfsinnflm. EMPl. Do you haveajob now? 0N0- (0) ,_ .. ayes. (nnrmsmwmfim V. 1'fo cut-early wot-kiln ask: EMPla. Would you like to work? D No (0) D Yes (1) D Not sure (2) EMPlb. What is keeping you from working? [check all that apply] Item Option Yes (1) No (0) EMPlaa. can't find something I D D like EMPlbb. no one is helping me D D EMPlcc. don‘t know where to go D D to get a job EMPldd. my physical health I! D EMPlee. my psychiatric Cl D disabilities EMPlff. afraid to lose my D D disability benefits EMPlgg. transportation D D EMPlhh. Other: D D STOP. GO TO PAGE 29 93 CURRENT EMPLOYMENT EMP2. Whatisthenameofyomjob?.lob'l‘ype EMPZa. Who do you work for? (e. 3.. company) Iowor/cforaW-Iwaabmjob, ask: EMPZaa. Do you M as a ckb staff person (mm-W)? ClYes (1) EINo(O) WZab. DomMinspecfkatsa'hk-odtodovecific tasks? ClYes(l) DNo(O) EMPZac. Doywworkasbothaclwstaffpersmandhiredtoda DYesa) DNo(O) specific tasks or work in with Wits)? EMP3. What do you do? (What type of job is this?) D (1) individual TE - pa/dshort-term gency 4' aimed 1» placements in integrated work setting. (club om contract) D (2) individual SE - paid, laryterm work in integrated work settiry. D (3) mobile crew SE - paid, gram emp/onnent in integmted work setting. D (4) sheltered workshop - segregated group employment, carsumers often perform piecework d are paid below minimwn wage D (5) competitive - paid, lary- term competitive work in integrated work settiiy. D (6) Other D (9) don‘t know EMP4 . How long have you held this job? months years EMP5 . How mmy hours a week do you work? #hours/wk EMP6 . Why do you work? EMP7. How much do you get paid? Is it: less than minimum wage ($5.25) (0) minimum wage ($5.25) (1) above minimum wage (Z) 94 EMP7a. EMPB. EMP9. How did you get this job? Dby self (1) Dwith clubhouse help (2) Dwith rehab help (3) Bother, explain (4) What kind of things are helping you keep your job? [Check all that apply.] Item EMP8a. EMPBb .EMPBc lEMPBd bMPBe limpet ' éwsg EMPBh isms. Who helps you keep your job? Option skills learned from work ordered day teaching how to do job getting transportation adjusting my meds TE or Employment Dinner learning how to get along with others at work, getting my housing situation in order self-management tools (what to do when anxious, distracted, etc) Other: Yes(l) U D No (0) D D [Check all that apply] Item EMP9a. EMP9b EMP9c. EMP9d. BMP90. EMP9f. Option clubhouse staff or job coach at clubhouse clubhouse members family fi'iend outside of the clubhouse job comb outside of the clubhouse boss or co-workers EMP93: Other: Yes (I) No (0) EMPIO. Job accommodations: [Ask 5. Check all that apply.] EMPIOc. Item EMPIOb. Do you have options for flex time, or Yes(l) scheduling? Do you have a supervisor or co-worker gives you cues and assists you in performing your lab? 95 No (0) l3 EMP910 Do you have the opportmity to modify d. your working conditions? (e.g., work I: D provides a quiet place to work, if needed, etc). EMPIOe. Other: D D EMPll. Would you like to work full time? (if member is working «40 per week) a No (0) D Yes (1) EMPlZ. What is keeping you from working full time? [Check all that apply.] Item Option Yes (I) No (0) EMPIZa. can't find something I like D '3 EMPIZb. no one is helping me D D EMPIZc. don't know where to go to D D get a job EMPIZd. my physical health D D EMPIZe. my psychiatric disabilities D D EMPIZf. afraid to lose my disability D D benefits EMPIZg. transportation D D EMPIZh. Other: D D EMP13. Is there anything that makes holding your job/position difficult for you? Cl Yes (1) Cl N o (0) If yes, what? EMEI l'lISTQ‘I- LAST 2 YEARS ThinkaboutthelastZyea-s,thatis,backtol998... EMP14. [If currently working ask:] Have you held any paid jobs in the last 2 years besides the current job you have now? [If not currently working ask=l Have you held any paid jobs in the last 2 years? 96 D No (0) man a Yes (1) EMP15. How many jobs did you have in those 2 years? # of Jobs: Interviewer: (fkave greater than 110b, use EMPI6-EMP20 upto 5 jobs, as needed. Job Time Line, if needed 1998 2000 Job 1 Job 2 Job 3 Job 4 Job 5 EMP16. What was the name of your job? Probe Be soecific about name of job (dishwasher, chauffeur, etc.) Ask for specific job title. Job 1: EMPlba. Who did you work for. EMPlbb. What did you do? (What type afjab is this?) Nature of job: Inth check one of the fol/owiry: D (1) individual TE - paid short-term agency « owned 2» placements in integrated work settiry. (club owns contract) El (2) individual SE - paid, [org-term work in integrated work settiry. D (3) mobile crew SE - paid, grocp employment in integrated work settiry. Worked with members from clubhouse D (4) sheltered workshop - segregated group employment, consumers often perform piech :5 are paid below minimum wage (5) competitive - paid, lary- term competitive work in integrated work setting. (6) Other (9) don't know 97 EMPléc. How long did you hold this job? months years EMPl6d. Was a this a part-time (less than 40 hrs.) or full-time job? D part-time D full-time or #hours/wk D both EMPlbe. Were you coming to the clubhouse at the time? D Yes (1) D No (0) EMPlbf. How did you get this job? D by self (1) D with clubhouse help (2) D with rehab help (3) El other, explain (4) EMPlbg. Why did you leave this job? didn‘t like it (1) co-worker or boss issue (2) contract ended/factory closed (3) dismissed (4) left for a better job (5) left due to illness (6) other, (7) Y ORY- 2 : 08 2 EMP17. What was the name of your 2nd job? Job 2: - EMP17a. Who did you work for? - EMP17b. What did you do? (What type of job is this?) Nature of job: 98 Dita-vial»- check one of the fol/cavity: EMP17c. (1) individual TE - paid short-term agency « owned a» placements in integrated work settiry. (club owns contract) (2) individual SE - paid, lazy-term work in integrated work settiry. (3) mobile crew SE - paid, gram employment in integmted work settiry. Worked with members from clubhouse (4) sheltered workshop - segregated grotp employment, consumers often perform piech 4! are paid below minimwn wcye. (5) competitive - paid, long. term competitive work in integrated work setting. (6) Other (9) don't know How long did you hold this job? months years EMPl7d. Was a this a part-time (less than 40 hrs.) or full-time job? EMPl7e. EMP17f. EMP17g. D pan-time D full-time or #hourslwk D both Were you coming to the clubhouse at the time? D Yes (1) D No (0) How did you get this job? D by self (1) D with clubhouse help (2) D with rehab help (3) D other, explain (4) Why did you leave this job? i: didn't like it (1) D co-worker or boss issue (2) D contract ended/ factory closed (3) Ddismissed (4) Dleft for a better job (5) Dleft due to illness (6) D other, (7) 99 OR - 2 ARS: OB EMPIB. What was the name of the 3"I job? Job3: - EMPIBa. Who did you work for? - EMPIBb. What did you do? (What type of job Is this?) Nature of job: Interviewer- check one of the followiry: D (1) individual TE - paid short-term agency 4r owned » phcements in integrated work setting. (club owns contract) D (2) individual SE - paid, lay-term work in integroted work settiry. D (3) mobile crew SE - paid, group employment in integrated work settiry. Worked with members from clubhouse D (4) sheltered workshop - segregated gram employment, conswners often perform piech :1 are paid below mim'mwn woge. D (5) competitive - paid, lay-term conpetitive work in integrated work settiry. D (6) Other ‘ . D (9) don't know EMP18c. How long did you hold this job? months years EMP18d. Was a this a part-time (less than 40 hrs.) or full-time job? D part-time D full-time or #hourslwk D both EMPIBe. Were you coming to the clubhouse at the time? Cl Yes (1) D No (0) EMPIBf. How did you get this job? I: by self (1) D with clubhouse help (2) D with rehab help (3) 100 D other, explain (4) EMP189. Why did you leave this job? D didn't like it (1) D co—worker or bass issue (2) D contract ended/factory closed (3) Ddismissed (4) Dleft for a better job (5) Dleft due to illness (6) D other, MYLQEM HIST ORV—LAST 2 YEARS: {OB 4 EMP19. What was the name of the 4th job? J ob4: - EMP19a. Who did you work for? - EMP19b. What did you do? (What type afjab Is this?) Mture of job: Interviewer— check one of the following: D (1) individual TE - paid short-term agency 4r owned » placements in integrated work settiry. (club aims contract) D (2) individual SE - paid, larycterm work in integrated work settiry. D (3) mobile crew SE - paid, groqo employment in integrated work setting. Worked with members from clubhouse D (4) sheltered workshop - segregated group employment, consumers often perform piecework d are paid below mim’mum wage. D (5) competitive - paid, [org—term competitive work in integrated work settiry. D (6) Other D (9) don't know EMPl9c. How long did you hold this job? months years EMPl9d. Was a this a part-time (less than 40 hrs.) or full-time job? D part-time 101 EMPl9e. EMPl9f. EMP19g. M D full-time or #hourslwk D both Were you coming to the clubhouse at the time? D Yes (1) D No (0) How did you get this job? D by self (1) D with clubhouse help (2) D with rehab help (3) D other, explain (4) Why did you leave this job? D didn't like it (1) D co-worker or bass issue (2) D contract ended/factory closed (3) Ddismissed (4) Dleft for a better job (5) Dleft due to illness (6) D other, (7) HISTORY-LAST 2 ARS: OB EMPZO. What was the name of the 5th job? Job5: - EMPZOa. Who did you work for? - EMPZOb. What did you do? (What type of job is this?) Mtire of job: Interviewer— check one of the followirg: 102 EMPZOc EMP20d. EMPZOe. EMPZOf. EMPZOg. 0m (1) individual TE - paid short—term agency 4' owned » placements in integrated work setting. (club owns contract) (2) individual SE - paid, [org-term work in integrated work settiry. (3) mobile crew SE - paid, group employment in integrated work settiry. Worked with members from clubhouse (4) sheltered workshop - segregated grouo employment, consumers often perform piecework d are paid below minimum woge. (5) competitive - paid, long- term competitive work in integrated work settiry. (6) Other (9) don‘t know . How long did you hold this job? months years Was a this a part-time (less than 40 hrs.) or full-time job? D part-time D full-time or #hours/wk D both Were you coming to the clubhouse at the time? D Yes (1) D No (0) How did you get this job? D by self (1) D with clubhouse help (2) D with rehab help (3) D other, explain (4) Why did you leave this job? D didn't like it (1) D co-worker or bass issue (2) D contract ended/factory closed (3) Ddismissed (4) Dleft for a better job (5) Dleft due to illness (6) D other (7), ZY -MPLOY Going back more than two years, that is before 1998... EMPZI. Have you ever held a full-time paid job? 103 D No (O)DE No, 510’ To NEXT/“6E, QUES HON EMPZb D Yes (1) EMP22. How many? # of jobs 1998 O Job 1 Job 2 Job 3 Job 4 Job 5 EMP23. What jobs did you have? How long did you keep this job? Why did you leave? What jobs did How long did Why did you leave? you have? you keep this job Reason for leaving: l=didn't like it 5=better job Jobs 2=co-worker/boss issue 6=due to Months held illness job 3=contract end =other (explain) 4=dismissed 23a. 23b. 23d. 23e. 23f. 239. 23h. 23L 23} M m: NowIwouldlIketoaskyouaboutthefilm. EMP26. What job would you ultimately like to have? EMP27. Why would this job be a great one for you? [Check all that apply.] Item Option Yes (I) No (a) EMP27a. pays well D '3 EMP27b. will enjoy the people in the work setting D D EMP27c. clean, safe and attractive place to work D D EMP27d. likes the kind of work D D EMP27e. uses the skills and talents I have D D 104 EMP27f. able to learn new skills 0 D EMP27g. great benefits EMP27h. people will show me more respect D D EMP27i. Other: D U EMP28.Do you have ideas about how you will work towards getting this kind of job? D No (0) Go to J ob Satisfaction, if person is working, page 42 If not working, skip to Social Support Section, page 45 D Yes (1) If yes, ask question EMPZ9. EMJ’29. If yes, how is the clubhouse assisting you to do this? [Check all that apply] Item Option Yes (1) No (0) EMP29a. have a job clubhouse EMP29b. meet with the job staff EMP29C. not doing anything 'EMP29d. have supported education EMP29e. referred me to rehabilitation EMP29f. Other: 105 APPENDIX C 106 APPENDIX C CORRIGAN RECOVERY SCALE (REC) (Giffon, D., Schmook, A., Woody, C., Vollendorf, C., & Gervain, M. , 1995) [Give Participant Card #4] Introduction: I am going to read you a lbt of statements that describe how people sometirnafeei about themselves and their liva. For each statement that I read, I want you to tell me which option on thh card dacribes the extent to which you agree or disagree with each statement. Item Question Strolyly Dis- Not are A” Stray/y Disq-ea og'ee Agnes RECl. I have a desire to l 2 3 4 5 succeed. RECZ. I have my own plan for how to stay or 1 2 3 4 5 become well. REC3. _ I have goals in life that I want to reach. REC4. I believe I can meet my current personal 1 2 3 4 5 goals. REC5. I have a purpose in life. RECb. Even when I don't care about myself, 1 2 3 4 5 other people do. REC7. I understand how to control the symptoms 1 2 3 4 5 of my mental illness. RECB. I can handle it if I get sick again. REC9. I can identify what triggers the 1 2 3 4 5 symptoms of my mental illness. RECIO. I can help myself become better. RECII. Fear doesn't stop me from living the way I 1 2 3 4 5 want to. RECIZ. I know that there are mental health services that do help me. 107 Item R5613. R5614. m There are things that I can do that help me deal with unwanted symptoms. I can handle what happens in my life. snugly Dis- Disqwe agree NotSuw Ayes Straw Agra R5615. I like myself. R5616. If people really knew me, they would like me. R5617. I am a better person than before my experience with mental illness. R5618. Although my SYMPW'M WY get worse, I know I can handle it. R5619. R5620. R5621. R5622. R5623. R5624. R5625. R5626. R5627. R5628. If I keep trying, I will continue to get better. I have an idea of who I want to become. Things happen for a reason. Something good will eventually happen. I am the person most responsible for my own improvement. I'm hopeful about my future. I continue to have new interests. It is important to have fun. Coping with my mental illness is no longer the main focus of my life. My symptoms interfere less and less with my life. 108 Item atesh'on snugly Dis- Not Sire Agnes Stray/y Dig-ea fee Alive R5629. My symptoms seem to be a problem for shorter periods of 1 2 5 time each time they occur. R5630. I know when to ask 1 2 5 for help. R5631. I am willing to ask 1 Z 5 for help. R5632. I ask for help, when 1 2 5 I need it. R5633. Being able to work is . 1 2 5 important to me. R5634. I know what helps me 1 2 5 get better. R5635. I can learn from my . 1 2 5 mistakes. R5636. I can handle stress. 1 2 5 R5637. I have people I can 1 2 5 count on. R5638. I can identify the early warning signs of 1 2 5 becoming sick. Even when I don't R5639. believe in myself, 1 z 5 other people do. R5640. It is important to have a variety of 1 2 5 friends. R5641. It is important to 1 2 5 have healthy habits. 109 APPENDIX D 110 APPENDIX D Sense of Conn-fly in Clubhouses (SOC) excerpts from .76. Buckner, 1988 - SOC Scale (items 1—13)& Clubhouse concept mapping results (items 14—20) [Give Participant Card #4] m.- hlowIwould/iketoaeksomequostibnsabouttheclubhouse. Foreach itetntlratIreodpleos-etellmelfyoustrotylydlsaywe, diw'ee, ay'ee, arstrotyly ayes. Item Question Strongly Disagree Dis— Not agree Sure Agree Strongly Agree $061 I feel like I belong to this clubhouse. 1 2 3 4 5 $062 The friendships and associations I have with other people in my clubhouse mean a lot to me $063 If the people in my clubhouse were planning something, I‘d think of it as something 'we" were doing rather than 'they' were doing. $064 If I needed advice about something, I could go to someone in the clubhouse. $065 I think I agree with most people in my clubhouse about what is important in life. $066 I feel loyal to the members in mLclubhouse. 5067 I feel loyal to the staff in my clubhouse. $068 $069 I would be willing to work together with others on something to improve my clubhouse. I plan to remain a member of the clubhouse for a number of years. 111 Item 50610 Qiestion I like to think of myself as similar to the people who are part of this clubhouse. Dis— Not agree Sure Strongly Disagree Agree Strongly Agree $0611 A feeling of fellowship runs deep between me and staff in this clubhouse. $0612 A feeling of fellowship runs deep between me and members in this clubhouse. 50613 Being part of this clubhouse gives me a sense of community. $0614 Being part of this clubhouse helps me to deal with my mental illness. $0615 $0616 Belonging to this clubhouse helps me have hope for the future. Being a member of this clubhouse helps reduce stigma that I feel in the greater community. $0617 $0618 $0619 $0620 Being a member of this clubhouse gives me a place to go. Being a member helps me learn new skills. Being a member helps me get a chance to find paid work. Being a member gives me something meaningful to do. 112 APPENDIX E 113 APPENDIX E DEMOGRAPHIC INFORMATION (DI) Imrldltttetofmdwtallttlebitabwtyotrbackgwnl. Ywntayslapanywestkns thatywdomtwmttomswen DIl. What is your date of birth? Month Day Year 012. [just want to confirm your gender: What is your gender? D Female (1) D Male (2) DB. How do you describe your race, ethnicity or cultural background? DI3a. Race/ethnicity V ”g D13b. If Hispanic is selected, Mark all that ‘ apply Mark one category No (0) Yes (1) Category Native American (1) Mexican Asian or Pacific Islander (2) Mexican American African American or Black (3) Chicano/Chicana White (4) Cuban Hispanic (5) Puerto Rican Multi-racial (6) Other Spanish Arab American (7) None Other (8) Specify 114 D14. What is the primary language that you use? Mark one I Language I Language English (1) Tagalog (7) Spanish (2) Polish (8) French (3) Korean (9) German (4) Vietnamese (10) Italian (5) Other ( l l)specify Chinese (6) DI5. Aside from how often you attend regular religious services, do you consider yourself to be: / one Against religion (1) Not at all religious (2) Only Slightly religious (3) Fairly religious (4) Deeply religious (5) Dl5a. How much is religion (and or God) a source of strength and comfort to you? lone None (1) A slight amount (2) Somewhat (3) A great deal (4) 115 DI5b. If you have a religious affiliation, which one do you identify with? / one '/ Religion ‘6 Religion Bahai (1) Muslim (6) Buddhist (2) Native American (7) 6hristian(3) Atheist (8) Hindu (4) Agnostic (9) Jewish (5) None (10) Other (11) Specify Educational status DI6. How far did you go in school? (Highest level of school completed.) Check one. ’ LEVEL Never went to school (0) 1" - 8*“ grade (1) 9'" - 12'” grade, but did not graduate (2) High School Diploma (3) 65D (4) Some college, less than degree (5) Completed certificate or license program (such as chef, plumber, electrician, etc.) (6) 2 year college diploma (7) 4 year college diploma (8) Master degree (9) Doctoral degree or professional degree (10) 116 DI7. Are you currently enrolled in an education program? Check one. ‘/ LEVEL Not currently enrolled (O) 65D program (1) Commmity college (2) 4 year college program (3) Post graduate program (4) Vocational training programs (5) Supported education classes outside the clubhouse (6) Continuing Education (7) D18. If you are not currently enrolled or attending a school or a program, would you like to go to school or continue yom' education? Cl Yes(l) Cl NOW) Interviewer: Please confirm : Consent Form Release for Diagnosis information/Employment Information Signed money reimbursement form 117 APPENDIX F 118 APPENDIX F Statewide data on clubhouse members for FY2000 N = 3613 Flinn Project data on clubhouse members 2000-2001 N = 245 Ethnicity State of Michigan Flinn Project Native American 0.7% 3.3% Asian Pacific Islander 0.5% 0% African American/Black 13.0% 9.4% White 83.5% 82% Hispanic 1.7% .4% Multi-racial 0.5% 4. 1% Arab American 0.1% .4% Age in Years State {Michigan Flinn Project Range: l7to 89 Ran&18t066 Mean: 44.08 Mean: 43.10 Gender Male Female State of Michigan 52.7% 47.3% Flinn Project 48.6% 51.4% Employment status Full time > 30 hours/week 13.2% Part time < 30 hours/week 4.6% Unemployed 27.2% Not in labor force 51.0% Retired 1.1% Sheltered workshop 2.7% 119 Educational Level State ofMic_higan Flinn Projects Less than high school 24.2% 19.3% M) school GED 70.0% 5.3% In school K-12 4.3% 3% In training program 0.7% >1% Special education 0.9% Not collected Income Brackets State of Michigan Flinn Project <$S,000 14.0% 10.8% $5,000 to $9,999 68.9% 61.4% $10,000 to $14,999 13.7% 15.8% $15,000 to $19,999 2.6% 1.7% >=$20,000 3.8% 2.9% ' Axis I Diagnosis State ofMiclLigan Flinn Project SchizoLhrenia & other psychosis 59.6% 53.4% Mood disorders 28.6% 33.5% All other 11.7% 13.1% 120 APPENDIX G 121 APPENDIX G MICHIGAN STATE UNIVERSII Y WefMlyhOildEcslcgy tZSBWestFeel-lel East Losing, MI 48824-1315 Telephsrw: (517) 355-0166 Fax: (517) 432-1344 Date DUClubhouseMsnIg-t MmfumfimmMMMML Weepprecisseyoiucfl'ortsinbelping mmmwdwnmmnuMp-Smummsm gash-imports dmdnwillpmvidedesaiptlwintbrmetinneboumhipnclubbouscs. wumamwm wmnwillgivemsswelles .maprojeminfornfionumdubm'spcmhtwmthsmnnilxmm MMMMMWWIWMMWWW folbwsthennsioruuddcfinhionusedinthsoaimlynippmedanpbym report. Menuhwmmelsomewldefinmmfilk kqeeonfldendel Allinfinuetionprovidodwillbepresuedinwet‘om You reepouuwiflnmbemduindifidudbddeufiolmemwwiflbeoodedn nemesofchrbhouscswillnctbemscbedtotheinformsthnprwided Remunbc, diceisnopuekyiornctehooingtopmidpstsinthismeyendmchibhouse meycbooummpsrticipetionetsnytime YouwillrcceiveSurvnyInin spprmmetelytwowets. Pleascrunnthscomplaedelveyby intheuvdopcpmviddihsrtyou ageisiorhslpinguswithtlisimponmproject Wewillbelnppytodisoissenyquenionsdm younisyheve. PlusefedheetocornnfinhuOmgsstSU-JSS-Olfiorswyflmu (517)335-0130. Sincerely, Esther Oneal. Ph.D. Senate Herman. Ph.D. Cam Ferguson, MSW. Co-Prtncipd Invention Principal Investigator Co-Prlncipnl Investigator Project Field Utrecht Project Diroctor Protein OMcer MidiigenSteteUniversity DeototCommunityl-leelth OeptolComnmnyHaslm Enclosure: Suvey ll. Prcqam Level Outcomes ReturnEnveiope USU is in Affirmative Action/Enid Opportunity Institution 122 SURVEY 1: CLUBHOUSE ADMINISTRATION & OPERATION (Part of the Clubhouse Evaluation Project funded by the Flinn Foundation) CHECKLIST M Sign consent form and return in envelope labeled “CONSENT FORM” M Complete and return Survey 1 in large envelope labeled “SURVEY I” ALERT!!! Date for Survey 11 Date for Survey III 123 The Clubhouse Model Evaluation Project Participant Consent Form for Clubhouse Managers Purpose Ihepurposeofthkanveyismdesmbcpmgnmuicinfumdimofsfldubbousuin Michigan. Theinfamdonwflldeembedwnngeofdifi'uencesmdoommonslidesexisting aaosselllbhousesinM'lehigan. Procedure mmmmammmmmmmmmt Adnununauon and Operations; Silvcy II, Program Level Outcoma; and, Survey 11!, Demogaphiclnformetion. Eacbnuveywillbemailedoiasepamdyintwo-wcckilurvalsl'o boadualbethenngeofdiflaencusndwmmndiduamonghfiebigmchlbhousqmmy nkchbhousemsnsgasmrcpeucanlplcdcnofsmnhdysmmtumbthccm timesatsixrncmhimuvsls. 3&0an hthcpsmmanypmpbhawfoundpafidpuinginthistypeofsudymboanaMm educationslexperience. ‘I'heint‘ornnliongetheredacrosschlbbouseswillbooompiledsnd reportedbaektoeechot‘thechlbhmsee Thiswillgiveyouenoppormnitycompereyaur dubhouuwahudubhousuinhficlfigsnamemmbcofprogmnmaucmthnwfllbe manlredinthesurvey. litbefirusaoieflthumeysisconlplmSIOOwillbegivento ymnclubhousessconpensationforyowpanieipation. Risks Weanticipetemrisktoyoufiomparticipetinginthisstudy. Thequesdonsintheauvcysre typicalofitenncovcrcdinprogramaneysinpsychosocislrehabilitation ThereisnOpensltyif youehoosenattopnficipete. VolaataryParttdpatlea Yompenicipetioninthisstudyissn'ictlyvoluntary. Whetherornotyouagreetopertieipatewill havenoefi'ectooyoujobudledubbouseorconununitymennlheethsgency. Yousret‘reeto withdrawfi’omparticipatimstsny time. However, the firstthreesurveys must allbeoompleted inorderforyourchlbhousctoreceivetheflOOcompensstion Confidentiality All information given to us will be kept completely confidential. Your individual-responses and infonnation will not be shared with others. Instead of using clubhouse names, we will use code numbers to identify your participant infometion form and your responses in the survey. The 124 onlypeoplewhowillhsvcsccesstoyourulswu’swillbetheresesrcbstefii Alldatswillbe contpiledendpresentedtogcthetmotonanindividualbasis. Questions orCoaecrus It'you havelpeetioosregardingthis project. pleasecellDr. EsthcrOnsgset 517-355-0166 at Michigan State University or Dr. Sandra Herman at 517-335-0130. CONSENT STATEMENT Iunda'stsndalloftheiniomationwrittaonthisfom. Ihsdsnopporunn'tytoraiscquestions andhevsthcnunswered. Bysigrfingdisconsernfornlemegrccingtoparticipateinthcsuldy undetheconditionslistedebove. Acopyofthisformwillbeprovidedmme. Participant Name (Print) Participant Signature MD Research Project Staff Signenu'e 125 Survey I - Clubhouse Administration and Operations ADMINISTRATION Medicaid Status YE; Is your program Medicaid enrolled? If yes, what was your effective date of enrollment? / / If no, are you interested in becoming a PSR/Clubhouse Medicaid provider? Isyolrprogramintheprocessoferrollment (agency has sent in service agency profile)? I Is Accreditation! Certification, Status Indicate whether the clubhouse has received certification or accreditation by any of the following organizations: __ CARF Accreditation _ J’CAHO Accreditation __ ICCD- C'ertifioation Statw Provisional effective date: 1 Year effective date: 3 Year effective date : Other: _/_ _ \\\ _/_ _/__ Budget 1. Do you know what your clubhouse annual budget is? _yes __no 2. Complete the funds allocated for each of the following areas: 5 What is the annual budget for the clubhouse program? Budget Detail 3 Annual Staff salary and fringes Number of FTE's S Arousal Facility cost: lease/rent/mortgoge 126 o. cums: 5m Up Check one of the items below that best describes how your clubhouse program developed: New program: A clubhouse developed with new staff and an off-site location. Program conversion: A clubhouse developed by redirecting staff md clients from one of the following existing program: _ Day Treatment _ Vocational Rehabilitation Program! Facility _ Drop In Center _ Other (please specify:) Staff Redirection: A clubhouse developed by recruiting members from the community and redirecting staff to work at the clubhouse from various other CMi-l services. Other (please specify): E. Computer Software Please list the computer programs used in the clubhouse: (ex. Windows 95 WordPerfect, Excel etc.) 1. Operating system: 2. Word processing program. 1. Spreadsheet program: 2. Database program: 3 Other (please specify:) 127 Location Checkone thatbestdescribesthe present locationof you' clubhouse: 1. In a community location separate from any other programs. In a traditional CMH building with other CMH/Agency Services In an off-site location with other community mental health services or consumer program. For off-site locations: . Check all file types of set-Weds) that slime with the clw: _ ACT __ Drop In _ Case Management __ Consumer Run/Consumer Owned Business _ Other (please specifyzl Club Environment The following list describes some features of a clubhouse program. Marl: all that apply. Off site location separate from other mental health services An address just for the clubhouse A lobby or entrance just for clubhouse members and staff A clubhouse telephone number Clubhouse members open and distribute all incoming clubhouse mail Sole responsibility for reception area tasks/functions given to members Club ‘owns' outdoor area adjacent to club for recreational use by club members. (This is more than the outdoor smoking area) 128 2. List below any other unique featu‘es of your clubhouse environment How do people get to the club? 1. Transportation/Access to Clubhouse For each mode of transportation mark the box that best describes the percentfle of people who us it. Mode of transportation 0% 25% 50% 75% 100% Walk Drive their own car Ride with another member Ride with family member Volunteer driver Ride regular public transportation Ride special public transportation, i.e. Dial-A-Ride, etc. Clubhouse or agency van Foster care providers drive people living Adult Foster Care Other: Closeness to Community Services Estimate the miles between the clubhouse and the following community resources. Business district or shopping area Bus stop CMH Clinic Services Grocery Store Social Security 6: Food Stamps Office, etc. ° 129 3. Hours of Operation More the regular hours of clubhouse operation? Hairs 4. On what holidays is the.clubhouse open? 130 III. CLUBHOUSE PROGRAM SERVICES A. Clubhouse Ordered Day Functions Please place a check mark in the box indicating the frequency of the activity. Please list any other activities and tasks that are part of your club‘s ordered day. Fania“; Daily 14 1.: 4mm 2 Once Not timesa timesa eyed- times ayear applicable week month a Makianeals in the kitchen Running a snack bar Greeting people coming in or calling Doing clerical tasks (mail, W eta) Publishingg newsletter Keeping track of members' attendance Cleaning the space used by the club Making repairs to the club building: RecyclinLclib waste Calling absent members Sending cards to members Helping members find places to live Members d: staff planning social activities Providing transportation for members Helping members initiate additional education 6: traini Helping members move to independent livflgf Finding roommates for members 131 Fm Daily 1-4 1-3 Ctlmes 2 Once We don't timesa timesa ayear times ayea- dathis week month aye.- Having information available about consumer issues (rights, SSI, housing, etc.) Having a thrift shop Holding medication awareness 009$ Running a lending library at the club Having members go to state wide club events Working on everyday living skills Having open houses at the club Working on social skills Holding social events (dances, Mo movies, etc.) Having events for members’ families Going to Power Day or other litical action events Havi_ngg speakers bureau Assisting members with medication issues Helping members stay in school Helping members move Helping members find furniture, etc. Shopping at the local grocery store Other: 132 Vocational Services 1. Ownservices Does the clubhouse provide its own vocational services? __yes If no, identify who does Relationship Wlfll MRS (nan: name change: in April to Dept for Cm Development) Relationship with Jobs Commission (Michigan Rehabilitation Services) Check all that applies with your clubhouse: _MRS funded program startup _cash match agreement established between MRS d: CMH _agreements set for fee for service _Other, describe the relationship Self Help or Support Groups Indicate any self help groups offered at the clubhouse program by placing a check ( ) before the item(s).: Schizophrenics Anonymous (SA) Alcoholics Anonymous (AA) Double Trouble or Groups for Persons with Mental Illness and Substance Abuse Men‘s or Women's Issues Group Alliance for the Mentally Ill (AMI) Other (please specify): —m Fundraising 1. How much money did the clubhouse generate through fundraising activities in FY98? S 2. List the types of fund raising activities utilized by the club: 3. How was the money used? 133 3. Housing a. Where do your active members live? _% living on their own or with a roommate(s) _% living with family members(s) _% in supervised independent living (SIP's) _% living in adult foster care % living in a special mental health facility 100% .0” Between October 1, 1998 and March 31, 1999, how many members moved from adult foster care or specialized mental health facilities to an independent or semi-independent living amngement (SIP): Now, please think about your members and staff for March, 1999. Please answer: Alcohol/Substance abuse What percentage of members have problems with % alcohol abuse or dependence _ % substance abuse or dependence _ % no problem 100% Ethnicity What percent of members identify themselves as: % White (non-Hispanic) % Latino (Hispanic any) % Black (non-Hispanic) % Native American 7. Asian American % Pacific Islander 7. Other 3 134 MemberAge Provide approximate percentages of members who are in these age ranges: _% under 18 years _% 18-21 years % 21-35 years % 36-50 years % 51-64 years 7. 65 and over é :2 Now, please think abwt you- members and staff for March, 1999. Please answer: Member Education Indicate the highest level of education received: % Less than High School % High School or GED % Some College or University % Associate's Degree % Bachelor's Degree % Graduate Degree % llll” § 9' Between October 1, 1998 and March 31, 1999, how many members participated in an education program (e.g. GED program, college, university or training program): c. Between October 1, 1998 and March 31, 1999, how many members completed an educational program (e.g. GED program, college, university or training program): 135 10. 11. Member Gender Provide approximate percentage of members by gender: _% female _% male 100% Staff Characteristics M 8: Staff Characteristics Educational Clubhouse ICCD Position FTE Degree training? training? - ail. YES/NO YES/NO m Staff 1 Staff 2 Staff 3 Staff 4 Staff 5 Staff 6 Staff 7 Now, please thihkabautmmembersandstafffa'nlamn, 1999. Pleaseansw: Volunteers How many volunteers do you have in a typical month? Approximately how many hours of service do volunteers provide in a typical month? Students Do you have students doing internships in your clubhouse? _yes _no If yes, how many students have you had in Fiscal Year 1998? Approximately how many hours did they spend as a group in the clubhouse in Fiscal Year 1998? - 136 IV. CLUBHOUSE ORGANIZATION A. Clubhouse Operational and Organizational Meetings 1. How is the daily work of the clubhouse assigned? (check one) a._ meeting in the member's assigned unit meeting of the whole clubhouse Other, b. Who Chairs the meeting? Member_ Staff 4. How often do you have meetings where general clubhouse issues are discussed? (check one) Daily Weekly Monthly Other (please Specify): Who Chairs the meeting? _Member _Staff 5. List any member advisory or other committees that handle member issues or various aspects of clubhouse operations or planning. Also indicate whether a member or staff chair the meeting. Who Chairs? Committees M = member, S=staff 137 Community Connections 1. In the past year list the boards or committees on which staff or members participate. (For example: CMH Board, CMH Advisory Committee, IAPSRS Board member, ClVlC Club, community housing or transportation committees. Please indicate who participates by using 5 : Staff 133.156.2492: Wm 1“ List any community projects in which the club worked with other organization(s) in the last year. Please indicate who participates by using 5 = Staff Aim Wm 138 MICHIGAN STATE UNIVERSII l capo-minor FamilyeChildEcolagy lzflmeuM East Lansirg, MI 48824-1315 Telephone: (517) 355-0166 m (517) 432-1344 Apti113, l999 DearClubbousoManaga'. MWchiganDepuuncdeunmuahyHahhmdhfidugaaSmcUnivadtymwnduahg an evaluation project involving Michigan clubhouses tint is funded by the Flinn Family Foundation Wcmukingalldubhouscmanaga-stousistusbycomplctingtlneemrveysabqn their prognrn that will provide us with descriptive information about clubhouses in Michigan: SmeyLAdnunisaadmandOpaafions;Swveyn.ngmLedeumand,vaeym, Demographiclnformation. Immanuwmfium Allint'omationprovidedwillbepruemedin Weform Yumoaseawfllnotbepreaaueduindividtnliaeddatafiommdub,“ winbecodedaommeaofcbblnuscawiunatbcmachadtothoinfomauonpmvidod Thereisnopanityfarndchoodngtopuficipueinthisnuvoyand'mchibhmnemycboose mdiscomimparddpatioanmyfimewithanenahy.ClubhwsathuchmumWe andoompleteaflflneauveyswfllbemSIOODOuoompensafionforpudcipafiaa Enclosed isaoonscntt'onnandvaeyl. lfywagreetopuficipatapleasereantbosignedconsentfotm andvaeyIscpamdyintheenvclopesenclosedfatyowconvcaieace. Pleasorettuntbe mformandvaeylbyApr-iliio, 1999. Anameivingbackmoonaemfomand SuvayLwewillaendStaveysHandmtoywintwo-weekintavals. Thankyouforoonsidaingmuroquosttopuficipueinthiainputaminitiative Wewillbe happytodiswssanyqucationsthatyoumayhave. PlusafeolfieotooontacgEatherOnagaat 517-355-0166 or Sandy Harman at (511) 335-0130. Sincerely, W . / Esther Onaga, Ph.D. Smdre Herman, Ph. D. Catherine Ferguson. .S.W. Co-Principai Investigator Princbai investigator Oo-Principei Investigator Project Field Director Project Director Projea Oi'ilcer Michigan State University Dept at Community Health Dept. «Community Health Enclosure: Consent Form Survey i - Adminishation 5 Operations Return Envelopes M50 is at Affirmative Action/Enid Opportun’ty Institution 139 Survey II - Program Level Outcomes A. Use of Psychiatric Hospitals 1. How many members were hospitalized between October 1, 1998 and March 31, 1999 in: State psychiatric hospitals Community psychiatric hospitals 2. What was the total number of days of hospitalization between October 1,1998 and March 31, 1999 in: State psychiatric hospitals _— Community psychiatric hospitals __ B. Type of Vocational Options Supported 1 Transitional Employment # Howmanychb members haveheldtransitional employment (permanent positions 'owned' by the clubhouse for the benefit of the clubhouse members) positions during the period October 1, 1998 - March 31,1999: Identify all of the transitional employment jobs that the club owns and the number of slots/positions: Name of Business Job Titles Hrs it of Usual it of Type of per TE length Positions Employment: week slots of time Individual, per Enclave, slot Mobile Crew How many members have a completed a TE placement during the period October 1, 1998 through March 3:, 1999.- 140 2. SupportedEmployment How many club members have held supported employment positions(individuals employed by a business or organization with staff supports),excluding transitional employment duri the period October 1, 1998 through March 31, 1999.- i Identify all of the supported employment (SE) jobs and the number of slots/positions: Name of Business Job Titles Hrs it of Usual # of Type of per SE length SE Employment: wk slots of time positions Individual, per Enclave, slot Mobile Crew How many members have a completed a SE placement during the period October 1, 1998 and March 31, 1999: 141 Competitive Employment How many chb members have held competitive employment (jobs held by individuals without direct support from the clubhouse) during the period October 1, 1998 - March 31,1999:__ y List the types of jobs held by individuals: What is the rage of rate of pay per hour for the individuals holding Competitiw Employment Positions? LN OtherfonnsofEmployment Have any clubhouse member been employed in a sheltered workshop/work activity program during the period October 1, 1998 - March 31, 1999? yes no If yes, how many are employed? Please describe the job: Is any clubhouse member employed in a consumer-run business? yes no If yes, how many are employed? Please describe the job: 142 C. Please describe any other forms of employment present among clubhouse members. 143 C. Supports. Pleasemakeacheckintheboxindicating frequency of this activity.l-lowofteninthelast6months(October1, 1998tlwoughMarch31, 1999)haveyoudoneanyoftheseactivities?Checkonlythosethatapply. TypeofSupport DOW WklyMonthly Qfl'l‘l Not Applicable Finding transitional jobs (TE) for members Assistinlmembers in fitting jobs Assisting members in getting community volunteer work Providing supported employment options Career plannLng Resume/interviewing skills preparation Job development Advocacy with employer Linkage with information on Social Security Work Incentive Coverrge of employee absences from commmujy jobs Life skill training/hygiene, cooking, Malia Job performance assessments Transportation to/from work Holding employee dinners How may usually attend? Supporting members to work independently Skills development (please explain): Job Club Other: 144 Please answer for the period October 1, 1998 to Much 31, 1999. 1 Total # of Competitive Employment Placements: 1. 30 or more hairs cowarrrve EMPLOYMENT 3 4 2. . . 5. # of 83 Minimum # Employed 6 # with persons wage or months Employer Above Medical Benefits 2. 20- 29 hours 3. 10 -19 hours 4. less than 10 hours 1. Total # of SE Individual Placements: 1. 30or more hairs SE INDMDUAL PLACEMENTS 2. 3. 4. 5. it of # Minimum #3 Employed 6 $3 with persons wage or months Employer Above Medical Benefits 2.20 - 29 hours 3. 10 -19 hours 4. less than 10 hours SE ENCLAVES 1. 30 or more hours 2. 20 - 29 hours 3. 10 -19 hours 4. less than 10 hours SE MOBILE CREWS 1. 30 or more hours Z. 20 - 29 hours 3. 10 -19 hours m Ius than 10 hours 145 TRANSISTIONAL EMPLOYMENT 1. 30ormorehotrs 2. 20- 29 hairs 3. 10 -19 hours 4. lessthcn 10 hours 1. 30ormore hours Z. 20- 29 hours 3. 1O -19 hours 4. less that 10 hours 146 - Sta-vey III DEMOGRAPHIC INFORMATION 1. Membership and Attendance Please provide figures for the following items based on your active members between October 1, 1997 through September 30, 1998. Active members are those who participate at the clubhouse 91.1%! onc nt . __ Total Active Members (unduplicated - count each person only once) __ Number Medicaid Eligible _ Members (non Medicaid ) __ Members who receive ACT services _ Number of new commers who become members between 10/1/97-9/30/98 __ Average daily attendance in September, 1998 For questions'Z-IO, please think about your members midyea- staff for March, 1999. Please mm: 3" Diagnosis As of (the month prior to the abte survey sent out): Provide approximate percentages of members’ primary diagnosis: % schizophrenia or other psychotic disorders _% bipolar disorder _7. major depression _% personality adjustment _% all others 100% 147 APPENDIX H 148 51 ”55-21. FAX: 5i 7M mung-um wuwm Warm Warm APPENDIX 1-1 September 14, 1999 TO: Esther Onaga 123 B W. Fee Hal RE: lRB I 98235 CATEGORY: FULL REVIEW TITLE: FLlNN FAMILY FOUNDATlON PROPOSAL-EVALUATlNG THE EFFECTIVENESS 0F cwenouses ANNUAL APPROVAL DATE: Sept-mar 24. 1990 newsman REQUESTED: July 13. 1999 REVISION APPROVAL DATE: September 13, 1B” TheUnlversityConsnitteeonReaearchlnvolvthumanSubiects’(UCRlHS)nviewatmlsproiectls completeandlampleaeedlaedvlsematlhenghtswidweiiaredmelamanalbiectaappeartobe adequately protected and methods to obtain hformed consent are appropriate. Therefore. the UCRlHS APPROVED THIS PROJECTS REVlSlDN. This letter approves the addition at site visits to the protocol. including the collection of observational, interview, and photographic data. RENEWALS: UCRIHS approval is valid for one calendar year. beglnnhg with the approval date ahavmabove. Projects contlmingbeyandoneyearmustberenewedwilhlhewean renewal form. Amaxirmmotiwrsuch expedited renewdareposslble. lrwestigatarswishhgtocontinueaproject beyondthatthneneedlosubmkltageinioracompleterevlew. REViSlONS: UCRIHS must review any changes it procedures hvolving human subjects, prior to initiation oithe change. limls isdoneatthe timeoirenewd, please use thegreen renewal form. To revise an approved protocol at any other time during he year. send your written request to the UCRIHS Chair. requesting revised approve and referencing the project’s RBI and title. Indude In your request a descrlpdan oi the crime and any revised hsaunerits, consent forms or advertisements that are applicable. PROBLEMSICHANGES: Should either at the following arise during the course at the work, notify UCRIHS promptly: 1) problems (unexpected side eflocts. complaints, etc.) involving human subjects or 2) changes in the research environment or new inl'orrnadon indicating greater risk to the human subjects than existed when the protocol was previously reviewed and approved. it we can be of lurlher assistance, please contact us at 517 355-2180 or via email: UCRIHSOpllotmau. edu. David E. Wright. Ph.D. UCRll-iS Chair DEW: ab 06! Sandra Herman Camenne forguson 149 517/335-le FM Sims-2m Wu: immature-M's E-Mt W rams-m women-m We“ hale-W WM MICHIGAN STATE u N l v E R 5.1 T Y December 5. 2000 TO: Esther DNAGA 123 B W. Fee Hall RE: lRB fl 93-235 CATEGORY: FULL REVIEW RENEWAL APPROVAL DATE: December 4, 2000 TITLE: PSYCHOSOCIAL REHABILITATION IN MICHIGAN; ”ll-IE CLUBHOUSE MODEL The University Committee on Research lnvolvhg Human Subjects' (UCRIHS) review at this project iscomplete analampieasedtoadviselhattherights andwell'areoilhehumansubiectsappearto be adequately protected and methods to obtain informed consent are appropriate. Therefore, 31. UCRIHS APPROVED Tl-lls PROJECTS RENEWAL. RENEWALS: UCRIHS approval is valid for one calendar year. beginn'mg with the approv‘ date shownabove. Pmiectsconnnumgbeyondoneyearmstberenewedwlmmegrewinnmmrm. A maximum at four such expedited renewal are possible. Investigators wishing to continue a project beyond that time need to submit It again for complete review. REVISIONS: UCRIHS must review any changes In procedures invotvhg human subiecta. prior to initiation of the change. ltlhls is done at me time at renewal. please use the green renewal form. To revise an approved protocol at any other time during the year, send your written request to m. UCRIHS Chas. requesting revised approval and referencing the project's IRB# and title. Include in your request a description at the change and any revised instruments. consent forms or advertisements that are applicable. PROBLEMSICHANGES: Should either of the following arise during the course at the work. natily UCRIHS promptly: 1) problems (unexpected side effects. complaints.‘etc.) Involving human subjects or 2) changes in the research environment or new information indicating greater risk to the human subjects than existed when the protocol was previously reviewed and approved. If we can be of further assistance. please contact us at 517 355-2180 or via emai: UCRIHS@pilotmsu.edu. Sincerely. awe Ashir Kumar, MD. interim Chair. UCRIHS AK: rj cc: Sandra Hannah Dept. of Community Health 51h Floor Lewis Bldg. Lansing, MI 48933 150 APPENDIX I 151 APPENDIX 1 Dear Clubhouse Members, Manager a Staff: In the past several years, very little formal research on the benefits of psychosocial programs and clubhouses has been conducted in the human services field. However, over the past two years, Michigan State University and the Michigan Department of Community Health have partnered a project called 'The Flinn Clubhouse Project” which has been designed to help us understand how clubhouse programs benefit their members. During this time, The Flinn Clubhouse Project has been working with several Michigan clubhouses in developing a greater understanding of clubhouse programs for people with mental illness. To date, several clubhouses have participated in various phases of the project such as completing mail-in surveys, implementing a member-driven computer database system, and participating in site visits. These and several other project activities have invaluably contributed to the clubhouse knowledge base in Michigan. One of the intended outcomes of the project will be to compile a hardka of unique clubhouse practices and positive psychosocial outcomes in Michigan Clubhouses. As we move into our third year, The Flinn Clubhouse Project would like to interview members about their experiences as a clubhouse member and their experience with mental illness. Our hope is that an in—depth interview will provide richer, more meaningful information that incorporates the multifaceted aspects of each individual's experiences and the impact of their participation in psychosocial programs. On the following page is an outline of how we will attempt to facilitate participation of those who are interested in the Member Interview. Please review the process and feel free to call Sandy Herman (517/335-0130) or Esther Onaga (517/355-0166) for clarification or further information. We hope that your clubhouse will seriously consider this opporttmity to be part of a unique knowledge base that will help increase understanding of clubhouse operations and people with mental illness. Sincerely, Sandra Herman, Ph.D. Su Min Oh Esther Onaga, Ph.D. Chandra Domell Katie Weaver Randall Francesca Pernice-Duca pd ("I IN) Flinn Clubhouse Project Psychosocial Rehabilitation in Michigan Member Interview Please review the following these 4 simple steps in assisting the participation of interested clubhouse members for the Member Interview. You will receive a packet of materials from the Flinn Clubhouse Project to assist you. First, 1. Interested clubhouses will fill out the attached RS VP form and fax back to the Flinn Clubhouse Project office at Michigan State University. 2. The Flinn Clubhouse Project office will contact you via telephone to inquire about possible date(s) and available space at the clubhouse or nearby facilities to conduct the one on one interview with members. 3. The Flinn Clubhouse Project office will send a letter of confirmation to you that will include the date(s) of the on-site interviews. This letter will also include response forms that interested members complete and return to you. a. Members interested in participating will complete the “Interview Response Form” and return it to you. b. You will compile the Interview Response Forms and mail them in a large envelope to The Flinn Clubhouse Project office so we can personally send reminders of the interview date and arrange for accommodations as needed. c. Members interested in participating will indicate whether they have a guardian (i.e., for members with a guardian, we must obtain consent from the guardian before an interview is conducted). d. We would greatly appreciate your assistance in sending letters to any guardian of those members who are interested in being interviewed. The Flinn Project will be responsible for notifying members about their interviews and sending reminders prior to the interview date. We will also send a large flyer to post in the clubhouse as a reminder for our upcoming visit. Procedures for Contacting Working Clubhouse Alumni or Working Members who Participate 1 Month or Less at the Clubhouse: 153 In keeping with our guidelines from the University Committee on Research with Human Subjects (UCRIHS), there are two ways in which you can assist in facilitating participation of these interested members in one of two ways: 1 . The clubhouse could distribute a postcard that we provide that includes the Flinn Clubhouse Project name and phone number where the person can call us collect about participating in the interview. OR, 2. He/ She can sign a release giving you permission to provide his/her name, address or phone number so that we can get in touch with them. The Flinn Project will provide all necessary materials to contact interested members and alumni for an interview. 154 Flinn Clubhouse Project Michigan Psychosocial Rehabilitation FAX/MAIL RSVP Member Interview Participation Please FAX or mail this response back to the Flinn Clubhouse Project office by (include date). D Yes, our clubhouse would like to participate in the interviews. D We are undecided: we would like more information. Clubhouse Name: Date: Clubhouse Manager: Clubhouse Phone: Please Fax to: Esther OM90. Ph.D. At 517/432-1344 Or Mail in the envelope provided to: Sandy Herman, Ph.D. Services Research Unit Michigan Department of Community Health P.O. Box 30182 Lansing. MI 48909-9853 155 APPENDIX J 156 APPENDIX J Flinn @lUbllouse Projecl Psychosocial Rehabilitation in Michigan Starting in August of 2000... The FLINN Clubhouse Project team would like to visit your clubhouse again and talk with you about your experiences at the clubhouse and your experiences with mental illness. We are planning to do 2 interviews with anyone who is interested in sharing their experiences. . The 1" interview will take place in the late summer to early Fall of 2000. . A 2"" interview may be done 6 months later. . Each interview will pay $20 in cash. . Each interview will be completely confidential. 157 Psychosocial Rehabilitation in Michigan Dear Clubhouse Member: The Flinn Project has visited your clubhouse in the last year to learn more about Michigan clubhouses. At that time, we spent the day interviewing staff and managers, and informally talking with members. We would now like an opportunity to interview you about your experiences at the clubhouse. We hope to gain a greater understanding of your hopes, feelings, and life as it relates to your clubhouse membership. The Member Interviews We would like to invite you to participate in personal interviews with a Flinn Project interviewer. > You will be paid $20 for completing each interview. > The interviews will take approximately 1 hour to complete. > Participation is completely voluntary. Interview Midentialily > All responses to the interview are strictly confidential and will not be shared with anyone outside of the Flinn Project team: members' responses will remain anonymous in any report. > Your privacy will be protected to the maximum extent allowable by law. What is the Interview About? The interview is like a life story: it asks questions about who you are, your feelings , and your experiences. > The interview includes talking about feelings of empowerment and recovery, achievements in daily life, work, social activities, and physical and emotional health. 158 ll ? The first interview will take place between August and November 2000, possibly followed by a second interview 6 months later, if you are interested in participating. The Flinn Clubhouse Project staff will coordinate a day that can accommodate those who are interested in participating. You will be notified when we will be coming to your clubhouse. We will try to choose a time slot that will best fit your schedule. If you are interested in participating in the interviews, please complete the attached 'Interview Response Form” and return to the Clubhouse Manager. We hope that you will be interested in participating! This will be a great opportunity to share with others how the clubhouse has worked for youl If you have questions about the interview, please feel free to call Esther Onaga at 517/355-0166. 159 The Flinn Clubhouse Project Psychosocial Rehabilitation in Michigan Interview Response Form PLEASE RETURN TO CLUBHOUSE MANAGER If you are interested in participating in a personal interview with a Flinn Clubhouse Project interviewer, please complete the information below so that we may contact you for an interview. . You will be paid $20 cash at the end of the interview for contributing your time and sharing your experiences. Do you have a guardian? D Yes D No Do you have any special accommodations? (e.g., language interpreter, sign language) D Yes , please specify C! No We will be coming to your clubhouse on By completing this response form you indicate your volmtary agreement to be contacted for an interview. UYes, I am interested in being interviewed. Please print followiry information: Your Clubhouse Name: Your Name: Social Security# - Your home address: City: Zip Code: Your home phone number: ( )- - Pleasechechallthe timesthatwouldbebestforyw [:1 Sam. - 9:00 a.m. E] 9:00 am. - 10 an. El 10 am. - 11am. [3 11 a.m.-12 p.m. D 1 p.m. - 2 p.m. U 2 p.m. - 3 p.m. Cl 4 p.m. - 5 p.m. El 5p.m. - 6 p.mCl After 6 p.m D Other time am/pm 160 APPENDIX K 161 APPENDIX K MQMfoerbhqueMtobeMeMgg Fliim Clibhouse Project Psychosocial Rehabilitation in Michigan Name of member: Purmse The purpose of this interview is to ask the member named above about a variety of topics - demographic information on who he or she is and where he or she lives, information about club participation and how he or she feels about the club, and information about areas in his or her life that may change with club participation. These areas are things like feelings of empowerment and recovery, achievements in daily life, work and social activities, and physical cmd mental health status. Amount of contact We will be interviewing clubhouse members over the next year, once in the late summer and fall of 2000 and possibly at another time in the spring and summer of 2001. Each interview will take about one hour. Benefits The clubhouse member will be paid $20 for the first completed interview. There will not necessarily be any other direct benefits to him or her. Risks No risk to the member is anticipated from participating in these interviews. If the member feels uneasy about any of the questions, he or she can choose not to answer them or end the interview. Volgqtgfl Partigimfim The member's participation is completely voluntary. Whether or not he or she agrees to participate will have no effect on the services received. The member is free to stop the interview at any time. The member does not have to answer any questions he or she does not want to answer. Confidentialifl All information given to us will be kept completely confidential. Individual responses and information will not be shared with others. The only people who will have access to the member's answers will be the research staff of the Flinn Clubhouse Evaluation Project. All data will be compiled and presented together, not on an individual basis. The privacy of the member named above will be protected to the maximum extent allowable by law. 162 If you have any questions or concerns regarding the study, please call Dr. Esther Onaga at Michigan State University (517) 355-0166 or Dr. Sandra E. Herman, at the Michigan Department of Community Health (517) 335-0130. If you have any questions and concerns about the rights of people involved in research, please call Dr. David Wright, Chair, Michigan State University, University Committee on Research Involving Human Subjects (UCRIHS), 517-355-2180. CONSENT STATEMENT By signing this consent form, I am being asked to agree to permit the clubhouse member named above, for whom I am legal guardian, to participate in this study under the conditions listed above. A copy of this form will be provided to me. Guardian Signature Date 163 APPENDIX L 164 APPENDIX L Participant Consent Form Flinn Clubhouse Project Psychosocial Rehabilitation in Michigan Purpose The purpose of the interview(s) is to learn about your experiences as a clubhouse member and your experience with mental illness. The interview(s) will cover a variety of topics that are related to your clubhouse membership and who you are. We will ask you demographic information about where you live, your clubhouse participation and how you feel about the clubhouse, and information about areas in your life that may change with clubhouse participation. These areas are things like your feelings of empowerment and recovery, your achievements in daily life, your work and social activities, and your physical and mental health. Interview Procedure Participating in the interview(s) will involve the following: Contacting You We will be interviewing you over the next year. The first interview will take place in the late summer/early fall of 2000. The second interview may take place 6 months later, in the spring/summer of 2001. You will be asked to give us permission to contact people or agencies who will be able to assist us in contacting you in case we are unable to locate you for a possible second interview. We will only ask them how we can contact you, and no other questions. sum The interview(s) will have several sections and questions. The interview(s) will be approximately 1 hour long. You can withdraw from the interview(s) at any time. Your answers will be strictly confidential during and after the interview(s). Your privacy will be protected to the maximum extent allowable by law. mm to You In the past, many people have found participating in this type of study an interesting and educational experience. For your participation in the interview(s), you will receive $20 in 165 cash for the first interview and we will pay you in cash if we are able to conduct a second interview. Risks We anticipate no risks to you from participating in these interviews. Some questions may be about difficult or emotional subjects. If you feel uneasy about any of the questions, you can choose not to answer the questions or end the interview. Voluntgy Particim Your participation in these interview(s) is completely voluntary. Whether or not you agree to participate will have no effect on the services you receive from the clubhouse or mental health services. You are free to withdraw from participating at any time. You do not have to respond to any question you do not want to answer. Midenfialm All information during the interview(s) will be kept strictly confidential. Your privacy will be protected to the maximum extent allowable by law. We will not use your name on the interview(s). Instead a number will be used to code your answers. The only people who will have access to your answers will be the Flinn Clubhouse Project staff. We will be interviewing about 300 people and all the answers will be grouped together did not on an individual basis. 166 MIW or (merits If you have any questions or concerns regarding this project, please call the people who are in charge of this project, Dr. Esther Onaga at 517/355-0166 or Dr. Sandra Herman 517/3350130. If you have any questions a concerns about your rights as participants of a study, please call Dr. David Wright, Chair, Michigan State University, University Committee on Research Involving Human Subjects (UCRIHS) 517/355-2180. Consent Statement You are being asked to participate in a study that may involve two separate interviews six months apart. You indicate your voluntary agreement to participate in the interview(s) under the conditions listed above by signing this consent form. I have read and been explained the procedures a. nature of the interview(s). I had an opportunity to raise questions and have them answered. I voluntarily agree to participate. Participant Name (Please Print) Participant Signature Date Interviewer Signature Date 167 APPENDIX M 168 APPENDD( M Variable Number Valid Missing Mean SD Length of 245 O 46.2 41.6 Participwon Sense of 242 3 160.4 22.9 Recovery Sense of 245 O 85.5 10.3 Community *Previous Work 245 0 History *Work 236 9 Participation ‘Social 245 0 Participation Staff training 245 O 1.3 .48 "‘ Relationship 1 89 56 with MRS *Employment 245 0 Programs Offered o categorical variables 169 APPENDD( N 170 APPENDIX N Clubhouse ID Clubhouse County Community Unemployment Rate 01 Alpena 7.8% 05 ’Clinton-Eaton-Ingham 2.8% 07 ’Emmett-Charlevoix- 10.9% Cheyboygan-Otsego O8 Genessee 9.8% 11 Houghton 6.4% 12 Huron 5.8% 14 Isabella 3.9% 17 Kent 3.2% 20 Lenawee 3.8% 21 Livingston 2.6% 23 Macomb 3.3% 27 Missaukee-Wexford 7.2% 30 & 31 Oakland 2.5% 36 St. Joseph 3.6% 38 Washtenaw 1.8% 39 & 42 Wayne 3.9% " indicates joint counties and employment rates are summaries 171 REFERENCES 172 References Andrews, H., Barker, J ., Pittman, J ., Mars, L., Streuning, E. & LaRocca, N. 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