Introduction

Since the original founding of Fountain House in the 1940s in New York City, the Clubhouse model of psychiatric rehabilitation has a long and rich history. With the increasing influence of the concept of “recovery,” though, some critics have raised questions about the degree to which this model can be considered “recovery-oriented” in its approach to integrating persons living with serious mental illnesses into the workforce and into the broader life of their local community (Raeburn et al. 2015). With over 300 clubhouses operating in 34 countries around the world (Clubhouse International 2016), these questions are of some consequence.

The key issue at the center of this debate is that of whether the skills that members learn, and other psychosocial gains they may make, within the context of the clubhouse can be transferred to other arenas of members’ lives. Whether, that is, developing a meaningful life and sense of belonging within the clubhouse leads to developing a meaningful life and sense of belonging within the broader community outside of the clubhouse. As one example of this concern, Raeburn et al. (2013, p. 1) fault the Clubhouse model for risking the promotion of “service dependence,” meaning that members come to rely exclusively on the clubhouse for meeting all of their social-emotional needs and therefore remain members for life. Gumber and Stein likewise argue that “clubhouses’ current emphasis on activities that focus on practical, work, and social skills may not be sufficient to help members feel more integrated into their community” (Gumber and Stein 2017, p. 9). Their study surveyed factors associated with community integration experiences of 92 members from different clubhouses in New York and found that: “Perceived support from family may be a key community support associated with adults’ views of social integration both within and beyond the clubhouse setting” (p. 8); findings that are consistent with previous research (Biegel et al. 2013).

In the following, we report one component of the findings of a systematic review of qualitative and quantitative research on the Clubhouse model that speaks to this issue of community inclusion. This component of the study specifically explores how members, staff, and family members experience the contributions of the Clubhouse model to community outcomes. Our companion review of quantitative studies of outcomes will be published elsewhere. While both quantitative and qualitative studies have been conducted on this model over the last 75 years, a clear picture of these outcomes has yet to emerge across the diverse societies in which this model has been implemented (Tanaka and Davidson 2015b). Given the aforementioned criticism of the model, and the significant role social and vocational arenas play in promoting overall wellbeing, irrespective of psychiatric status, explorations of the role such arenas can play in helping individuals accomplish their life and vocational goals may be useful in guiding future policy and practice.

Methods

To produce an overarching synthesis of what has been learned about the role of the clubhouse in promoting community life, meta-ethnography was used (Noblit and Hare 1988). This method is particularly useful when synthesizing qualitative findings across studies about the same topic (Zimmer 2006). Meta-ethnography involves the following seven steps: (1) getting started, (2) deciding what is relevant, (3) reading the selected studies, (4) determining how the studies are related, (5) translating the studies into one another, (6) synthesizing translations, and (7) expressing the synthesis (Britten et al. 2002; Noblit and Hare 1988). The core component of the interpretation of meaning contains three levels (Hammer et al. 2009; Zimmer 2006). This means that the results of individual studies are not simply compared and reported, but a higher order understanding is sought trough synthesis of the individual findings. The first level of interpretation is identified when reading the original authors’ presentation of participants’ experiences (first-order concepts); the second level is identified when collecting, comparing, and analyzing the key themes or concepts across selected studies (second-order concepts); and the third level is created when identifying and synthesizing higher-order constructs across selected studies (third-order concepts). Importantly, the meanings expressed in the raw data (quotes in original studies) are used to validate third-level interpretations (Britten et al. 2002; Murray and Stanley 2015; Zimmer 2006).

This work requires that investigators to engage in advanced hermeneutic processes of meaning-making, that is, “puzzling together” collages of text bodies, similar to how a bricoleur “works with his hands and uses means comparable to those of a craftsman” (Kinn et al. 2013; Lévi-Strauss 1966, pp. 16–17). A bricoleur is creative and open-minded, combines different materials and techniques, and builds new constructions of previous constituents in playful movements between imagination and reality (Kinn et al. 2013; Lévi-Strauss 1966). Unlike step-by-step processes, a synthesizer works as a bricoleur; by intuitively stepping back and reorganizing pieces of text to construct new meaning outside of traditional limitations of creations (Kinn et al. 2013). What we hope has emerged from this process is a rich and complex picture that integrates findings that emerge as consistent across individual studies.

Systematic Search

The research group (L.G.K., K.T., L.D.) established criteria for which studies were to be included in two phases. Initially, it was planned to examine qualitative and quantitative evidence concerning perceived and measured effects of the Clubhouse model, using the matrix method and guidelines for systematic review outlined by Garrard (2014). Following this decision to locate the broader clubhouse literature, the first author (L.G.K.) and a librarian carried out a systematic key word search in the following five electronic databases: AMED, EMBASE, Ovid MEDLINE (R), Psych INFO, and Cinal. Being aware that there is limited research on this topic and that the model dates back to the 1940s, we did not limit the search by any subject terms related to diagnosis or population, and we imposed no time limits. The following subject terms, which were modified for each particular database, were used: ‘Fountain House’ OR ‘Club House’ OR ‘transitional employment’ OR ‘work-ordered day’. In addition, a hand search of reference lists of all potentially relevant articles and names of first authors of the included articles were checked. These two search strategies identified a total of 690 articles. Following the removal of duplicates, 411 articles remained.

Inclusion Criteria

Preliminarily peer-reviewed original research papers in English using recognizable and established quantitative and qualitative methods were included if they were about those with experience with a clubhouse; adults with SMI/members, staff, or relatives of members. No geographical criteria were set. The review process was carried out in three phases. First, the first (L.G.K.) and second (K.T.) authors screened and reviewed all 411 titles and abstracts independently. They identified both qualitative and quantitative studies that might be related to the overall research question (subjective and objective outcome of clubhouses). Secondly, review decisions were compared and discussed, leading to agreement on 68 potential articles, both qualitative and quantitative. For the overwhelming 343 studies that were excluded, it was clear that they were neither quantitative nor qualitative primary research. Consequently, theoretical articles, meta-analyses, meta-syntheses, book reviews, letters to editors, non-peer reviewed articles, and program descriptions were excluded.

Third, the first and second authors read the 68 articles in full text. However, 21 were excluded, as they neither matched the research question nor the inclusion criteria. Next, each of the remaining 47 articles was listed and described in two preliminary matrixes: one quantitative and one qualitative. Each matrix was presented to the research group (four co-authors). Unknown articles were shown in full text on a screen. During this process, the research group excluded six more studies due to their not being empirical. Given the total number of articles and differences in method, the research group decided to conduct two systematic reviews: one meta-ethnography, including 11 qualitative articles, and one descriptive synthesis, including 30 quantitative articles. The latter review will be reported elsewhere.

For the meta-ethnography, the research team avoided rule-based judgments, used no checklists and evaluated the qualitative studies in a reflexive hermeneutic dialogue (Stige et al. 2009). Accordingly, no articles were excluded on the basis of quality alone. However, as recommended by Campbell, the following two screening questions were used: “Does the article report findings of qualitative research involving qualitative methods of data collection and analysis and are the results supported by the participants’ quotes?” and “Is the focus in the article suited to the synthesis topic?” (Campbell et al. 2003, p. 674).

Sample

Key features of the included qualitative articles are described in Table 1. Five studies wee conducted in the USA, one in the USA/Finland, one in Sweden, one in Canada, one in Korea, and two in Australia. The methods used for qualitative analysis include: grounded theory (5); unspecified qualitative approaches (3); a narrative approach (1); and a hermeneutic phenomenological approach (3). One study built on previous quantitative studies (Biegel et al. 2013; Pernice-Duca 2008; Pernice-Duca et al. 2015). The data collection methods employed were in-depth and semi-structured interviews (7); observations (2); focus groups (3); or a combination of these. A total of 202 clubhouse members were involved. The samples ranged from 4 to 105, aged 18 to 65. There were 34 clubhouse staff, and there were 35 relatives of clubhouse members, aged 25 to 89 years. Both males and females were involved in all samples.

Table 1 Studies describing members, staff and family experiences of the contributions of the clubhouse model included in the metasynthesis
Full size table

Analyzing and Synthesizing

Determining How the Studies are Related and Identifying Second-Order Constructs

The first (L.G.K.) and second (K.T.) authors followed Noblit and Hare (1988) third and fourth steps. Separately, they read the included articles repeatedly and discussed them. The first author developed mind maps of the articles’ results sections: brief outlines of main findings (second-order concepts) and selected verbatim quotations of informants’ perspectives (first-order concepts). Next, features from the articles—authors, year of publication, country of study, sample of informants, context, data collection, and data analyses—were logged in a preliminary table. This draft resulted in a final table, listing citations and location, purpose, design, and subjective outcomes (Table 1). To be faithful to the original meanings and concepts, the terminology used in the included articles was preserved in the grid. Tables and summaries were presented and discussed in the research group.

Determining How the Studies are Related and Translating the Studies Into Each Other

The first author (L.G.K) recorded second-order concepts across the 11 included articles in a preliminary matrix, and presented it to the research group. Noticing common, recurring themes (second-order concepts) as well as areas of divergence and dissonance, the research group compared and contrasted how the second order concepts across the studies were related to each other. The research group agreed that the concepts were comparable (reciprocal translation analysis) (Noblit and Hare 1988). Mind maps of each article, or the original articles when necessary, were used to re-contextualize reinterpretations. Then, the research group translated comparable second-order concepts into each other by hand. Using a whiteboard, they categorized and coded concepts into a preliminary “mixture.” In these intertwining processes of second-order concepts, the following questions were asked: “What is this grouping about? How does it relate to the review question? How is it similar to or different from all the other groupings?” (Murray and Stanley 2015, p. 183). Thereafter, the research group continued in carefully performing a thematic analysis and interpretive reading of the meaning of the concepts (Noblit and Hare 1988). This process involved an analytical development of preliminary third-order concepts. For instance, across studies, they recognized that clubhouses were similarly described as places that facilitated members’ growth. Consequently, this evolved into the theme “Creating Ways of Flourishing” described below.

Synthesizing Translations

The first author (L.G.K.) continued processes of synthesizing second-order concepts, which involves processes of comparing and contrasting united concepts across the original studies. The final third-order concepts and the metaphor were developed and discussed on Skype with the last author (L.D.): By refreshing ways of analyzing and understanding the original findings (second-order concepts), we (L.G.K. and L.D.) created new overall meanings of the studies’ elements (third-order concepts). For example, as the synthesizing processes progressed, we synthesized second-order concepts such as clubhouses as “a haven”, “a respite”, and “a helpful, welcoming place to reconstruct life” into the third-order concept (theme): “Stepping out of limiting realities.” Likewise, the research group thoroughly synthesized all second-order concepts, creating four third-order concepts (themes), outlined below. Moreover, to construct new knowledge about the phenomenon under exploration, the research group wove the third-level interpretations together (a line-of-argument synthesis) (Noblit and Hare 1988) into the overarching metaphor “Pushing the Boat Out.” The second author (K.T.) and third author (C.B.) validated the metaphor and the third-level concepts (themes) by email.

Results

The metaphor “Pushing the Boat Out” was chosen because it best captured how 202 members, 34 staff, and 35 family members interviewed in the included articles experienced the Clubhouse model for adults living with serious mental illnesses. The following section outlines the rationale behind this metaphor and frames third-order concepts within this context.

“Pushing the Boat Out”

Parallels can be seen between how clubhouses are valued—as places for members’ attachment to others and to a shared place—and ways in which boats on seashores are commonly perceived. As conveyed in an old American saying (Shedd 1894), “Ships are safe in harbors, but that’s not what ships are for.” Seamen need assistance to push their boats out into the water. Clubhouse members need help to push themselves out into the “conditions of getting a life” in order, hopefully, to flourish not only inside but also outside of the clubhouse.

This metaphor was chosen, in part, because everyone needs help “to push their boats out,” not just persons with disabilities. For centuries, seamen have built boats that are too heavy to move alone. Comparably, over the course of a lifetime, people—both with and without mental illnesses—may experience personal or social burdens that are too heavy to carry alone. In such conditions, when people may be neither capable of undertaking valued activities nor to connect to their loved ones, many are left to feel lonely, useless, and miserable. They may not be able to manage their concerns alone, may find it difficult to join with others, and may not be offered the right kind of help. As a result, they may become “stranded” on their own deserted island. On the other hand, they may find others who can be helpful in lifting their burden or encouraging them to re-engage in life. Despite such encouragement or companionship, people may struggle to trust these others or take a risk in stretching their comfort zone. They may have difficulty grasping the right moment, “jumping into the boat” in a safe way, or may have difficulty paddling safely through the vicissitudes of everyday life.

Usually, a seaman, being located on the beach beside his boat, experiences vital “moments,” that is, emotional and bodily awareness of how the world works, such as textural feelings of dry sand, wet sand, rocks, shells, seaweed, wind, sea, sun, and maritime activities. Similarly, a clubhouse (“beach”) can be labeled as a nice place where members learn how everyday life works, such as developing friendships, skills, routines, and roles and making contributions. Clubhouses offer members significant time-outs from disenfranchised and complicated lives. Clubhouses can be like “calm beaches”—comforting, protective bays for people to anchor on.

However, because people tend to choose secure and familiar places, it may become difficult to leave, “to push their boats out” into the sea (i.e., the society and workforce). A seaman needs help to release his boat from hindering spots (i.e., a lack of scaffolding or a stony beach). A clubhouse member may need help to “let go” of his or her doubts, chaos, mistakes, and negative inner voices. However, because asking for and receiving help from others is embedded within acts of generosity, as well as puzzling behaviors of give and take, it might be difficult—for both clubhouse members and seamen—to push their boats out. Within the context of this overarching metaphor, four themes related to subjective outcomes of the CH model emerged from our meta-synthesis of the literature: (1) stepping out of limiting realities, (2) anchoring, (3) creating ways of flourishing, and (4) prospects of a life outside the clubhouse.

Stepping out of Limiting Realities

Across the included studies (Carolan et al. 2011; Coniglio et al. 2012; Dorio et al. 2002; Kang and Kim 2014; Kennedy-Jones et al. 2005; Tanaka and Davidson 2015a; McKay et al. 2012; Norman 2006; Pernice-Duca et al. 2015; Perrins-Margalis et al. 2000; Schiff et al. 2008) narratives revealed that clubhouses’ organizational and social structure provided persons living with mental illnesses with the context necessary for creating meaningful lives, that is, a sense of interconnectedness and “respite” (Tanaka and Davidson 2015a) from troublesome lives. Clubhouses were described in varied but positive metaphorical terms, such as “an in-between, cultural playing arena”. (Norman 2006, p. 190), a “haven” (Kang and Kim 2014, p. 472), “home,” “hometown,” and a place for “being, doing, and belonging” (Carolan et al. 2011; Coniglio et al. 2012; Kang and Kim 2014; Kennedy-Jones et al. 2005; Schiff et al. 2008). These quotes illustrate that participants interviewed in all of these studies predominately valued the protecting, stimulating, and non-judgmental ingredients of the clubhouse model. As one member said:

… [a] Safe environment with people who understood just what I had been through, and not having to explain myself … I just needed to get some confidence back member; (Kennedy-Jones et al. 2005, p. 122).

For members, staff, and family members, clubhouses were “more than just work” (Tanaka and Davidson 2015a, p. 275), they were healing settings (Kennedy-Jones et al. 2005; Norman 2006). As one member said: “Helping others helps me not think about my problems. I feel like I have a purpose and can help others. It feels nice to do that when you are usually the one who needs help from others” (Norman 2006, p. 129). Several studies (Carolan et al. 2011; Coniglio et al. 2012; Kang and Kim 2014; Kennedy-Jones et al. 2005; Tanaka and Davidson 2015a), emphasized that members, working alongside staff and peers in productive and recreational activities, discovered opportunities for bonding. As another member said:

The difference is the work-ordered day and that wasn’t there at the drop-in center … If people are typing or doing the Pioneer Post they … work and make relationships at the same time which I think is very important … Whereas at a drop-in center, there is no structure. You can just sit down next to anybody and do a task and before you know it, you know them … it’s easier for me to be in a work environment and make friends than be in a ‘sitting down, doing nothing’ environment (Coniglio et al. 2012, p. 157).

Studies found that clubhouses nurtured processes of recovery, which were illustrated in members’ statements of “feeling alive” (Kang and Kim 2014, p. 474) or “getting onto the right path” (McKay et al. 2012, p. 186). In various ways, all the included studies conveyed how clubhouse activities brought into members’ lives a number of biological, psychological, and social changes. Evidently, the so-called normalizing (Schiff et al. 2008) and accepting settings in clubhouses tended to boost members’ drives, self-trust, social-capacities, and self-images. Members described positive outcomes, such as “getting aware of [my] own resources” (Norman 2006) and learning “little things…like going out with friends I met through the CH, like going to a restaurant” (Kennedy-Jones et al. 2005, p. 122). Being a clubhouse member assisted individuals in escaping isolation and developing their self-management and social skills. Like one member said: “I think it is very helpful for me to come here. To help me deal with stuff, and I am glad because if not, I’d probably be in the hospital again” (Carolan et al. 2011, p. 128). Likewise, another member explained how the clubhouse community had benefitted him:

Everything I do here has helped me to recover and it gave me myself back and that’s really good … it has helped me every step of the way ... All of this has helped because I don’t have any outside support ... being able to talk ... it’s all helped me to recover ... I know I have a lot more to learn and a lot further to go ... but now I know I can do it (Carolan et al. 2011, p. 129).

In the same vein, a third member in the same study described how staff had helped her:

I feel accepted here. I remember coming here on my third visit and I was talking to one of the staff and I remember saying that I don’t like to talk about my mental illness, and she was like, why not? And I remember thinking, maybe she is on to something, and I realized it would feel good to talk about it. And here, they understand (Carolan et al. 2011, p. 129).

Similarly, studies (Carolan et al. 2011; Coniglio et al. 2012; Dorio et al. 2002; Kang and Kim 2014; Kennedy-Jones et al. 2005; Tanaka and Davidson 2015a; McKay et al. 2012; Norman 2006; Pernice-Duca et al. 2015; Perrins-Margalis et al. 2000) highlighted the Clubhouse model’s democratic philosophy: a culture of egalitarianism and positive expectations that cultivated members’ senses of value, autonomy, and empowerment. As one member said: “I find here that your opinion does mean something—a member having an idea is not a foreign idea—like in a day program where it does not happen. Here it seems like it is fostered” (Schiff et al. 2008, p. 70). Most articles described how clubhouse members and staff valued the principle of having the right to pick between: structure versus flexibility, preferred versus imposed duties, individuals’ versus collective needs, as illustrated in the next quotations:

…. That’s really good with the CH they tend to focus on the stuff you can do … just encouraging people and they have … the work-order day …[and] the voluntary nature of the CH … you’ll constantly be asked to do stuff but if you don’t want to, that’s okay … whereas other programs you have to do what you’re told … or you have to go home (Kennedy-Jones et al. 2005, p. 122).

…The CH, a place to come and have friends, and wanting a place to type, stuff like that. Keeps me going. Gives me something to do instead of thinking about my problems all the time. Cook a good meal. They don’t force you to volunteer for anything ... Letting you work at your own pace; come out of your shell at your own pace. I prefer clerical work to kitchen work. I like banking work too (Carolan et al. 2011, p. 128).

However, there was some divergence in how the clubhouse communities were experienced. Contrasting the positive features described above, some studies (Norman 2006; Perrins-Margalis et al. 2000; Schiff et al. 2008) reported certain negative responses. For instance, some members “felt pressured by too many demands” (Schiff et al. 2008, p. 72) and others said: “when you come to a certain level you are not welcome to help anymore … tasks are delegated to certain persons” (Norman 2006, p. 188). The latter study also reported “a shy member had a hard time making his/her voice heard at meetings” (Norman 2006, p. 188). Likewise, it was stated that some members “felt misunderstood, not respected or not treated as equals” (Schiff et al. 2008, p. 71).

Of note, some studies also reported that some members found it difficult to face their own “shadows”—that is, their mental illness—at the clubhouse (Kang and Kim 2014, p. 475). They disliked being confronted with peers’ ongoing symptoms (Kang and Kim 2014; Kennedy-Jones et al. 2005), or their own losses and uncertain future due to mental illness, as well as interpersonal problems (Dorio et al. 2002; Kang and Kim 2014; Schiff et al. 2008). Member comments such as “I’m better than you are” or “I feel sorry for you” (Kang and Kim 2014, p. 475) illustrate their tendency of judgment when meeting someone who struggled with, for instance, hallucinations. Moreover, some members’ problems concerning social interactions at the clubhouse were described: for instance, they disliked peers’ puzzling behaviors (Coniglio et al. 2012), felt overwhelmed (Schiff et al. 2008), or felt “too involved in the wellbeing of others … sometimes not knowing where the boundary between caring and interfering lies” (Coniglio et al. 2012, p. 159). Despite this, the importance of learning how to solve problems was emphasized, as illustrated by one member’s statement: “It is about discussing issues. Giving advice and providing advice from experience and finding a common ground” (Coniglio et al. 2012, p. 157).

With regard to why people disengage from clubhouses, Schiff et al.’s study showed that members and staff agreed that both symptoms and improvements, such as getting a job, could lead to non-participation. However, while staff tended to explain individuals’ absences at the clubhouse in relation to “readiness,” members identified issues such as “negative factors in the organization climate and stressful interpersonal relations” (Schiff et al. 2008, p. 72) as reasons for discontinuing participation.

Anchoring

In addition, most studies (Carolan et al. 2011; Coniglio et al. 2012; Kang and Kim 2014; Kennedy-Jones et al. 2005; Norman 2006; Perrins-Margalis et al. 2000; Schiff et al. 2008) described how members feelings of belonging to the clubhouse were healing. By contributing to the collective resources in work-ordered days, members felt anchored to the place, which formed their motivations and senses of connectedness. For instance, Norman (2006) found that “work tasks became meaningful when members considered themselves as members and vice versa” (p. 188). Through their clubhouse affiliation, individuals felt related (Carolan et al. 2011; Coniglio et al. 2012), identifying staff and peers as “family” (Carolan et al. 2011; Kang and Kim 2014; Schiff et al. 2008) and like “a big brother through tough times and good times” (McKay et al. 2012, p. 186). One study (Coniglio et al. 2012), which investigated peer support within the Clubhouse model, revealed how individuals gradually transformed their roles, from being clubhouse members to becoming “unit members, then respected peers, and finally, valued friends” (p. 156). Said one member about the first phase: “You’re coming to a place where there are people and you’re not alone. Not like staying at home where you’re by yourself and you have no one to talk to” (Coniglio et al. 2012, p. 156). Most studies stated that individuals appreciated the openness and closeness of the clubhouse groups, as illustrated in several quotes below:

I just like to be around other people, socialize with other people who have problems similar to yours, people that understand you (member) (Carolan et al. 2011, p. 128)

When I was a newcomer, I didn’t know anything about the CH. So I was only participating in my unit meetings. But other members invited me to join a creative writing class. With their help, I got to know about the CH (member) (Carolan et al. 2011, p. 130).

Here I find the relationships good, they are honest, you can go in and out of them—you don’t need them all the time … It’s just the relationship thing got me here right in the beginning—at Self Help I felt like I was “a plant in the garden,” you know. They’d come and water me (member) (Schiff et al. 2008, p. 69).

The best thing about the CH is talking with my friends. We drink coffee and talk about our lives and tell jokes. I really like it (member)(Kang and Kim 2014, p. 474).

Interestingly, some studies reported how members’ personal changes had transformed or influenced their life outside the clubhouse. For example, one study, which explored how relatives of members valued clubhouses, described “less burden and greater positive family interactions” [Pernice-Duca et al. 2015, p. 446]. Another study reported that members felt like they belonged to the physical reality of the clubhouse. As one person said: “I belong to the Fountain House. Whenever I go there, there’s my spot and my history. My pictures are hanging on my unit’s wall” (Kang and Kim 2014, p. 473). Another member in the same study contrasted his positive experiences of sharing meals at the clubhouse with negative incidents from his home. As he recalled:

I could not eat with my father at the same table because I knew what he thought of me … He treated me like nobody. He also thought I did not deserve to eat because I did not make any money (Kang and Kim 2014, p. 472).

Creating Ways of Flourishing

My roles are receptionist, editing, and helper. I see myself as a contributor by coming to CH … I contribute to the functioning of the house and to other members. We give and we receive … It all gives me a sense of purpose; self-esteem and you feel like you’re not just a vegetable. You’re actually doing something worthwhile (member) (Coniglio et al. 2012, p. 157).

In various ways, the studies reported, “the combination of members’ own willpower and support from the staff as intermingled factors pushed the processes of recovery forward” (Norman 2006, p. 188). Evidently, learning and testing skills facilitated members’ growing occupational identities, through which they could connect to own short-term and long-term life goals. As one member said:

Well, yeah gaining more skills that you didn’t have previously and accessing them here … like typing and stuff like that … you can work on areas of your life and get a job … if they come here and they want to work towards a goal, they can do that. Like me, now I’m trying to work on a goal of learning how to type. Maybe I’ll do the data processing at home, and stuff like that (Carolan et al. 2011, p. 129).

These improvements were described as outcomes of members’ involvement in work-ordered days, meetings, and social events at the clubhouses. As one member said:

In the beginning, I was totally focused on work, but after a while I started to join some of the meetings. This was after I realized that I could handle the working tasks. I started to engage with what was happening around me. I joined a Sunday dinner, a working dinner, I joined a barbecue evening, and so on (Norman 2006, p. 188).

Essentially, it was revealed that participation in significant clubhouse activities supported individuals’ changes in role-identification “from sick to productive” (Coniglio et al. 2012, p. 157). For instance, Norman et al. found that “giving and gaining was a way to become aware of your resources” (Norman 2006, p. 188). Additionally, according to Norman et al., meaningful clubhouse doings were those that were “needed, necessary and part of a wider context” (p. 187). Several studies (Dorio et al. 2002; Kang and Kim 2014; Kennedy-Jones et al. 2005; McKay et al. 2012; Norman 2006) reported that the Clubhouse model, and success in occupational performance, boosted members’ personal growth, as illustrated below:

I was picked for [this] county ... for achievements and things I have done. I was surprised ... 300 people. That’s the New Me. That’s another thing I want to get good at ... learn how to speak in front of people, and say what I want to say without notes ... and be good (Carolan et al. 2011, p. 129).

Importantly, there were several stories that described members’ value of staff input towards their growth, as reflected below:

I really appreciate the philosophy of the CH too—members and staff working together. I don’t know if there are many other organizations like this—it seems like the members and staff “melt” together. For somebody coming in I think it is hard to tell them apart (M) (Schiff et al. 2008).

Most studies highlighted the helpful aspects of working side-by-side with staff and peers. For instance, Tanaka and Davidson’s study revealed that work-ordered days helped NYC members and Finnish CH members “in the issues dealing with self-image” (p. 274). The same study described how members talked about useful get-up-and-go pushes from staff: “She’s like, oh, you can do anything you want, just do it … you don’t have to worry about it, like that. And that made me feel good. (And you really do it.) Yes … I felt satisfied” (Tanaka and Davidson 2015a, p. 276). Likewise, studies (Carolan et al. 2011; Coniglio et al. 2012; Kang and Kim 2014; Tanaka and Davidson 2015a; Schiff et al. 2008) emphasized the importance of staff contributions to members’ personal development. As one member said: “Staff helped me get my trust back,” “staff gave me new life,” and “staff got me talking again” (Carolan et al. 2011, p. 129).

Prospects of a Life Outside the Clubhouse

From the perspectives of families, Pernice-Duca’s study suggested that clubhouse membership influenced individuals’ roles at home and their interactions within families. As one family member said:

Our involvement has become more positive. We talk about more positive things. He’s able to do more things. When he was younger he wanted to stay in his room and not participate in things so it’s more positive now. He doesn’t stay in his room at all now … before he’d go in and close the door and be by himself, now he likes to be out (Pernice-Duca et al. 2015, p. 452).

Moreover, several studies (Carolan et al. 2011; Coniglio et al. 2012; Tanaka and Davidson 2015a; Schiff et al. 2008) revealed how the clubhouse community of practice inclined members’ attitudes towards their own shortcomings and prospects, as illustrated by the quotes below:

I love to help out. I love it but I couldn’t do it there [in a previous employment position] because I was too slow. Here I can do it because I’m good at it and they don’t care about slowness (Coniglio et al. 2012, p. 157).

The clubhouse is work and the spirit of community–or the spirit of community and work … I think I want it in that order … We talk a little bit too much of work, but out of the work comes the spirit of community. For one member work can mean to come through the front door without taking the jacket off and for another it can be to empty the refuse pails (Norman 2006, p. 188).

Most of the included studies showed that the value of the Clubhouse model related to members’ vocational recovery lay in the opportunity it provided for participation in the broadest sense. Staff, members, and family predominantly reported that collaborative and supportive clubhouse communities qualified persons with severe mental illness to take control of their everyday lives, including manage loneliness, activities of daily living, symptoms, stress, and fatigue and address their lack of meaning and motivation. However, there were some passages that described how significant helpers had actively “pushed” individuals into the arena of work. As one member said: “They can help with employment ... like helping to find a job” (Carolan et al. 2011, p. 129). However, although some studies (Dorio et al. 2002; Kennedy-Jones et al. 2005; McKay et al. 2012; Norman 2006) explained how some clubhouses had helped members enter educational programs, transitional employment, or long-term work, there were surprisingly few success stories about members getting into paid employment. The two infrequent stories are quoted below:

They [staff] approached me one day and said: ‘you’ve been coming in and doing reception and doing kitchen … we think you would be really good doing this [TE] job … as a back-up, just occasionally … doing a couple of hours’ … ‘We could drive you to work and … [staff member] from the kitchen will be there with you and that’ll be like being in the kitchen only you’ll be doing something else … so I did that … and when I got my first pay I was like, oh money, this is good (Kennedy-Jones et al. 2005, p. 122).

A guy who I’d worked with earlier on in my career took me under his wing … he got me to do another job that I could handle and I got a bit more respect from people … [He] sort of kick-started me back on track again with my career and it’s been pretty good the last year or so (Kennedy-Jones et al. 2005, p. 121).

According to Kang et al.’s study, clubhouse members tended to distinguish between two roads to rehabilitation. The first was through paid jobs in society, and the other was by staying well at the clubhouse. Dorio et al. found that clubhouse members had more chances of keeping a job if they had good coping skills in managing their mental illness, positive attitudes, and realistic vocational goals.

Discussion

“Pushing out the boat” as a metaphor holds promise in facilitating discussions about the subjective outcomes of the Clubhouse model and for expanding knowledge about clubhouses as multi-dimensional programs that provide social, educational, and vocational opportunities for adults recovering from mental health problems. Building on previous research (e.g., Raeburn et al. (2013), this study shows that members, staff, and family predominantly experience clubhouses as helpful and encouraging settings abundant with mutual everyday activities that guide individuals into processes of personal growth. Work-ordered days boost members’ development of occupational identity and occupational competence, defined as “the degree to which one sustains a pattern of occupational participation that reflects one’s occupational identity” (Gallagher et al. 2015; Hammel 2014; Kielhofner 2008; Phelan and Kinsella 2009).

The ability to make purposeful and meaningful choices about what to do has long been known to influence people’s health and wellbeing and to be essential for their survival (Gallagher et al. 2015). Correspondingly, on a personal level, the occupations, structures, and group influences at clubhouses can be described as essential for members’ creation of their future and possible selves (Phelan and Kinsella 2009). Unsurprisingly, and consistent with existing literature (Hancock et al. 2015; Tanaka and Davidson 2015b), this study revealed that the clubhouse community contributes to members’ wellbeing in several ways. First and foremost, clubhouse members are offered the occupational choices, resources, spaces, time, and people they need to create “a new interactive me.” In other words, on a relational level, adaptation to the clubhouse community may help a member build a social identity and become involved in processes of recovery that are coupled with feelings of acceptance, hope, meaning, and belonging (Boutillier et al. 2011; Davidson 2003). Engaging in interactive activities and working alongside staff and peers at the clubhouse enables members to ground their search for meaning, relations, value, respect, and affiliation, thus offering a group to which they can belong. These aspects highlight how the dynamics among the person, occupation and setting shape people’s occupational performance (Gallagher et al. 2015; Kielhofner 2008; Phelan and Kinsella 2009). The processes of attachment demand the individual’s willingness to explore their fears and ground their motives and beliefs in productive and social engagement; in terms of our metaphor, this is analogous to “stepping out of limiting realities, anchoring and harboring the boat.”

Next, this metasynthesis revealed that clubhouse members strive to “create ways of flourishing” and “search for a life outside the clubhouse.” The individuals’ directions can be perceived by being aware of the clubhouse as a practice community, by noticing the ways individuals’ walk, or chose not to walk, into new learning circles and how they attune their emotional, behavioral, and cognitive responses towards shifting demands and tasks. Progress among clubhouse members can be observed in their ways of exploring the clubhouse’s inner and outer life: how they attend meetings and working units, show initiative, speak, share positive and negative experiences, give and take, cooperate, become visible in their doings, and when they try transitional employment. Moreover, other methods of “pushing their boats out” are revealed in individuals’ ways of telling stories about refreshed everyday life experiences: doing, being, becoming, and belonging inside the clubhouse community. Implicitly, members are involved in meaning-making processes about personal past, present and future (Davidson 2003). In so doing, many can realize that there are many ways of “pushing a boat out”; or some might appreciate being on “the beach” (the clubhouse) and continue, “to harbor their boat” there. For instance, being offered the choice of partaking in productive, meaningful occupations can help them learn about their own and others’ views about work (paid/unpaid) and reflect upon how work is understood and valued in diverse cultural contexts. The clubhouse society contributes significantly in shaping which occupations are accepted.

However, participation in work-ordered days within the context of a clubhouse community can be seen as a pathway for cultivating belonging (“anchoring”) and for offering the member spaces to grow (“stepping out of limiting realities” and “creating ways of flourishing”), including explicit acknowledgment that identities are created through engagement in a community (Phelan and Kinsella 2009). In other words, this study demonstrates in what ways the collective and relational dimensions of occupational engagement at clubhouses influence members’ formation and re-formation of occupational identity. This matches holistic and social-cultural perspectives, where occupations transform the environment as well as the person in ongoing and promising ways (Hancock et al. 2015; Kielhofner 2008; Phelan and Kinsella 2009). This finding opposes the dominant individualistic discourse in the psychosocial and vocational rehabilitation literature that tends to emphasize a person’s need to build “self-efficacy, self-confidence, self-esteem, personal success, personal motivators, personal goals/achievements, and personality traits” (Phelan and Kinsella 2009, p. 86).

Because most clubhouse members are allowed to work at their own pace and within their own space, consistent with their values and interests, they are preparing for the last step, which is to choose whether to be pushed out or not, to decide whether he or she is ready for “the real world” or the workforce. However, because “belonging is about feeling safe, worthy, accepted and loved” (Gallagher et al. 2015, p. 5), it is important to recognize that may clubhouse members appreciate protected and respectful “playgrounds.” They need to grow as “a doer” among peers and friends before they can decide to search for innovative sites (partake in the exciting but unpredictable world outside the clubhouse).

Implications

Consistent with previous research, i.e., (Biegel et al. 2013; Chen 2017), this meta-synthesis has shown that for clubhouse members, there are primarily two courses involved in the Clubhouse model: “anchoring” and “pushing their boat out.” First, to anchor, a clubhouse member needs to identify the clubhouse as a protecting, nurturing, respectful, and welcoming place to connect to. Second, consistent with previous research, i.e. (Raeburn et al. 2013; McKay et al. 2016), the implications of this meta-synthesis is that clubhouse community must prepare and empower their members for the opportunities to search for work and a social life outside of the clubhouse. When considering the implications of this meta-synthesis, our findings have shown that clubhouses are valuable peer-driven communities for meaningful doings for individuals to build self-confidence, relations, and perspective—all aspects crucial for processes of recovery. Clubhouses provide people a place to establish an anchor in a supportive environment where they can try things out and regain their self-confidence; from there, they may choose whether or when to push their boat out. However, it is important to appreciate that many members might indeed choose not to, as the seas may seem too rough, or their boat may not yet feel strong enough for the arduous journey. Further research is needed to examine members’ experiences with integration into mainstream social networks and employment. It will also be important to examine how practitioners can intentionally interact with Clubhouse members and their families to promote the individuals’ processes of social integration outside the clubhouse.