Journal of Psychosocial Nursing and Mental Health Services

The Clubhouse Model as Exemplar: Merging Psychiatric Nursing and Psychosocial Rehabilitation

Sarah P Farrell, PhD, RN, CS; Evadne S Deeds, MS, CRP

Abstract

Many principles between psychiatric nursing and psychiatric rehabilitation overlap - so much so that psychiatric nurses have much to learn from and offer to the field of psychosocial rehabilitation and the psychiatric rehabilitation approach.

Psychiatric nurses should be familiar with psychosocial rehabilitation, as many psychiatric nursing beliefs are congruent with those of psychiatric rehabilitation.

A training site for undergraduate nursing students at a local clubhouse has served as a natural setting for psychiatric nurses to train for and contribute to the field of psychiatric rehabilitation.

Psychiatric Rehabilitation

The mission of psychiatric rehabilitation is to increase the functioning of persons with psychiatric disabilities so they can be successful in their environments with the least amount of ongoing professional intervention (Anthony, Cohen, & Farkas, 1990).

Psychiatric Nursing

Psychiatric rehabilitation has been practiced by a variety of mental health professions. Many psychiatric nurses have not embraced the tenets of psychiatric rehabilitation fully, however, and have been absent in some of its program development over the past 10 to 15 years.

Although nursing educators tend to steer clear of many psychosocial rehabilitation settings, practicing community mental health nurses actively engage in supporting principles and practices of rehabilitation (PalmerErbs & Anthony, 1995; Thompson & Strand, 1994). In general, these nurses perceive the principles and practices of rehabilitation to be congruent with the nursing process, therapeutic nursing interventions, and the role of the nurse.

Although much of psychiatric nursing takes place in the community mental health setting, historically, community mental health nurses have been called on to administer the medication clinics in these settings. Those who saw a greater role for nursing in the community often were considered therapists, team leaders, case managers, or titles other than psychiatric nurse.

The message was that nurses either gave medication or lost some nursing identity. The role of nursing often was seen as disease and symptom oriented.

Contributing to this misunderstanding is the almost exclusive use of inpatient settings for undergraduate education in psychiatric nursing. Psychiatric nursing often is taught as a setting-specific profession because practicums and clinicals often are restricted to inpatient units of major teaching hospitals.

Based on several factors, including how nursing schools are accredited, nursing clinicals may be taught with groups of 10 students per instructor. Inpatient settings provide an easy locale for group work, because patients are available and groups are structured in a geographically convenient manner. Therefore, student nurses may graduate with little understanding of the mental health system, rehabilitation or recovery models, or the patient as a consumer of services.

Setting for Nursing Education and Training

Using settings with a rehabilitation approach can enhance undergraduate nursing education because of the emphasis on increasing clients' functioning level. Much of undergraduate education involves relevant theories of human growth and development, communication, and the nursing process. Practicums in inpatient settings are more likely to highlight group and aggregate pathology and symptomatology than strengths.

Comparison of Philosophy

Rehabilitation and treatment are different approaches. Rehabilitation models evolved as an outgrowth of disappointment with traditional medical models of treating individuals with chronic mental illness (Anthony et al., 1990).

Rehabilitation approaches developed without a unified theoretical framework, but roots are found in mainstreams of contemporary psychological thought (Dincin, 1975). These include understanding of the personality (e.g., Freudian approach), understanding of behavior (e.g., Skinnerian approach), and a humanistic Rogerian approach. Combined with theories and research from the biological, developmental, family systems, and sociocultural arenas, the rehabilitation framework is unique in its combination of theories and practices.

Nursing theory developed in a similar way, borrowing from other theories and evolving over time. Nursing theories therefore seem more congruent with the rehabilitation…

Many principles between psychiatric nursing and psychiatric rehabilitation overlap - so much so that psychiatric nurses have much to learn from and offer to the field of psychosocial rehabilitation and the psychiatric rehabilitation approach.

Psychiatric nurses should be familiar with psychosocial rehabilitation, as many psychiatric nursing beliefs are congruent with those of psychiatric rehabilitation.

A training site for undergraduate nursing students at a local clubhouse has served as a natural setting for psychiatric nurses to train for and contribute to the field of psychiatric rehabilitation.

Psychiatric Rehabilitation

The mission of psychiatric rehabilitation is to increase the functioning of persons with psychiatric disabilities so they can be successful in their environments with the least amount of ongoing professional intervention (Anthony, Cohen, & Farkas, 1990).

Psychiatric Nursing

Psychiatric rehabilitation has been practiced by a variety of mental health professions. Many psychiatric nurses have not embraced the tenets of psychiatric rehabilitation fully, however, and have been absent in some of its program development over the past 10 to 15 years.

Although nursing educators tend to steer clear of many psychosocial rehabilitation settings, practicing community mental health nurses actively engage in supporting principles and practices of rehabilitation (PalmerErbs & Anthony, 1995; Thompson & Strand, 1994). In general, these nurses perceive the principles and practices of rehabilitation to be congruent with the nursing process, therapeutic nursing interventions, and the role of the nurse.

Although much of psychiatric nursing takes place in the community mental health setting, historically, community mental health nurses have been called on to administer the medication clinics in these settings. Those who saw a greater role for nursing in the community often were considered therapists, team leaders, case managers, or titles other than psychiatric nurse.

The message was that nurses either gave medication or lost some nursing identity. The role of nursing often was seen as disease and symptom oriented.

Contributing to this misunderstanding is the almost exclusive use of inpatient settings for undergraduate education in psychiatric nursing. Psychiatric nursing often is taught as a setting-specific profession because practicums and clinicals often are restricted to inpatient units of major teaching hospitals.

Based on several factors, including how nursing schools are accredited, nursing clinicals may be taught with groups of 10 students per instructor. Inpatient settings provide an easy locale for group work, because patients are available and groups are structured in a geographically convenient manner. Therefore, student nurses may graduate with little understanding of the mental health system, rehabilitation or recovery models, or the patient as a consumer of services.

Setting for Nursing Education and Training

Using settings with a rehabilitation approach can enhance undergraduate nursing education because of the emphasis on increasing clients' functioning level. Much of undergraduate education involves relevant theories of human growth and development, communication, and the nursing process. Practicums in inpatient settings are more likely to highlight group and aggregate pathology and symptomatology than strengths.

Comparison of Philosophy

Rehabilitation and treatment are different approaches. Rehabilitation models evolved as an outgrowth of disappointment with traditional medical models of treating individuals with chronic mental illness (Anthony et al., 1990).

Rehabilitation approaches developed without a unified theoretical framework, but roots are found in mainstreams of contemporary psychological thought (Dincin, 1975). These include understanding of the personality (e.g., Freudian approach), understanding of behavior (e.g., Skinnerian approach), and a humanistic Rogerian approach. Combined with theories and research from the biological, developmental, family systems, and sociocultural arenas, the rehabilitation framework is unique in its combination of theories and practices.

Nursing theory developed in a similar way, borrowing from other theories and evolving over time. Nursing theories therefore seem more congruent with the rehabilitation approach than with the medical model of symptom reduction and cure.

Nursing students may want to use principles and beliefs learned in class. However, inpatient settings often are limited to treatment approaches, with a focus on symptoms, medication, and psychotherapeutic strategies such as group, occupational therapy, and recreational therapy.

History of Community Mental Health

The Community Mental Health Center Construction Act of 1963 provided matching federal funding to states for the development of comprehensive community mental health centers (Foley & Sharfstein, 1983). However, the goal of building and staffing community mental health centers (CMHC) never was achieved, with the change of administration and passage of the Omnibus Budget Reconciliation Act of 1981.

Each state implemented the public policy of de-institutionalization in different ways. In Virginia, for example, few CMHCs were built as intended. The need for community support systems was met through creation of Community Services Boards (CSBs) that provide community support through mental health and substance abuse services to the localities.

Community Support System

In the era following de-institutionalization, consumers, families, clinicians, administrators, educators, researchers, and policy makers saw that communities were not ready to accept the new challenges of providing a mental health care system (Bachrach & Lamb, 1989, 1983; Granet & Talbott, 1978).

Debate subsequent to de-institutionalization policies resulted in a federal initiative - the Community Support System (CSS). The CSS is a conceptual framework providing consistent principles for states to use in development of their own Community Support Programs (CSP).

The CSS identifies individuals ensconced in case management as the bridge to 10 areas of need: client identification and outreach, mental health treatment, health and dental services, peer support, family and community support, income support and entitlements, housing, crisis response services, rehabilitation services, and protection and advocacy.

In Table 1 , CSS principles as components of an effective community support system (Stroul, 1989) are compared with beliefs of psychiatric nursing (Taylor, 1994). Psychosocial rehabilitation and nursing philosophies evidently are more alike than different. Each views the person as a biopsychosocial being.

Philosophy and Approaches

Psychiatric rehabilitation, a term often used interchangeably with psychosocial rehabilitation, is a clinical technique that includes functional assessments and rehabilitation plans. The focus of the psychiatric rehabilitation approach is on skills rather than on symptoms (Anthony et al., 1990).

Clubhouses

Psychosocial rehabilitation is vital to community support systems. Clubhouses were developed through the National Institutes of Mental Health (NIMH) funding to states for Service Systems Improvement Projects. In Virginia, psychosocial rehabilitation programs became part of the community support systems in the respective CSBs around the state. Virginia lists 53 separate psychosocial rehabilitation programs that provide services for 90 of its 95 counties (Rebholz, 1995). Of those programs, 11 have been identified as Fountain House model programs (see description following).

The psycho social rehabilitation movement has accelerated both nationally and internationally. Currently, the International Association of Psychosocial Rehabilitation Services (IAPSRS) encompasses all aspects of community rehabilitation services offered for people with serious long-term mental illness: clubhouses, case management, peer support, employment, and consumer and professional training.

Fountain House Model Clubs

The "Fountain House model" is a phrase often heard at conferences and seen in the literature. Those involved in clubhouses may inquire of another program: "Are you a Fountain House model program?" There are many factors that set the Fountain House model apart from others; Fountain House programs enjoy strict training and standards setting and a significant history.

Historical significance

Fountain House began in the late 1940s in New York City when a group of former state hospital patients began meeting on the steps of the New York Public Library to seek fellowship. The group, known as We Are Not Alone (WANA), organized into a social club known as Fountain House.

In 1955, John Beard, a community mental health pioneer from Detroit, infused professional staff with a major prevocational program. He also advised them to keep the social emphasis as a meeting place for former patients. The professional staff were to provide continuity.

Now, more than 40 years later, the term "Fountain House model" stands for clubhouses that adhere to the standards and training of the original model. Although many clubhouses take pride and honor in that distinction, changes in funding and accreditation make some of the standards unrealistic, albeit noteworthy (Beard, Propst, & Malamud, 1982).

Blue Ridge House

Blue Ridge House, funded by the Region Ten Community Services Board, was established in 1979 as a Fountain House model clubhouse that facilitates social and vocational adjustment for persons with serious mental illness. This program empowers its members to adapt to living in the community after hospital stays; to develop social supports; to increase abilities in functioning and being independent; and to learn - or relearn - skills needed to become competitively employed.

Since 1992, Blue Ridge House has served as a training site for undergraduate nursing students from the University of Virginia.

Belief system

At the core of the clubhouse model is the message relating to the importance of membership, and of being expected, wanted, and needed. In addition, there are four fundamental beliefs that drive the model:

* A belief in the potential productivity of the most severely disabled psychiatric client;

* A belief that work, and the opportunity to aspire to and achieve gainful employment, is a generative and reintegrative force in every human being, and therefore must be the central ingrethent of the Fountain House model and must underlie, pervade, and inform all activities that make up the lifeblood of the clubhouse;

* A belief that people require opportunities to be together socially;

* A belief that a program is incomplete if it offers a set of vocational, social, and recreational opportunities, yet neglects the circumstances in which its members live. Thus, housing programs are explored and considered for individuals. The clubhouse does not provide residential programs, but will work with those programs to ensure that members have access to options.

Table

TABLE 1

TABLE 1

Description of members

Each individual, called a member, has a serious mental illness. Each has a goal to increase functioning and attain satisfaction in this goal. Members are diverse in the nature of functional capacities; the common factor among members is a psychiatric diagnosis that seriously impairs everyday functioning in major life activities.

Some members also have secondary diagnoses, such as mild mental retardation, alcohol or substance abuse, and physical illnesses. Members' abilities range from people who cannot read to people who have earned PhDs.

With the support of clubhouse staff, members design their own rehabilitation plans, developing goals, objectives, and staff interventions that will increase their ability to succeed.

People with mental illness differ little from the general population. They work toward attaining a safe place to live; work that is meaningful; and the regard, respect, and love of others.

An undergraduate student attending Blue Ridge House wrote the following in her log: "Based on my inpatient experience, I tried to put a professional barrier between the patients and myself. In the community and the clubhouse I gained a great deal of respect for how people with mental illnesses struggle with the same things I do, only they have more barriers."

Administering the program depends on member involvement. The fundamental belief is that, given time and commitment, a productive and satisfying life is a reasonable and attainable goal for every member.

Standarte fer clubhouse programs

Standards for clubhouse programs fall into a number of distinct categories: membership; relationships; space; workordered day; employment; functions of the house; and funding, governance, and administration (Propst, 1992).

Membership

Membership is voluntary and without time limits. A collégial approach is the key to interactions. In the clubhouse milieu, nothing is done to clients; the clubhouse, members, and staff work together with one another.

The collegial relationship bespeaks respect, affirmation, and confidence in others and self. These relationships - members-staff, members-members, and staff-staff - help members take chances and attempt growth steps.

Members frequently suffer from the negative symptoms of their illness; many have lost levels of functioning because of their illnesses or may not have had needed skills to begin with. Participants greet, welcome, and give and receive support from one another. They increase their ability to make choices about every aspect of their Uves. They learn to deal with challenges, problems, and life management, and support and encourage others to do the same things.

As members leave the club to pursue increased activities in the community, they serve as effective role models for other members, who see that success can be achieved. They are supported, formally and informally, by the clubhouse community.

Staff

Clubhouse staff have generalist roles and are full time. The number of staff is intentionally small to facilitate members' own responsibilities.

The clubhouse has its own identity, including name, address, and telephone number. Staff in a psychosocial program such as Blue Ridge House function differently from many mental health treatment modes. They help members identify unique ways each can contribute to club operations. Staff find ways to accentuate the positive contribution of each member, emphasizing strengths and capabilities.

Staff effort tends to be informal and relationship oriented. By de-emphasizing the patient status of the member, staff create an atmosphere where the member's inner resources may grow and counter the negative impact of the illness. As documented in nursing literature, relationships foster hope, a therapeutic concept (Byrne, Woodside, Landeen, Kirkpatrick, Bernardom, & Pawlick, 1994).

Each clubhouse staff member at Blue Ridge House carries an average caseload of 20 individuals, but the emphasis is on "working with" (Freund, 1993).

Work

The work-ordered day engages members and staff side by side in running the clubhouse. The focus is on strengths, talents, and abilities; therefore, the workordered day is inconsistent with medication clinics.

The day parallels normal working hours, 5 days a week. Leisure activities usually take place on weekends and evenings.

The value of work recently has been accepted as an emphasis in réhabilitation of persons with mental illness (Harding, Strauss, Hafez, & Lieberman, 1987). People with psychiatric disabilities are difficult to rehabilitate vocationally (Anthony & Blanch, 1987), but for a person with psychiatric disabilities, work has psychological and economic benefits.

Table

TABLE 2Occupational Areas Available in Clubhouses

TABLE 2

Occupational Areas Available in Clubhouses

Employment is encouraged and clubhouses enable members to return to normal work through Transitional Employment Programs (TEP). One Fountain House staff member, Ralph Bilby (personal communication 1985), describes how businesses and agencies can benefit mutually from participating in TEP. He quotes a Wall Street Journal headline, "When a good deed becomes a good deal." The clubhouse helps members secure, sustain, and upgrade employment.

Pre-vocatlon units

The concept of pre-vocation units is important for people with serious and chronic mental illnesses because they have lost corresponding social skills and may be experiencing negative symptoms of schizophrenia such as apathy, poor grooming, and lack of motivation (O'Connor, 1991). These negative symptoms affect work practices such as punctuality, appearance, communication in a work unit, staying with a task, and asking for time off or assistance appropriately.

Blue Ridge House offers five prevocational work units: clerical, program support, maintenance, cafe, and kitchen (Table 2). Members are encouraged to explore and choose the work unit that interests them and to assume a level of responsibility that they can handle successfully. Clubhouse responsibilities foster other skills for work, such as knowing to go to bed on time for work the next day, structuring time, and allowing time to get to work.

As they work together to accomplish these functions, staff and members often re-examine their notion of disability.

Along with "getting the job done," a dynamic agenda complements the unit activities throughout the day. This agenda, developing pre-vocational skills, includes:

* being on time

* volunteering for tasks

* following instructions

* asking for help

* learning to initiate

* attending on a selected schedule

* developing start-to-finish skills

* increasing attention span

* reducing frequency of breaks

* learning to negotiate leave

* learning to manage life events to serve employment goals

* learning to work as part of a team

* learning to accept feedback

* learning appropriate socialization with co-workers and supervisors

* learning good grooming and hygiene

* having increased self-esteem

Members have the opportunity to develop confidence in themselves as they practice basic pre-vocational skills. These will increase their potential for success in future efforts. Additionally, undergraduate nursing students, once exposed to the rehabilitation model, increase attention to their own professional behavior checklist, which is similar to the members' list.

Houses

Clubhouses are located convenient to local transportation and provide member education such as literacy and computer skills training. Members are encouraged to take advantage of adult education programs in the community.

Weekend and evening program

The inability to get along socially with other community members tends to be a huge barrier to community adjustment for persons with serious mental illness. They may be alone and isolated, with few opportunities for successful socialization.

Clubhouses offer evening, weekend, and holiday social programs that provide the experience of being with others and participating in the community through normalizing resources (e.g., shopping, recreation, movies, ball games).

Collaboration

The clubhouse seeks and maintains effective relationships with family, consumer, community, and professional organizations. At Blue Ridge House, families are encouraged to visit. Clubhouse members use the resources of the larger community, town, or city, and benefit from local community resources (e.g., universities, businesses, community colleges). Likewise, members often take their skill development to the community (e.g., volunteering in community or local hospital or reading for the blind).

Blue Ridge House enjoys the support of an organized group of community citizens and business leaders, "Friends of Blue Ridge House," who help clubhouse members with community integration. Additionally, the Family Alliance groups work closely with the clubhouse as a resource and mutual source of support. Blue Ridge House, besides its affiliation with IAPSRS, participates in the Virginia Clubhouse Association and Virginia Mental Health Consumers Association.

Conclusion

The clubhouse is a place to belong, a place for meaningful work opportunities, and a place that offers the opportunity for members to help themselves and each other develop productive and satisfying lives. The clubhouse environment may not be conducive to all working styles. Staff must be comfortable with flexibility and constantly changing roles. At times, staff need to work with members to structure the environment and set limits. A common staff role is modeling situations that members encounter in their üves so they can work on those scenarios in a safe and nonthreatening environment.

One nursing student observed a clubhouse staff member playing cards with a couple of members. The staff worker helped one member know that another member would benefit from direct feedback rather than from the staff worker. Helping this happen in the safety of the clubhouse is one step toward improving communication in the larger community.

Community Mental Health Nursing

The notion of recovery from illness is basic to nursing with its focus on concepts of person, health, environment, and transitions (Meléis, 1991). A paradigm is a standard way of seeing (Hardy, 1980). A paradigm shift takes place when new ways of viewing phenomena occur. It is a reorganization of values, perspectives, and meaning (Kühn, 1970).

Barriers to Change

The mental health system has been slow to adapt to the same changes this patient population has: that of moving the locus of care from the inpatient setting to the community. Parish (1989), a nurse writing early CSP literature from the NIMH perspective, argues that systems tend to safeguard the status quo, and identifies four possible motivations for disciplines that have been slow to adapt: vested interests in traditional solutions; profitability of non-community support approaches; affinity for the tangible; and lack of stimulus or advocacy for change.

Nurses have witnessed all of these motivations within the mental health system. With the advent of new approaches to managing care, however, advocacy for change may be possible. Undergraduate nursing students in this setting speak of a new awareness of the necessity to advocate for funding and quality programs for this population.

Opportunities for Change

Many principles of psychiatric rehabilitation are complementary and compatible with beliefs of psychiatric nursing. Both focus on social and environmental - rather than s.trictly medical - care models (Cnaan, Blankertz, & Saunders, 1992). Thus, a paradigm shift is natural for nursing as changes in health care occur and accessibility to inpatient psychiatric hospitalization declines, lengths of stay are shortened, and treatment moves hito the community.

With managed care and government agencies emphasizing accountability for outcomes of service delivery systems, nursing skills may flourish in community settings. Outcomes for care include recognition of unproved functioning, satisfaction, and quality of life rather than a restrictive focus on illness imposed and fostered by inpatient treatment models.

Implications for Nursing

The team concept in the clubhouse is similar to that of an inpatient unit. Although knowledge of clinical symptoms is helpful in the community arena, the rehabilitation staff focuses on abilities.

Integrating advantages of education in an inpatient setting with advantages of outpatient work can occur in undergraduate education. In a 10-week clinical rotation for nursing students, the students practiced developing treatment plans using the nursing process with a focus on psychopathology on a 20-bed locked inpatient unit for the first 5 weeks.

The group terminated that setting and oriented to the community mental health setting, and learned that individual psychopathology was not enough. The community focus is on recovery; the perspective of the individual recovering with strengths and abilities in concert with the community and environment. The students are asked to consider how the individual adapts and recovers based on resources of the community. What interplay exists to match the person's needs and what the community offers?

Conclusions

What have we learned about merging psychiatric nursing and rehabilitation?

First, we have learned about respect. Student logs reflect what a former patient says best: "The very least that people with psychiatric disorders deserve is dignity; simple courtesy; respect; and unequivocally, the very best services that mental health professionals can offer" (Stocks, 1995). In the most powerful sense, respect means shifting the paradigm from a narrow focus on symptom reduction to a broader focus on recovery.

A key ingrethent to understanding rehabilitation is the concept of recovery. Persons with disability do not "get rehabilitated" (Deegan, 1988). Rather than being passive recipients, persons in the community mental health system are recovering. This recovery process is the foundation on which rehabilitation services are built.

The new paradigm embraces the notion that a person with a mental illness is not a diagnosis or a group (e.g., SMI =seriously mentally ill or CMI=chronically mentally ill). Persons in the community mental health system are not cases to be managed, but individuals recovering beyond the limits of disability who can make use of appropriate services and technologies.

The advances in understanding rehabilitation models offer new and exciting ways to view recovery. The hope of living, working, and loving in a community is a significant advance from previous notions of how to care for persons with mental illness. Nursing can be part of that progress.

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TABLE 1

TABLE 2

Occupational Areas Available in Clubhouses

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