The Clubhouse Model of Publicly-funded Support

Author Thomas Insel, advocate for mental health reform, mentions the clubhouse model, where daytime facilities meet multiple needs of the mentally ill. This page is intended to help those interested in setting up a clubhouse as an intentional community for a specific vulnerable population. This content may help you to understand more context and have sources to quote when promoting your planned micro-facility. The section in bold describes a town that functioned effectively as an intentional community for the mentally ill.

In the show notes as background: There’s a paradox that sits at the center of our mental health conversation in America. On the one hand, our treatments for mental illness have gotten better and better in recent decades. Psychopharmaceuticals have improved considerably; new, more effective methods of psychotherapy have been developed; and we’ve reached a better understanding of what kinds of social support are most helpful for those experiencing mental health crises. But at the same time, mental health outcomes have moved in exactly the wrong direction. In the United States, there is a death by suicide about every 11 minutes, and about half of those who die by that method have not received mental health care. Rates of anxiety, depression and eating disorders have skyrocketed among young people in recent years. From 2009 to 2015, rates of emergency room visits for self-harm more than doubled for girls ages 10 to 14. Thomas Insel understands the contours of this disconnect as well as anyone. A psychiatrist and researcher, he was the director of the National Institute of Mental Health for 13 years, and has served as a special adviser on mental health care to California’s governor, Gavin Newsom. But in his new book, “Healing: Our Path from Mental Illness to Mental Health,” he admits that even the herculean efforts made by the mental health community have fallen short. The book explores how badly we’re failing at mental health care, and how much more we could do with what we have already discovered, and what we already know. “Put simply, the mental health problem is medical,” he writes, “but the solutions are not just medical — they are social, environmental, and political.”

…about social isolation, whether or not ours society has evolved in a way that has eroded community, that has led to unusually small families, less support than we’ve seen for people at most times in human history. What is the context in which the people layer, the social layer of mental health plays out now. And how do we we need to understand that as a contributor or possible solution to the problems people have? …we are running an experiment on our society in which we have made people much more mobile, in which family size has gotten a lot smaller, in which—this is not true for everybody obviously, but it is true for a lot of people—in which when people are young they move often away from their social support networks at the time when they need a minimum support. We often seem to me to be optimized for people’s 20s. You move somewhere, you’re pursuing a job…but then as your life changes and you needs support, you have children, you have health problems, you age, mental health problems, all the things that make us interdependent on others, our lives are in places where we don’t have a lot of support for that, and our families are much smaller and what we can ask of each other is somewhat less, so you talk a lot throughout the book about isolation as a cause here, but you say that social isolation is the most under discussed dimension of serious mental illness that there is, and I was thinking about that for this, because when you think about whether not we’ve created a society that is poorly set up for mental illness, we have all these policy solutions we’re talking about, but one way in which the past might have been better is that there was simply more community. There’s other people who knew you, and so I’m trying to draw you out a little bit on this question, because there are things policy can do, but it can’t do all this, and we’ve used the word family a bunch of times but around the edges… families people are out seeking care and help from policymakers, but families are the people that deal with this for the most part, families are the places where people with illness go to back to when they are out of the mental hospital or wherever, so the actual question of how it gets dealt with in a real way would be much more located in family and the community than a lot of policy is making it sound [response by interviewee]. Yes and no …I’m going to push back a little bit but this idea that policy doesn’t help us to create family and community ’cause I think absolutely it could and should. This is another area of American exceptionalism where we have not committed to that in this country. It is not a value for this country, never has been, and that shows up particularly now….Vivek Murthy, who’s surgeon general is a good friend, he’s done a terrific job in pointing this issue out around this sort of disconnection we all have in an era where everybody is online connected more than ever supposedly, there’s a greater sense of loneliness, which is different than being alone, but a sense of loneliness … that is a feature of mental illness which is one of the most disabling and difficult. When you talk to people who recover they almost always start by telling you about a person who had their back, someone who who they trusted who gave them hope. And so in putting my vision about how to fix this problem together I came up with those three ps. That wasn’t my idea to idea very wise street psychiatrist in la who also was running the la county department of mental health, Jonathan Sharon, who said, “it’s really people, place, and purpose. If you provide those, people will in fact recover. So the first part of that, the social support is I think entirely critical, and it’s a great place to start, and it could come from family, it could come from a peer who’s been down this road, it could come from a neighbor. There are all sorts of ways to make that happen, and to build it into policy starts with things like having parental leave. It’s not in our value system, and I do think there’s a policy issue here that we ought to bring front and center. That’s one of the reasons why I said the problem here is medical, but the solutions are social, environmental, and also political. We need to actually get on top of this and say, “Hey, we care about community, we care about family, we care about making sure that people are not lonely, and we will build pieces into place to make sure that happens.” That’s where I mentioned the clubhouse, which is just one example of what we can do to make sure that happens. (59:00)

[Interviewer] One of the parts of his work is that it really affected me in the way I think about it, is the way that loneliness changes people’s social nature. It makes them more wary, it makes them more snappish…because it activates a sense of threat at an almost biological level. It also makes people a little harder to help. And that is so much truer for mental illness. I mean people who were very depressed or schizophrenic, and of course psychotic who struggle a lot with anxiety…it often ends up isolating them, and so that then creates the conditions for those conditions to worsen. I’m curious, not here on the policy level but on the human level, how you tell people who do have some degree of severe mental illness around them, to maintain that connection without feeling sometimes like they’re downing themselves. [Response by interviewee] So obviously this has been contentious piece of the history of healthcare for many years families were considered part of the problem not part of the solution, and they’ve been kept out and sometimes they still are, and one of the ways in NAMI that advocacy organization can be so helpful and has been helpful is to engage them and to make sure that they do advocate for being part of the solution, because they are critical, and they will be. When I was writing the book , one of the kind of inconvenient truths that just kept coming up over and over again, what became of clear to me was that families are really critical, so let me turn this around a little bit, because I think your focus on the loneliness and the kind of despair that comes with that and that sense of futility is really for me an invitation to say it doesn’t have to be that way, that we can provide a lot of support here, so this isn’t like having to come up with an MRNA vaccine. This is coming up with an individual, maybe somebody who’s had a similar experience who wants to be helpful, wants to pass it forward, and can actually make a huge difference. This isn’t incredibly expensive. It’s not incredibly high tech. It’s not really a mystery. You don’t need stem cell biology to do this. You simply need to be willing to engage people who care, and help them to reach out to someone who’s been really struggling. We have this whole new peer movement, which I think is going to transform the way care is provided. I’m actually in the middle of starting up a company that’s actually trying to scale this, so that we’ll have a chance to see how all of those recovery services not only work at scale, but they actually save money for the healthcare system. They reduce the amount incarceration. They reduce a lot of the other problems that we’re seeing downstream, simply because a lot of what we is simply provide social support to people who’ve become very isolated and kind of locked into their own paranoid grandiose psychotic world that is not where they need to be…. It’s this small town that’s been around since the 12th century where there was a myth about a murder that took place there that was really horrendous and a shrine there that was developed for the saint who died defending her purity in the 13th 14th 15th century families began bringing their children to the shrine and there were enough of them that as the town grew, the families would sometimes leave the kids there, and the young people would stay behind, often people with serious mental illness or something like that and they ended up being taken in by the community as what ultimately became a kind of adult foster system, so they would work on the farm. They would essentially be part of a family, and this has gone on over hundreds of years. And it’s this beautiful story about a different approach that really is about inclusion and acceptance. By the way it’s different than where I’m coming from and a lot of advocates are now, which is saying we need recovery. They don’t really say people need to recover. They just say people need to be accepted and they can contribute. That really is a story that we do need to hear, that there’s a different way, because what we do here [in the U.S.] is we incarcerate people. We let them become homeless. And we do as little as possible to help them recover. (1:06:25)

Reference: New York Times. (2022, July 22). A top mental health expert on where America went wrong. The Ezra Klein Show [Podcast]. https://podcasts.apple.com/us/podcast/the-ezra-klein-show/id1548604447?i=1000570786999

Book recommendations: Nobody’s Normal by Roy Richard Grinker, American Psychosis by E. Fuller Torrey, Crazy by Pete Earley

Mentions: “Wealth-Care Reform” by Ezra Klein, “Together” by Vivek Murthy, “Vivek Murthy on America’s Loneliness Epidemic” episode from Vox Conversations