Introduction

The Clubhouse model is a type of psychosocial rehabilitation that provides individuals with mental health concerns opportunities to engage within their communities through a variety of programs and services (ICCD 2015). Programs offered within the Clubhouse reflect the “work-ordered day”, which involves operations of the Clubhouse (e.g., clerical work, food preparation, marketing); transitional and supported employment opportunities; as well as a number of social activities that are organized by the Clubhouse. The recent global pandemic caused by COVID-19 has interrupted the service provision of Clubhouses around the world, leading to many Clubhouses having to rapidly adapt their programming to meet the needs of their members. Documenting and sharing lessons learned can provide a template for innovation for other community-based mental health organizations during COVID-19.

Clubhouse Model of Psychosocial Rehabilitation

The efficacy of Clubhouse participation on various outcomes has been well researched. A recent systematic review indicates that participation in the Clubhouse decreases mental health symptoms, hospital visits, and increases overall well-being (McKay et al. 2018). Further, studies have indicated that members work more hours and attain a higher wage than individuals involved in other services (Schonebaum et al. 2006). Additionally, members have been found to show improvements in schizophrenia symptoms (Tsang et al. 2010), relationships (Mutschler et al. 2018), access to social support (Biegel et al. 2013), greater quality of life and self-esteem (Gold et al. 2016) and less feelings of stigma (Jung and Kim 2012).

Research has found that individuals with severe mental illness have smaller or less satisfactory social networks (Corrigan and Phelan 2004). Therefore, they often suffer from social isolation and do not have enough resources to depend on during times of need. Strengthening the relationships and social networks of individuals with severe mental health issues is a goal of all Clubhouses. Clubhouses provide a community for members that includes acceptance, a sense of belonging, and reduction of stigma, which in turn, promotes the development of meaningful relationships (Mutschler et al. 2018).

Mental Health Impact of COVID-19

The global pandemic of COVID-19 has had a significant impact on psychosocial outcomes due to increased isolation, financial unpredictability, and overall stress. Recent data from the COVID-19 pandemic suggests that Canadians reported increases in anxiety from 5 to 20% and increases in depression from 4 to 10% (Martin and Cooper 2020). Further, the report indicates that 33% of participants had limited access to mental health supports and 27% reported a decreased quality in supports (Martin and Cooper 2020). Research has found that those with pre-existing mental health concerns are particularly vulnerable during a pandemic due to barriers in accessing healthcare, such as discrimination, access to information, and service closure (Yao et al. 2020). In addition, the added stress of COVID-19 can aggravate pre-existing conditions due to higher stress, which has been found to be especially salient for individuals with symptoms of psychosis (Kozloff et al. 2020). This is of note as many Clubhouse members identify as individuals with a severe mental illness, including psychosis-spectrum disorders (Raeburn et al. 2013).

Purpose

The recent global pandemic caused by COVID-19 has interrupted the provision of in-person services typically offered by Clubhouses, leading to the decision to either close their centre or to rapidly adapt their programming to meet the needs of their members. In Canada, many Clubhouses decided to adapt their programming and introduce new innovations in Clubhouse services to support their members. To date, no research has been done on the experiences of Clubhouses during the COVID-19 pandemic, including member challenges, the implementation of innovations, and successes or challenges. The Mental Health Commission of Canada has recommended that services evaluate interventions during COVID-19 and quickly share the lessons learned in order to decrease COVID-19-related mental health concerns (Mental Health Commission of Canada 2020).

The purpose of the present study was to document and synthesize the experiences of five accredited Clubhouses across Canada during the COVID-19 pandemic in order to create an overview of best practices. The research questions included: What are the challenges of members during COVID-19? How have Clubhouses adapted to meet members' needs? What were the successes and challenges of the adaptations? The results can be used by other Clubhouses as a guide of adapting service provision as they navigate the pandemic and the future of in-person services.

Method

Sample

The present study employed a qualitative case study design that included five accredited Clubhouses across Canada. These Clubhouses represented Alberta (n = 1), Nova Scotia (n = 1), Ontario (n = 2), and Prince Edward Island (PEI; n = 1). Interviews were conducted with key stakeholders from each of these sites including staff, members, and directors. Stakeholders that were not able to attend an interview were offered the option to complete an open-ended interview via an online questionnaire. The sample of individuals who participated in the interviews consisted of a total of 22 participants, of which 4 identified as members. Further, 7 individuals participated in the online survey, with one of them being a Clubhouse member. The participants represented all five Clubhouses, with the range of interviewees from each site being 4 to 7. Administrative data was also collected from sites, including rates of member participation in various implemented programs.

Interview Guide

The semi-structured interview guide was derived from the integrated Promoting Action on Research Implementation in Health Services (i‐PARIHS) framework (Harvey and Kitson 2016) and included themes relevant to the research questions, including problem identification, characteristics of innovation, appraising evidence, mechanisms for embedding change, and networking. The interviews asked participants what programs were adapted; what challenges occurred after the adaptations, as well as what parts of the programs were adapted effectively. Participants were then asked to describe the process of program adaptation, which included recognizing member needs, innovation, and implementing the adapted programs. Finally, participants described both the challenges and successes of the newly adapted programming.

Procedure

Staff at the various Clubhouses were informed about the study by their Executive Directors. Members who had been a part of the implementation process (e.g., consultation, planning, executing) were also invited to participate in the study. Potential participants contacted the primary researcher to participate in the study and gave informed consent to complete the interview. The interviews were approximately 45 min in length and were conducted over Zoom. Detailed notes were taken as close to the spoken word as possible by another member of the research team during the interview. Additional stakeholders who were unable to schedule an interview due to time restraints were provided the option to fill out a Google Form containing the interview questions with long answer text boxes. Administrative data, including participation rates across programs, was provided by all Clubhouses.

Analysis

The data was analyzed using thematic analysis in order to identify themes across Clubhouse sites (Braun and Clarke 2006). The authors independently reviewed and coded transcripts and then met regularly to discuss codes and create larger themes. Consensus of the themes and organization of themes was an iterative process between original transcripts, codes, and themes. Data was collected and analyzed until saturation was evident. Themes were further refined after feedback from the Clubhouses, including staff and directors. The research was approved by the Health Research Ethics Board of Alberta.

Results

There were four major themes that emerged from the data. These included member challenges, Clubhouse adaptations, challenges with adaptations, and Clubhouse being forever changed. These themes included various subthemes that will be further discussed below and are described in detail in Table 1.

Table 1 Description of themes
Full size table

Theme 1: Member Challenges

The first theme addressed difficulties members faced during the pandemic, which included four subthemes. Participants noted that members identified increased mental health symptoms due to COVID-19; increased isolation and loneliness; difficulty accessing services; and disruption of routine, including the engagement in the work-ordered day.

COVID-19 Leading to Increased Mental Health Symptoms

Participants described that due to the uncertainty surrounding COVID-19, members experienced increases in mental health symptoms, including anxiety and depression. Members who had anxiety and depression symptoms prior to COVID-19 often experienced increases in these symptoms; while those who did not have these symptoms previously began to experience them. This was substantiated by participants who noted:

I think what has compounded for our members, is issues around their mental health, if you were already anxious, increased anxiety, already depressed, increased depression, and if you didn't exhibit these symptoms prior to COVID-19, we have seen members that are increasingly showing anxiety and depression because of the isolation” (Participant 15).

Members also described feelings of anxiety and fear surrounding the pandemic. One member reported: “I am very afraid to get the virus… I may not be back at the Clubhouse until there is a vaccine… I am really afraid of what is going to happen to me if I have to stay at home for another year” (Participant 10b).

These quotes illustrate that increased mental health symptoms were a major challenge that participants faced, and this challenge existed irrespective of mental health symptoms prior to the pandemic. The uncertainty and fear surrounding the pandemic led many members to feel anxious and depressed.

Isolation and Loneliness

The second subtheme that emerged from the research data was feelings of isolation and loneliness during the pandemic. Participants discussed that members reported increased feelings of loneliness due to being required to socially distance or isolate themselves. This often led to mental health problems for members who used the Clubhouse for social connection and were now required to isolate. A member discussed the difficulties she faced surrounding isolation: “I have so much trouble with isolation and now it’s almost like I am forced to do that, almost making [me] regret that time [I] was isolating” (Participant 3).

Other participants expressed similar sentiments around isolation, reporting that members often faced increased mental health issues when they were forced to isolation themselves. Participant 11a and Participant 11b explained that:

There was a lot of fear as to what was happening, there was definitely increased anxiety. The whole idea of the Clubhouse model being a community centre or hub is based on the model that it is important for people not to isolate. Isolation can have huge effects on people’s mental health- increased anxiety and depression.

Participants also reported feeling of loneliness during the time they were required to socially distance themselves, as opportunities for social connection became limited. Participant 5 reports this challenge: “[There is] concern for their own well-being of being isolated, even sadness of just missing the people that they would typically lean on for companionship”.

Access to Services

The third challenge that members reported was accessing services for their functional needs. Participants reported a multitude of service disruptions that members faced. When food banks and other organizations shut down this limited access to food and mental health services. In addition, accessing transportation to obtain groceries and other needs such as medications and health appointments was also a challenge for members due to disruptions in members transportation systems. Participant 18 discusses many of the service disruptions that members faced:

Food insecurity was a thing, a lot of difficulty with working around the public health and safety measures. How they are going to get to the bank or their medications? Groceries. All those things.

Limited access to transportation due to disruptions in services was also challenging, limiting opportunities to be able to get to and from essential services that members required. Participant 6 reported,

Transportation has been an issue here… our bus system here is really poor… so people haven’t been able to get out to get their groceries. That has been a struggle for people.

Disruption of Routine

The final and fourth challenge that members faced when Clubhouses closed was disruption of their daily routines. Participants reported that members struggled when their daily routine was disrupted. Clubhouse added structure and regularity for members, providing companionship, support, and meals. When Clubhouses closed, members lost the structure that had been built into their lives through engaging in the Clubhouse and work ordered day. Participant 11b discussed the need for structure that had become disrupted:

People need to be getting out. The Clubhouse for a lot of members adds structure to their day. So, I think that if we don’t have structure and we don’t get outside, these are all things that the Clubhouse model is based on. We are going to see some deterioration.

The loss of structure was repeatedly discussed as a member challenge. Participants were no longer able to come into the Clubhouse, participate in chores and work, and generate a sense of routine and consistency in their lives. Participant 6 elaborates on this:

I think the challenge in my eyes was they lost structure, so we have about 25–30 people that use Clubhouse on a daily basis, and we have people who spend four hours a day with us, who come have lunch with us, people who need employment with us, so taking out meals, taking out support and taking out structure.

Theme 2: Clubhouse Adaptations

The second theme examined the adaptations that Clubhouses implemented over the course of the pandemic, including increased communication, expansion of the meal program, and sustained program delivery through technology.

Increased Communication

One Clubhouse adaptation that was made was increasing the amount of communication Clubhouse staff had with members. This included increased newsletter provision, outreach to members, and extended access to help lines by the Clubhouse. All of these services were previously offered by the Clubhouses but were increased significantly during the pandemic. Participant 13 discusses the adaptations made to the monthly newsletters:

We used to do a newsletter once a month, now we're doing it every 2 weeks, we included exercises, always what's going with COVID, and colouring and activities that people could engage in with the newsletter.

Other adaptations included increasing the amount of outreach to members. This involved a significant increase in calls to members, with one Clubhouse reporting a 425% increase in calls and a 100% increase in call length from 2019. Across all Clubhouses, 10,663 calls were made over the months of April and May 2020. Increasing outreach was done consistently across every Clubhouse and is discussed by Participant 9:

When we started making calls, I told staff to ask members when they wanna be called and when they were available and if staff wanted to take off a couple hours in the morning, they could do the calls at night. We were trying to figure out when they were lonely, and staff started making calls every day.

Participant 18 stressed the importance of remaining in communication with members:

Consistency of reaching out with members to make the effort. I think that was the most important thing. Letting them know we are still available to them for help. Calling them and checking in and telling us about their day is so important. It was vital that we let them know that our relationships are going to continue even if the centre is closed.

Expansion of Meal Program

In response to the food challenges that were consistently reported across all Clubhouses, existing meal programs were expanded. The expansion of meal services involved delivery of meals, food baskets, and groceries to members houses. Over the first 2 months that the Clubhouses were closed, approximately 7224 meals and 242 food hampers were provided across the five Clubhouses. This was done in order to fulfill members functional needs for accessible food. One staff member reflected:

The food is now being produced by the staff in the Clubhouse. So, we did one meal a day, two meals on Friday. There is a whole group of staff that do that and then another group that delivers the meal. Members come to the Clubhouse every day to pick up the meal. (Participant 10a).

Members who could pick up their food from the Clubhouse also discussed that the food pick up provided the opportunity to engage in social connection as well as lifted some of their financial burdens. Participant 10b, a Clubhouse member, expanded on this:

Some of the benefits is that the food is free- so that is helping us financially. Also, it gives routine. I go at the same time every day, I get to see [Clubhouse staff member], and it is the highlight of my day. So, grocery shopping is a difficult thing for me due to physical health, so getting the food is helpful. I am talking to other members who are getting their food. I have become friends with a few that I haven’t been friends with before. We social distance and just talk to each other.

Sustained Program Delivery through Technology

Participants reported that Clubhouses used various technological resources to fill the gaps within their services including Facebook, Zoom, and Slack. Typical Clubhouse programming that was offered via video calls included unit meetings, health and wellness sessions, social recreation, community meetings, and housing meetings. Across the months of April and May, attendance to video meetings across the five Clubhouses was 2289 members. Participant 16 discussed the use of Facebook to deliver programming and stay connected to members:

Facebook was an easy way to touch base with people because some people don't answer phones and people would be able to reach out whenever they wanted to reach out. I know with social recreation, some people did trivia on Facebook, that went really well because you could chat back and forth… a good way to keep social connection even though you weren't right next to each other.

Members noted that having meetings over Zoom was a way that they could stay connected with the Clubhouse and lessen their feelings of loneliness and isolation. One member noted:

Currently we have unit meetings over Zoom. It gives the members the opportunity to ask questions and find out what is going on. The staff is encouraging people to call if they have problems or issues. We are still a community even if we can’t come together physically. We are not social distancing, we are physically distancing, we are still a social community (Participant 10b).

Participant 7 discussed another program that was offered through Clubhouse that engaged members in the work ordered day:

The one thing that is still challenging is getting people involved in the work order day, so that was tough to see… something that I picked up was Slack… to get people involved in the work order day. So, I started that with a couple of members, and people really liked it. As people got more and more used to it, it has become integral to keeping people involved in work.

Theme 3: Challenges to Adaptations

When Clubhouses began to adapt their programming in response to the pandemic, they inevitably faced some difficulties when implementing new changes. The two main challenges that Clubhouse faced with respect to their adaptations were found in the use of technology as well as challenges in reopening the Clubhouse.

Technology

Access to technology was a challenge that was mentioned by every Clubhouse. Clubhouses noted that some members did not have access to the internet or devices (e.g., smartphone/tablet) which limited their ability to stay connected with the Clubhouse. On the other hand, members who did have access often struggled with using the various applications such as Zoom or Slack, due to the learning curve involved with the new technology. Participant 18 discussed the technology barriers that many members reported which ultimately impaired participation in virtual programming:

One drawback about Zoom is that some members don’t have access to a computer, some don’t know how to navigate media platforms. For people who are tech savvy it’s no problem, but for other members it was more of a challenge. We are hoping to try and teach more social media platforms in the Clubhouse so that more members can click into Zoom or Teams.

Ultimately, those who were more familiar with technology had an easier time accessing virtual platforms and participating in virtual programming. Those less familiar with technology struggled with the virtual programming and were not able to participate in programming to the same extent. This is expressed by Participant 7:

Everybody reacts a bit differently, some people that were more tech savvy jump at the chance to be involved at home, members we hadn't seen involved in the Clubhouse for a while came out of the woodwork to be involved with Zoom, Slack, because it fit really well for them. The people that were not tech savvy, it hit them a lot harder and it was a lot harder to stay connected to them.

Reopening Challenges

Participants discussed challenges with re-opening the Clubhouse and following guidelines put forth by various public health organizations. These guidelines required social distancing, safety protocols, and limited number of members onsite. These barriers led to prioritizing members who were having the most challenges, limiting the time members can stay at the Clubhouse, and maintaining physical distance during side by side work. These changes are all shifts from the usual Clubhouse standards and practices, that strives for equal opportunity in participation. Participant 12 elaborates on some of these challenges:

Just how the Clubhouse is organized now is different and I am more worried about following the model now than when we were closed. For example, the “side by side work” and having to maintain a 6 feet distance and not having as many people in different areas of the building. I think we are going to have a harder time sticking with the model now than when we were doing the virtual stuff.

Many of the new safety requirements limited the time members could spend in the Clubhouse and required them to book appointments in order to come into the Clubhouse, which is a shift from the previous standards of members being able to come into the Clubhouse anytime. Participant 16 discusses the impact of some of these new guidelines:

Now that we are reopened, we have to go with guidelines of public health and safety, and we are only allowed so many members and normally everything is totally open, and everyone is working together. Some members that would come every day, and stay all day, only get mornings which is really hard to explain and for members to accept.

Another challenge with respect to reopening included prioritizing who is allowed to come into the Clubhouse first. This was often the members that were in higher levels of distress and was a significant shift from the usual standards of equal participation.

Theme 4: Forever Changed

The final theme discusses the permanency of the adaptations and innovations that have been made by Clubhouse during the pandemic. The changes that have been made have left a permanent mark on all Clubhouses, as it is unclear as to whether Clubhouses will be able to exist as they once did. Many Clubhouses reported that these changes would be permanent even as Clubhouses began to reopen, as a new and innovative way to engage members who cannot come into the Clubhouse. This is expressed by Participant 7:

I don’t think Zoom is going away permanently. It is going to be a long time for people that are vulnerable, they probably won't be able to come out until stage 3, which won't be until a vaccination, so we will want to keep the Zoom meetings at least for the rest of the year. I think they will become a part of the new norm because if people can't make it to Clubhouse they can attend and be involved from home.

Other participants reported that adapting the existing programming resulted in better programming and higher levels of engagement. This meant that these new changes could be maintained in the future to create better programming. Participant 11a and participant 11b elaborate on this:

We’re seeing members getting involved in things they typically wouldn't, or meeting people they wouldn't have before. We are a pretty big Clubhouse, that means there could be a lot of people that you don’t get to meet. So, I think that part has been an added bonus. So, I think when we do open back up, those people might stay connected with those who they met online and stay connected with activities they took part in.

All Clubhouses discussed maintaining the new programming that has been developed even after Clubhouses are fully operational. Ultimately, maintaining remote programming will allow Clubhouses to engage more members and has created a permanent change in the way the Clubhouse operates. Upon reflecting this theme to the Clubhouses, they noted that COVID-19 has been a “silver lining” in that they have been forced to push forward and innovate the way they interact with members.

Discussion

The purpose of the present qualitative study was to synthesize the experiences of five Clubhouses in Canada during COVID-19, including the needs of members and the adaptations put in place by the Clubhouses. The results provide insight into how Clubhouses continued to support members during COVID-19, despite not being able to access services in person at each Clubhouse location. These results are particularly important due to the elevated mental health concerns that individuals with mental health problems have exhibited in response to the COVID-19 pandemic.

The results of the study indicated that members reported a number of challenges during the pandemic, including increased mental health symptoms and feelings of loneliness, as well as difficulty accessing mental health services. Research has indicated that mental health concerns in Canada have risen significantly due to the COVID-19 pandemic, while access to services has decreased due to many services closing their doors (Martin and Cooper 2020). Participants noted that often their Clubhouse was the only service provider that was still offering any kind of programming, which speaks to the importance of Clubhouses during this time.

Clubhouses were able to fill gaps in mental health service provision and were also able to meet the needs of members in a number of other areas. For example, many Clubhouses noted that food banks in their communities had shut down, which led to the Clubhouses stepping in to fill this role. The importance of this resource is underscored by recent research on financial stability during COVID-19, with one study suggesting that not being able to afford to prepare during the pandemic, for example, by stockpiling food or being able to afford emergency purchases, leads to increases in mental health symptoms (Yao et al. 2020). The present study highlights how Clubhouses provided an important service to a large group of Canadians with mental health concerns that would otherwise not have their mental health or functional needs met by other services.

Clubhouses have always played a key role in supporting relationship building. This was particularly true during the COVID-19 pandemic as many members reported feelings of loneliness and isolation. However, Clubhouses were able to bridge these feelings through online programming and services, highlighting the effectiveness of creating social connection through the internet. A review by Alvarez-Jimenez et al. (2014) found similar results, reporting that internet-based support can create social connectedness, which in turn improves socialization as well as psychotic symptoms and depression. Similarly, Berry et al. (2017) found that individuals who used the social media platform Twitter to discuss mental health issues allowed them to feel a sense of belonging as well as mitigate feelings of loneliness. Clubhouses online programming effectively combated the mental health issues that arose as a result of COVID-19 to foster community, connection and combat feelings of isolation that members discussed. However, it is important to note that while technology has tremendous potential for improving social connection among those with mental health concerns, it is not a complete replacement for in person programming. Some members reported that they were eager to go back to the Clubhouse and preferred the in-house programming over the online platforms. Ultimately, both technology and in person programming play essential roles in allowing Clubhouse members to create social support networks, feel a sense of belonging, and decrease mental health concerns.

Limitations

Despite the numerous strengths of the present study, limitations exist. First, it is unclear whether the results of this study are generalizable to Clubhouses in other parts of the world, or Clubhouses that are not accredited. It is possible that the difficulties faced by Canadian Clubhouses are different from what are being experienced by other Clubhouses who may have even more difficulty accessing food security, social services, and technology. Further, in the context of the pandemic, it is possible that potential participants did not have the capacity to participate in the present study, therefore missing especially vulnerable individuals in our sample. Further, data was not collected regarding specific psychiatric diagnoses of members and how these diagnoses were impacted during COVID-19. This is important information to be captured, particularly by quantitative data, to understand how mental health symptoms changed over time and whether Clubhouse participation mitigated mental health symptom worsening. Despite these limitations, the results of the study are the first to provide insight into how Clubhouses have supported their members during the COVID-19 pandemic and will assist others in navigating challenges as they arise.

Implications

The present study highlights how Clubhouses in Canada were able to adapt quickly in order to meet the needs of their members. The adaptations that were put into place were developed with the Clubhouse Standards as a guide, leading to successful implementation due to the adaptations aligning with the organization's values. Importantly, other organizations that have a collaborative, recovery-oriented approach may benefit from the approach that was taken by Clubhouses. Participants noted the theme that Clubhouse is forever changed; however, it is evident that as long as Clubhouses are guided by the recovery-oriented standards that inform their work, members will have their needs met.