It's Monday morning at the East Corner Clubhouse in El Cajon. In a combined meeting/dining area, maybe 700 square feet in size, 30 people are spread out amongst two tables and three rows of chairs. The majority of the group seems barely awake; one guy dozes in a chair, his head tilted back against a wall. Several sip from cups of coffee. The lethargy is palpable and it's difficult to keep from yawning.
Joan Cefalu, the clubhouse program director, sits at a desk in the middle of the room from which she, with help from two facilitators, will spend the next 40 minutes figuratively grabbing by the shoulders as many attendees as possible and trying to shake them out of their funk. Their vehicle for rousing the dozers is the standard Monday question: so what did you do this weekend?
Laundry, says a guy to Cefalu's right. She reminds him that he told her last Monday that he had spent the weekend doing laundry. She asks him what else he did. He tells her he stayed in bed. "There's nothing else better to do," he says.
"Call somebody-call a friend," Cefalu replies.
"I'll be going out to dinner with a friend in a couple weeks," he tells her. Good, she says, you gotta get out. It's a message she'll repeat several times, hoping it'll sink in.
"There's a lion out there," he tells her.
The comment seems to phase no one and without missing a beat, one of the facilitators jumps in. "Yeah," he says with a grin, "there's a lot of lying going on out there."
San Diego County has nine "clubhouses," like East Corner, where folks with serious mental illness can go to socialize, get job training, take part in organized activities-essentially to get out of their apartments, assisted living homes or board-and-cares where they might otherwise spend the day doing little more than watching TV or laying in bed-activities that would eventually make even a mentally fit person become depressed.
The clubhouse concept started more than 50 years ago in New York City when 10 patients in a state mental hospital realized that self-help within a supportive community was the best route to recovery. Upon discharge, the group moved into a 4,000-square-foot Brownstone with a fountain in the back and dubbed the place "Fountain House." Since its inception, Fountain House has had 16,000 members and serves as a model for clubhouses in the U.S. as well as worldwide. The mission statement of Hillcrest's Meeting Place clubhouse echoes Fountain House's founding ideology: "The clubhouse is set up to offer members the feeling of belonging to a large family. Instead of providing institutional "treatment,' The Meeting Place offers... opportunities denied to anyone who has lived apart from society: jobs, companionship, housing, acceptance."
A day at the East Corner Clubhouse, open usually from 8 a.m. until 4 p.m., might include a half hour of gardening in the building's decent-sized yard, 45 minutes of meditation, lunch, a computer class and maybe a group field trip. Membership is free, lunches cost $1.50 and members are expected to help maintain the facility and take a lead role in planning programs and activities. In mental health parlance, clubhouses are referred to as "consumer-driven programs."
Cefalu says that skills people learn at the clubhouse-anything from how to take a bus around town to vocational training-are intended to fill gaps in their lives where important stages of development might have been lost to mental illness. The onset of schizophrenia, for example, usually occurs during a person's early to mid 20s when that person might otherwise be going to college or starting a career. It could take 10 years, however, for the illness to be diagnosed and brought under control.
"Once people have reached stability, they come to a point where... whatever that step is that they didn't do, they need [to do] to re-enter society," Cefalu explained.
Unless you've been there-trapped under the weight of depression, stuck on the low side of a bipolar cycle or simply terrified of what the outside world might hold in store-it's hard to understand how it feels to be sapped not only of initiative but also the belief that you can take steps toward improving your life. People with mental illness can become "career patients," says Dr. Piedad Garcia, the county director of adult mental health services. In order to move towards recovery, a person has to belief that they can and will get better.
"You as a client have been taught, "You're not going to be cured; you're going to be mentally ill for the rest of your life. You're not going to work, really, because look at you'-that's kind of the attitude," Garcia told CityBeat. "We've had to educate clients in, "Yes you can do it.' We've had to empower clients to know that they can manage their own illness."
Zaidoon Alkhashin has been coming to the East Corner clubhouse for five years. Diagnosed with schizoaffective disorder-a combination of schizophrenia and mood swings-he was once a math major at San Diego State University, but his illness forced him to drop out one year short of a degree. Alkhashin said he recently spent five months in the hospital, and for the month and a half since he's been out, he hasn't missed a day at East Corner.
"People who don't come here stay in bed all day," he said. Stay in bed and you'll end up in the hospital, he explained. The more active you are, however, the more you'll benefit. The clubhouse's monthly newsletter for November features a poem by Alkhashin-one of 60 he's written since being hospitalized. "This place is like no other," the poem reads. "I'll be coming here for a long time, to keep me going in life."
Clubhouses operate under the philosophy of biopsychosocial rehabilitation, commonly shortened as psychosocial rehabilitation. Marty Adelman, who heads East County services for the Community Research Foundation, the East Corner Clubhouse's parent organization, describes psychosocial rehabilitation as focusing on "the whole person and everything that affects that person-biology, psychology, social interactions with people."
Psychosocial rehabilitation's been around for 20 years, but it's only recently been recognized by the mental health field as a "best practice"-a model for treatment. Previously, medication ruled as the best, and sometimes only, way to treat severe and persistent mental illness. And up until the 1960s, the mentally ill were often forcibly institutionalized. (California's 1967 Lanterman-Petris-Short Act made involuntary hospitalization illegal and directed counties to provide "community-based" care for the mentally ill.)
People like those Joan Cefalu tries to motivate may have been told in the past that staying on meds was the only way to keep their illness in check, but today Cefalu and practitioners like her are telling those same patients that taking a walk, going out for dinner and a movie, looking into a part-time job-in other words, going about their lives with as much normalcy as possible-might be just as effective as their daily dose of Effexor or Lithium.
Psychotropic medications can have a dulling affect on cognitive processes, says Garcia. They can cause not only lethargy but also weight gain, which further hampers motivation. Psychosocial rehabilitation seeks to mitigate the effects of the illness as well as negative effects of medication-with the goal of lessening the need for medication.
"Psychosocial rehabilitation has a theory in it that people can and do recover," said Adelman. "If you're a schizophrenic, getting better might simply mean working a job at McDonald's, sweeping the parking lot.
"Work competes with symptoms," he said. In other words, something as basic as the act of sweeping could be enough to distract a schizophrenic's attention away from the voices in his head.
When the County Mental Health Department found out this past spring that $16 million was going to be cut from its $255 million operating budget, directors turned to clubhouses for help. Adult mental health services opted to close five day-treatment centers, which served some of the county's lowest-functioning clients. The plan was to move those clients into clubhouses. Garcia said doing so had been a long-term goal-part of the county's five-year plan to fully implement psychosocial rehabilitation programs. The budget cuts simply meant that those plans would have to be accelerated.
"When we made the decision [to close day rehab programs], we made it within the context of, what are the best practices in psychiatric care," said Garcia, adding that research on day-treatment programs has shown that outcomes didn't always support the cost.
Day rehab and clubhouses are like the difference between high school and college, said Cefalu. At a clubhouse, members aren't expected to show up, though staff will go looking for a member who suddenly disappears. Clubhouse members, too, look out for one another. Day treatment, on the other hand, was mandatory and clients were monitored much more closely by therapists and caseworkers.
In making the switch from a day treatment program to a clubhouse, individual transition plans were put together for each day-treatment client. "It was a very methodical process," said Garcia. "It may not be the best in terms of the results and impact on clients in the short term, but in the long term, I think it's going to be best."
The county gave Adelman $140,000 to assist East Corner in taking on former day-rehab clients. Adelman, however, opted to split the money up to provide continued intensive services for clients who need specialized attention before making the switch to the clubhouse's less-structured setting. Those clients might spend the morning in outpatient group therapy and join clubhouse activities in the afternoon.
East Corner already has a delicate membership, 80 percent of the 150 active members are diagnosed schizophrenic, Cefalu said. (A random sampling of clubhouse members across the county, part of a 2002 study, showed that schizophrenics accounted for 53 percent of clubhouse populations.) While some East Corner members have been able to take on part-time jobs, there are some who struggle with basic communication skills.
"To assume that all clients in day rehab can go to [a] clubhouse is a poor assumption," Adelman said in an early-October interview with CityBeat. "There's some people who would handle the transition just fine, but there are some who are not stable, who need more monitoring."
When CityBeat spoke to Adelman last week, he said that at a recent meeting with county staff, two clients who'd made the switch from day rehab to the clubhouse were asked how they were handling the transition. "A lot better than we thought it was going to be," was their answer.
John Klecker and Carol Resurreccion, both therapists at the East Corner Clubhouse, said budget cuts forced layoffs of vital staff who could have made clients' transition even smoother. "We're still treating the same amount of people, but with less resources," said Resurreccion. Klecker said that so far staff and clients have proven resilient, though both he and Resurrecction worry about the long-term effects of budget cuts and also about the stability of the mental health system as a whole, given the state's financial situation.
"You can't keep taking and taking and expecting positive outcomes," said Klecker.
Community Research Foundation's East County program, of which East Corner is a part, lost 35 percent of its $1.3 million budget to county reductions. The Meeting Place in Hillcrest scrapes by on an annual budget of only $182,000 a year for its 68 active members.
All clubhouse funding comes from the county unless a clubhouse has a parent organization or is able to pull in outside support.
The San Diego chapter of the National Alliance for the Mentally Ill (NAMI) has praised the county's shift to psychosocial rehabilitation, but in June, when budget cuts were being finalized, the organization expressed concern that clubhouses were lacking funding necessary to take in day rehab clients.
Last week San Diego NAMI Executive Director Bettie Reinhardt told CityBeat that while she's not heard any complaints from clients affected by day rehab closings, clubhouses are now providing services "for more folks than they're funded for."
A report by the San Diego County Grand Jury in April 2001 described the county's mental health services as "grossly underfunded."
"The principal problem identified by the Grand Jury was under-funding," the report reads. "This, in turn led to insufficient personnel, limited treatment facilities and the incarceration of too many mentally ill at great expense. In short, the mentally ill are underserved in this county."
In the mid '80s, San Diego County was, per capita, the second lowest funded in the state-and still hasn't crept much higher. Previous county health and human services directors for too many years put mental health at the bottom of the priority list and at times went so far as to "sell back" state-funded mental health services.
It took two lawsuits against the state to boost funding, but even now, says Garcia, San Diego is still playing catch-up.
One of those two lawsuits was filed in 1988 by three clients, one of whom was Dan Reese, co-founder of The Meeting Place. On behalf of Reese and the other two plaintiffs, lawyers from the Legal Aid Society successfully sued the state to restore $3.3 million that had been cut from San Diego County's mental health budget. Reese argued that he had benefited significantly from county services and inadequate funding could deprive other clients that same opportunity.
Reese died in 1995. His legacy, however, includes a housing development-Reese Village located downtown-and an annual client achievement award that bears his name. Near the entry to The Meeting Place is a framed tribute to Reese.
Peter Kress helped Reese found The Meeting Place nearly 20 years ago. As the story goes, the clubhouse's first members-all county mental health clients who had met at Hillcrest's Gifford Clinic-held monthly board meetings on a bench in Balboa Park after getting kicked out of local restaurants. "It's kind of hard to hold a board meeting on the patio of a restaurant without causing customers to be offended," Kress acknowledged, adding that those early meetings weren't free of spirited disagreement.
It took the group three years of grant writing to secure $5,000 from the San Diego Community Foundation. The money allowed Meeting Place members to pay stipends to trained program coordinators, and for $1 a month, the group rented space from the now-defunct Psychiatric Management Resources in Hillcrest two or three nights a week. In 1992 they got a county grant that allowed them to move into their own place on Robinson Street, behind Whole Foods market. Along the way, the board formed a corporation, learned how to navigate county bureaucracy and also took on a contract to manage low-income housing in Barrio Logan where seven Meeting Place members now live.
Kress says that when The Meeting Place first got started, its founders knew nothing about the Fountain House or other clubhouses like it. "We had a lot of questions about, did we know what we were doing. We had a lot of questions about, were we capable of doing what we were designing [to do], to set a precedent here in San Diego," he recalled.
What they simply wanted, said Kress, was a place mentally ill folks could come a couple nights a week just to get out and do something. "People are paying their rent and utilities and are taking home sacks of potatoes for food," he said. "We offered food."
The goal was to help people become more outgoing, to build up their confidence and shake the social stigma that plagues the mentally ill. "We empower people to be proud of what they are and be proud of the things they do here," Kress said.
Kress said his leadership role with The Meeting Place helped his own recovery. Diagnosed with paranoid schizophrenia and depression, he said the disease has abated as he's gotten older-he's 51 now-but "being on the board of directors, it was a responsibility I had to live up to. I couldn't be out at the beach smoking dope, which would have been normal for me back when I was 17. You don't bring that kind of thing when you're responsible for the well-being of other consumers."
Kress is remarkably low-key given that The Meeting Place has endured for nearly 15 years and has a current active membership of 68. Five years ago, the organization secured a spacious, two-story house on Park Boulevard with three small apartments in the back, which are rented out to members. Director Sharron Hedenkamp said their lease is up this year, and she's hoping the building's prime location won't drive the rent out of their reach.
Within a year, The Meeting Place is hoping to earn certification from the International Center for Clubhouse Development (ICCD), Hedenkamp said. If certified, which requires the clubhouse to meet 35 well-defined standards, The Meeting Place will become the first clubhouse in California to earn such a distinction.
A day at The Meeting Place begins with a group session, during which the day is planned out-what's for lunch and who's going to make it, what events are planned for the afternoon and the days ahead. After the meeting, the lunch crew heads to the kitchen and the news crew heads upstairs.
Hedenkamp, a former associate producer for Channel 10 news, suggested to members they start up their own news program, which they dubbed KTMP. At around 10:30 a.m. each day, the news crew-an anchor, camera operator and prompter-gathers in the clubhouse's upstairs office to film a five-minute segment that's played later that day. The news program updates members about daily activities and what's coming up-a trip to the movies, for example. On a recent Friday, news anchor Sam Boodman, a natural with his commanding voice and New York accent, let his viewers know about the progress of a member who's been trying to quit smoking.
The show is taped with a tiny, handheld Samsung video camera mounted on a tripod. The news crew adds a music intro by holding up one of the headphones from a CD player to the camera's microphone.
Boodman moved to San Diego from New York five years ago. "New York can either eat you up alive, or you can succeed," he said. "I did succeed, but the city started eating me up alive and I had to get out of there." Diagnosed with major depression, he's been through electroshock therapy and says he has good days and bad. At one point he stopped coming to The Meeting Place and staff member Jeannette Hilton and Hedenkamp came looking for him. "They pulled me back in," he said.
He's been the news program's anchor for the past couple months. "Just about everyone in this joint doesn't want to go in front of the camera," he said. Boodman recently missed a day of taping, and when he returned was reminded by his replacement that being on camera is no easy task. (Indeed, CityBeat's reporter and photographer were forced to make a guest appearance on KTMP.)
"I've been lucky enough to find a place like this," Boodman said. "People here are like my second family."
Hedenkamp's pride in the burgeoning news program is evident, though she apologizes quickly for the tiny camera and makeshift music system. She's especially proud of her news anchor. "I cannot tell you what [the news program] has done for him," she told CityBeat.
Hedenkamp said the Meeting Place didn't take on any extra members when day-treatment facilities closed, though the clubhouse is always adding new members-an overwhelming majority of members are referred by friends rather than caseworkers or therapists. "They [the county] get a lot of bang for their buck out of this place," said Hedenkamp. "Dollar for dollar we produce some of the best results around."
But it's not the financial benefits that matter. On a recent Wednesday at The Meeting Place, a member named Joseph talked about the job he just secured as a limo driver with the help of other Meeting Place members. It will be his first job in eight years. Mel, who runs the clubhouse's "bank" by collecting lunch money and selling bus passes and event tickets, looked up quickly from his work to comment on the clubhouse's efficacy.
"You get to grow," he said. "You get to move on."
In order to fulfill ICCD certification requirements, the Meeting Place must have 25 percent of its active members participating in a temporary employment program. Meeting Place staff coordinates with employers to train clients for entry-level work. Potential employers who'd like to participate in the program can contact Sharron Hedenkamp at 619-294-2058.