Benefits and qualities of groups in human services Final

Wanna Grab Some Dinner? Social Relations Between Helping Professionals and Members of

Community Mental Health or Other Human Service Organizations

Jonathan D. Prince, Olivia Mora-Lett, Marina Lalayants, and Adam Brown Silbmeran School of Social Work at Hunter College, City University of New York

Purpose: Could practitioners and members (consumers) of mental health or other organizations interact socially by regularly going out for drinks or dinner together, for example? The American Psychological Association explicitly states for example, “your psychologist shouldn’t also be your friend.” However such social interactions have occurred for decades in certain clubhouse-modeled community mental healthcare, and maybe research and a more balanced perspective is warranted. Design/Method: We interviewed six clubhouse staff that interact socially with members and held three focus groups with 20 members. Results/ Conclusions: In relation to what we call a social interaction policy, we herein highlight: (a) four policy dimensions (e.g. activity types; relationship closeness); (b) a spectrum of policy challenges (e.g., dealing with romantic overture; feelings of exclusion or hurt and effects on mental health; symptom flare-up while out socializing; financial constraints of members such as dinner costs on limited incomes); and (c) a wide variety of policy benefits such as: (a) learning opportunities for members who can process with staff the ups and downs of social relationships; (b) social skill and network development; (c) enhanced assessment across different times/ settings; (d) addressing stigma among staff who must grapple with internal resistance to spend free time with members; (e) enrichment of staff social life; (f) reducing internalized stigma among members when staff value them more holistically; and (g) empowerment of members when staff freely (and optionally) offer a valuable resource (spare time). We offer suggestions for certain types of agencies that may wish to implement social interaction policies.

Public Policy Relevance Statement Although dual (or multiple) associations between providers and members (consumers) of mental health service organizations have been explored extensively over decades, this exploration has covered random encounters (e.g., running into members in grocery stores, on one extreme) to close friendships on the other extreme. In a more focused way, however, researchers have yet to study regular social interactions (e.g., optional dinners or drinks) between providers and members. We therefore studied these interactions qualitatively (interviews with providers and focus groups with members), for both parties have actively pursued such get-togethers for over 70 years in certain clubhouses. In relation to this social interaction policy, we highlight policy dimensions, challenges, and benefits, and offer suggestions for non-clubhouse agencies that can weigh policy implementation against maintenance of the status quo (e.g., in order to preserve integrity of clinical relationships).

Supplemental materials: https://doi.org/10.1037/ort0000552.supp

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

A ss o ci at io n o r o n e o f it s al li ed

p u b li sh er s.

T h is ar ti cl e is in te nd ed

so le ly

fo r th e p er so n al

u se

o f th e in di v id u al

u se r an d is n o t to

b e d is se m in at ed

b ro ad ly .

Adam Brown https://orcid.org/0000-0001-5833-8811 We wish to thank Vicki Lens, PhD for her invaluable assistance in reviewing

earlier drafts of this article. We have no conflicts of interest to disclose.

Correspondence concerning this article should be addressed to Jonathan D. Prince, Silberman School of Social Work at Hunter College, City University of New York, New York, NY 10035, United States. Email: [email protected]

American Journal of Orthopsychiatry

© 2021 Global Alliance for Behavioral Health and Social Justice 2021, Vol. 91, No. 4, 545–557 https://doi.org/10.1037/ort0000552

545

W hat would happen if practitioners (i.e., service provi-ders or staff) and members (i.e., consumers or clients)of mental health or other organizations started to regularly socialize by going out for drinks together, for example, or going to baseball games or out to dinner? Such activates (some- times referred to as boundary crossings; Zur, 2020) do not violate codes of ethics or standards set by licensing boards (e.g., Sonne, 2007; Zur, 2020). In short, on a regular basis, could service providers spend free time with people under their care? The answer is yes potentially, or at least yes maybe, for social lives have been shared for decades in some clubhouse-modeled community mental health pro- grams. Perhaps this is only possible in certain clubhouses, for they differ in important ways from other community mental healthcare (e.g., near-total equalization of power between staff and program members). Beyond clubhouses, the American Psychological Association (2020), explicitly states for example, “your psychologist shouldn’t also be your friend.” Yet certain clubhouses operate under a different philosophy, and maybe research and a more balanced perspective are warranted. Surprisingly, social relations between clubhouse staff and mem-

bers have yet to be studied empirically. We therefore interviewed six clubhouse staff that spend free time with members, and held three focus groups with 20 clubhouse members in order to better under- stand from both perspectives (staff and members) what we herein refer to as a social interaction policy (an unwritten or informal one, in this case). Our two research questions include: (a) what are the dimensions of this policy? and (b) what are its challenges and benefits? We conclude by questioning whether other agencies could adopt such a policy, perhaps in order to enhance care (e.g., by building rapport outside of the office), or whether instead the status quo should be maintained (e.g., in order to preserve integrity of clinical relationships). In relation to our rather contrarian idea that such a policy could indeed be considered elsewhere (e.g., other forms of community mental healthcare, where having drinks with service recipients or sharing other social activities is often prohib- ited), we understand that we will be met with resistance. We captured this resistance by recording an experienced clinician’s response to the suggestion:

I am excited by innovative approaches to treatment but this (social interaction policy) makes me very uncomfortable. (There are reasons) why these boundaries haven’t been crossed : : : There is a power dynamic that is involved. Consumers are not in the relationship as an equal. They pay a fee or someone pays a fee on their behalf and they are there to receive services. When you extend that relationship outside the agency, there is a tremendous amount of risk to the consumer to fall into line or have the relationship be on terms that are comfortable for the person who is in a position of power. It makes me so uncomfortable, this idea that these people are out there : : : (believing that) clinicians are their friends, and they are not. They have a job that they get paid to do : : : Consumers are a captive audience. This risk for manipulation and coercion is so high.

These concerns are logical for clinicians who have been trained to believe that some distance between staff and members of mental health or other organizations is necessary in order to maintain clinical objectivity, for example, where friendship could influence adversely the ability to think and act impartially in clinical practice. There may also be concerns relating to legal liability (e.g., harm to members or staff outside of agencies) or ethical breaches (e.g., if

a romantic connection were to develop). For all of these reasons, most mental health or other agencies prohibit many or most social interactions. In addition, students of mental health in schools of psychology or social work, for example, are often taught to avoid such social relations, for educators convey necessity of boundary- setting.

However clubhouses can be different. With over 300 programs in more than 30 countries worldwide, clubhouses are publicly funded community mental health agencies that offer employment, housing, social support, education, and access to medical and psychiatric services in a single setting (Clubhouse International, 2020). In relation to other community mental healthcare, clubhouses are especially conducive to social interaction policies, for clubhouse members and staff share equally in the tasks of running the organization. In work-ordered days, both members and staff partic- ipate in the intake and orientation of new members, hiring of new personnel (as well as training and evaluation), fund-raising and policy decision-making, program evaluation, advocacy, and public relations, membership on the Board of Directors, residential place- ments, food preparation, and building upkeep (e.g., side-by-side bathroom cleaning by both staff and members: Clubhouse International, 2020: Doyle et al., 2013). Thus member empower- ment is central to the clubhouse model.

Of course, clubhouses also have limitations. Fidelity to the clubhouse model across clubhouses may be inconsistent, and although clubhouses have been shown to produce certain favorable outcomes in relation to some other forms of community mental healthcare, these outcome studies could benefit from more rigorous methods (McKay et al., 2018). Much of the clubhouse research has focused on Fountain House (in New York City), the very first clubhouse. We also focus on Fountain House in our single-agency case study of social interactions. The extent to which social inter- actions are pursued in other clubhouses remains unclear.

Background: The Fountain House Model and Staff-Member Relationships

Founded in 1948, Fountain House now has about 1,300 members with severe mental illnesses. At Fountain House, members and staff work together in one of seven areas (communications, culinary, education, horticulture, reception and membership, research, or wellness). Thus clubhouse staff and members can spend entire work-ordered days together doing a wide range of activities (Chen, 2017; Herman et al., 2005; McKay et al., 2018), and that can lead naturally to close connections and friendly get-togethers outside of the agency. Doyle et al. (2013) underscore other ways that the Fountain House model is conducive to social interaction between staff and members. The building itself is designed with this purpose in mind, for there are no staff-only locations (where members cannot enter), and the facility is deliberately understaffed in order to require member collaboration with staff in all daily undertakings (e.g., from building upkeep to program design and evaluation). Even though rehabilitation from severe mental illness is the central goal, the intention is to create a work environment that resembles most other work environments. In this way, the need to be needed is satisfied among Fountain House members in the same way that such need is satisfied in the labor force more generally. Labor force participants can become quite close at work (and interact socially after work), and this closeness is the goal among members

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

A ss o ci at io n o r o n e o f it s al li ed

p u b li sh er s.

T h is ar ti cl e is in te nd ed

so le ly

fo r th e p er so n al

u se

o f th e in di v id u al

u se r an d is n o t to

b e d is se m in at ed

b ro ad ly .

546 PRINCE, MORA-LETT, LALAYANTS, AND BROWN

and staff that are often described as a Fountain House family (Doyle et al., 2013, p. 43). Social interaction is not the only way that Fountain House staff

empowers members. For example, in its strengths-based approach, staff highlights talents of members who capably com- plete work-related tasks in order to counteract focus on symptoms or problems (deficits) in many mental health practices. In fact, psychiatrists (or other professionals that can focus on deficits) cannot deliver care at Fountain House (although a closely affili- ated psychiatric and medical center is located nearby, and referrals are often made to a wide variety of practitioners). Member choice (such as choosing staff to work with, tasks to pursue, and amount of time to invest) is maximized to counteract a lack of agency in certain traditional interventions. Although Fountain House staff has the years of experience and the same graduate degrees as counterparts in other mental health agencies, they commit to emptying “a bag filled with power” (Doyle et al., 2013, p. 59) that they bring to work each day in order to address what they (and others: e.g., Rothman, 1978) view as a history of elitist or paternalistic care. One way to reduce this power imbalance is to interact socially with members after work. Social interactions are encouraged at Fountain House but not codified in any written policies such as mission statements.

Conceptual Framework

We use intergroup contact theory to contextualize these social interactions. Intergroup contact theory (e.g., Page-Gould et al., 2008;

Pettigrew et al., 2013; Stathi & Crisp, 2010) is used most often to understand improvement in race relations. More specifically, friendly encounters across races have been shown to reduce preju- dicial beliefs when members of dominant cultures (in-groups) interact amicably with oppressed counterparts (out-groups). The shared time: (a) increases empathy for people in the out-group (and vice versa) and (b) reduces anxiety and enhances comfort. Less frequently, intergroup contact theory has been applied to persons with severe mental illness (the more frequently marginalized out-group). In this context, amicable social interactions help the in-group (staff and other individuals without severe mental illness) to see the out-group more holistically and in a better light (with increasing empathy after repeated get-togethers). In short, it reduces stigma. At the same time, persons with severe mental illness (out-group members) may become more comfortable (less anxious) among individuals without severe mental illness after friendly interactions by: (a) building trust through intergroup contact and (b) feeling less like outsiders and more included in majority (in-group) culture. Encouragement of these intergroup activities (social interactions) by Fountain House governance is key, for approval from authority significantly enhance intergroup contact outcomes (e.g., Page-Gould et al., 2008; Pettigrew et al., 2013; Stathi & Crisp, 2010). Staff social interactions with members of mental health or other

agencies are largely unexplored in published literature, yet there is a much broader discussion of dual (or multiple) relationships in mental healthcare (e.g., Auteri, 2014; Dewane, 2010; Koocher & Keith-Spiegel, 2017; Mok, 2003; Pope & Keith-Spiegel, 2008; Pope & Vetter, 1992; Sonne, 2007; Zur, 2020). However this discussion covers too much territory, for it includes running into members in

grocery stores (i.e., very brief random encounters, on one extreme) to providing psychotherapy to a close friend because the psycho- therapist is the only practitioner in a very small town (i.e., close friendship, on the other extreme). Thus while the literature does indeed cover friendly get-togethers (often using this small-town scenario), the coverage is fleeting and superficial and focuses largely on avoiding harm to the practitioner (e.g., losing licensure and the close friend in the small town) when the friendship/professional relationship (i.e., dual association) is inescapable and then sours. Nowhere in this decades-long literature (that we could find) is discussion: (a) solely on friendly get-togethers (that doesn’t also include running into members in stores, for example, and all other types of encounters with varying intensities); (b) on how friendly get-togethers or other dual associations by might beneficially be pursued (optionally and with care, and only at certain times and with certain individuals with varying degrees of closeness) instead of avoided whenever possible; or (c) on the empirical benefits of such get-togethers (described herein, along with a similar number of challenges), although some scholars do in fact describe (anec- dotally) some potential advantages.

In relation to these advantages, Zur (2020) suggests that dual relationships can reduce power differential, help prevent isolation among members, and increase knowledge of members that is not accessible in brief office-based visits. Similarly, other scholars (e.g., Sonne, 2007) suggest that trust and therapeutic alliance can grow in certain dual relationships. Nevertheless, the vast majority of the literature focuses on how providers must try to avoid serious potential problems that can accompany dual associations. For example, Dewane (2010) suggests that, “we should be concerned with dual relationships primarily because they can hurt clients but also because they can hurt the profession and social workers” (p. 18). Koocher and Keith-Spiegel (2017) warn that, “lax professional boundaries can act as a precursor to exploitation” (p. 6). Some of the caution is grounded in this slippery slope argument, where dual relations can lead to sexual activity. Zur (2020) suggests that the slippery slope argument is erroneous, unfounded, and even para- noid, and that exploitative providers will exploit with or without dual relationships. Nevertheless, we concur that professionals must be mindful and indeed cautious in certain situations or with certain individuals (highlighted herein by Fountain House staff).

In sum, after describing social interactions (including benefits and challenges) in our case study of Fountain House, we put forth a simple question. If social relations can be pursued at Fountain House (which is admittedly well-suited for the practice), why can’t it be done elsewhere (or at least simply tried or even considered)?

Method

Sample and Data Collection

After obtaining Institutional Review Board approval from Hunter College, (463180: Fountain House Research), we held hour-long individual interviews with six Fountain House staff members (at least 1 year on the job: one executive, one supervisor, three direct service providers, and one accountant) and three hour-long focus groups with 20 Fountain House members (17 male, 15 white, 11 over age 40, 18 unmarried). All Fountain House members have severe mental illness (typically schizophrenia, bipolar disorder,

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

A ss o ci at io n o r o n e o f it s al li ed

p u b li sh er s.

T h is ar ti cl e is in te nd ed

so le ly

fo r th e p er so n al

u se

o f th e in di v id u al

u se r an d is n o t to

b e d is se m in at ed

b ro ad ly .

WANNA GRAB SOME DINNER 547

or major depressive disorder). About half of the members have co-occurring substance use disorders, and about 40% have a history of homelessness. Service providers and supervisors at Fountain House have master’s degrees (most often in social work or psychology) and (typically) many years of work experience. In relation to selecting staff for interviews (by the first two

authors), a supervisor at Fountain House chose individuals who have socialized over the years and formed personal relationships with Fountain House members. We audiotaped and transcribed each interview. Interview questions included: (a) Can you tell us what you do when you socialize with members outside of normal working hours (weekdays 9–5)? (b) Can you describe relationships that have formed in this way? (c) What boundaries do you establish in meeting with members outside of normal working hours? and (d) What are the advantages and challenges of socializing with members outside of normal working hours? In relation to the three focus groups with 20 Fountain House

members (5–8 per group), members simply agreed (voluntarily) to participate on the day of data collection, and the first two authors together facilitated each of the three focus groups with members. We audiotaped and transcribed each group. Focus group questions included: (a) What have been your experiences in socializing with staff outside of normal working hours (weekdays 9–5)? (b) Can you describe relationships that have formed in this way? (c) How has this changed your relationships with staff? (d) How has this differed from your experience in other mental health agencies? (e) Have there been times where you felt let down or left out by staff, when socializing with them?

Data Analysis

In three stages, we used content analysis to understand themes and patterns in our data (e.g., Hsieh & Shannon, 2005; Lingard et al., 2008). In the first stage, a post-doctoral student in social work (the second author) examined themes and patterns in each of the six staff interviews and in each of the three focus groups with members of Fountain House. In the second stage, the post-doctoral student synthesized all of the information by: (a) grouping together themes and patterns that emerged in all five of the staff interviews and (separately) in all three of the member focus groups, and (b) creating a taxonomy of the underlying content. In the third stage, the first author (a professor of social work) further synthesized the findings by: (a) reexamining the themes and patterns, and relations between them; (b) combining similar themes and adding new ones when indicated; and (c) linking direct quotes to the data.

Findings

We decided to present findings together for: (a) interviews with Fountain House staff; and (b) focus groups of Fountain House members (i.e., instead of having two separate sections), as we found substantial overlap in the two perspectives. We first describe the nature (dimensions) of staff-member social relations, and then cover benefits and challenges. Additional quotations from staff and mem- bers that underscore our findings are presented in Appendix I. We conclude with a broader discussion of social interaction policies and offer suggestions for policy implementation.

Dimensions of Social Relations Policies

We found four dimensions of social interaction, including: (a) activity types (e.g., movies, sporting events, drinks, or dinner); (b) relationship depth (e.g., casual acquaintance, close association); (c) relationship impetus (e.g., shared interests, natural connection); and (d) relationship choices on what information to share or withhold for example, or whether or not to pursue or end relationships.

Activity Types. Fountain House staff and members share free time together in a variety of ways, but common examples (in rough order of frequency) include going out to eat, taking walks, getting drinks, going to movies, shows, or concerts, going to museums or art galleries, attending sporting events (especially Mets baseball games), attending weddings or graduations, going to birthdays or other kinds of parties, singing karaoke, attending lectures or conferences, visiting friends or loved ones in hospitals, pet-sitting for each other, and yoga. In addition, phone calls, texts, and social media posts are common- place, and staff and members just hang out at home. Finally, staff and members travel together, especially to conferences, or even stay overnight together in staff homes. Family members (e.g., spouses, children, parents) are included in some events. Most members report feeling comfortable approaching staff in order to socialize, rather than waiting to be approached (see Appendix). There are only two rules, including: (a) romantic relations are prohibited and (b) personal information about members must be kept confidential.

There can be subtle differences even within a particular type of social interaction. For example, going out to lunch can differ from going out to dinner. According to one staff:

There are members that say, hey you know, do you want to go out to lunch, and I’m like sure let’s do that. And I think there’s also a difference : : : (between) having lunch during the day : : : than in the evening : : : The feeling is maybe more like a business lunch (while) in the evening it could be different.

Relationship Depth. Apart from four Fountain House members (20% of our sample) who report never socializing with staff, others report weekly, biweekly, or monthly get-togethers. With respect to relationship depth, members describe a continuum from acquaintance to close connection. As elsewhere, close relation- ships are somewhat rare (and valuable) while free time is shared to varying degrees with a potentially wide variety of individuals. Both members and staff can decide not to participate at all in certain events or with certain individuals, even despite multiple invitations, and staff can decline to participate in activities that may seem inappropriate (e.g., certain weekend trips). Importantly, staff has opportunities to process saying no to members, which can be clinically advantageous when it allows members to get feedback in handling any letdown or disappointment. As with relationships elsewhere, some come and go while others remain steady over time. Quotations in the Appendix underscore our findings.

Relationship Impetus. Our question on factors that lead to social connections left some of the staff stumped. One simply shrugged and asked, “I don’t know. How do you make a friend?” Similarly, according to another staff, “it’s just kind of natural and organic. There’s no particular rhyme or reason. (Asking me which members I choose to connect with) would be like asking me (why) I go out with some co-workers and not others.” Likewise, a member

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

A ss o ci at io n o r o n e o f it s al li ed

p u b li sh er s.

T h is ar ti cl e is in te nd ed

so le ly

fo r th e p er so n al

u se

o f th e in di v id u al

u se r an d is n o t to

b e d is se m in at ed

b ro ad ly .

548 PRINCE, MORA-LETT, LALAYANTS, AND BROWN

suggests that, “I don’t think it’s any different (from anywhere else).” Connection (clicking) is important, and if it doesn’t happen right away, several members report waiting until there is a connection with staff before choosing to interact socially with them. As elsewhere, mutual interests tend to unite staff and members, and they get together so support each other’s artwork, for example, or music performances. Time spent together helps (i.e., hours shared during the work-ordered day: see Appendix).

Relationship Choices. As in any other social relationships, staff and members choose what to share and what to keep to themselves. According to a staff:

(I share) personal stuff but again that's to varying degrees. If I’m for example going through a breakup probably not everybody is going to know about it, cause I don’t want you to know about it. You sort of keep things to yourself versus things that you’re more open to sharing.

Or according to a supervisor:

I often talk to employees about boundaries, especially when I’m talking about self- disclosure in a traditional setting and you only disclose when its therapeutically beneficial. So here we take more of an opposite tactic (where) you can disclose as long as it’s not therapeutically harmful : : : So there’s certain topics that I would talk about and certain topics that I wouldn’t.

Thus most staff appears to share freely instead of choosing only the material that is therapeutically helpful. After all, staff is not working when they socialize with members. In other words, staff can share almost anything with members unless it would be harmful to self-disclose. Thus some screening of content occurs, but most content is not screened out if no harm is done. In addition to deciding what to share, staff can choose to socialize

with members individually or in groups. Group get-togethers can be seen as a safer bet when, for example, a new member of the opposite sex asks to go out for dinner or a drink. Once relationships are established over a period of time, individual encounters may be more commonplace. Staff members can choose not to socialize with people under their care (i.e., on their caseload instead of elsewhere in the agency). For example, according to one staff member, “I wouldn’t (socialize) with somebody if I’m their worker because that would be a conflict : : : (I would only socialize with) a member of Fountain House : : : (that is) not someone that I’m directly responsible for supporting. There’s no rule around that but for me I set those boundaries.” Thus, if they so choose, staff can decide to get together with only those members who have other primary care workers. All of the staff in our sample choose to participate only in

activities that they enjoy. “That’s how I want to spend my Sunday afternoon, playing softball. And it's a bunch of great people to do it with, so I’m not making it an official thing. I’m not doing it because its Fountain House, I do it because its something I want to do.” People can choose to avoid get-togethers entirely. As one member puts it, “Me personally, I wouldn’t want to hang out with staff after (working hours at) Fountain House ... I wouldn’t want something to come out. If I say something in confidence it can actually be used against me.” Thus this particular member does not trust that what is said outside of Fountain House will remain confidential or that shared information will not come back to haunt him. Without even providing a reason, another member similarly refuses all social interactions with staff. “I develop relationships with the members

here. Not the staff. Don’t do bars, don’t do bowling, don’t do movies : : : Give me a member to hang out with. I don’t want a staff.” Most members refer to certain (close) staff as friends, but others

may be reluctant. For example, according to one member, “You might not call them friends : : : I would consider them more of a professional relationship.” Likewise, most staff feels comfortable referring to certain (close) members as friends, but one staff in our sample does not. “Its friendly but its not a friendship.” The decision by some staff avoid the term friend could be seen as a type of boundary setting. A variety of choices are made with respect to boundaries. For example, one staff will not spend major holidays with members and their family. Boundaries differ at clubhouses from both: (a) boundaries outside of mental health agencies (e.g., where romantic relations could possibly evolve in the general population) and (b) boundaries at other mental health agencies (e.g., where rules largely prohibit social relations outside of the working alliance). According to one staff:

It’s not that boundaries don’t exist. They do exist and they’re very strong but you have to be more vigilant with our (clubhouse) boundaries because : : : it’s not a wall separating staff and members and so you have to develop the boundaries : : : I would say that we’re crossing boundaries : : : (for) the boundary is more fluid but it exists : : : It never goes away. It’s always there but it’s not a giant wall.

Thus boundaries in clubhouses differ from one social connection to the other and must be considered on a case-by-case basis. For instance, one staff will have a drink with members but will not get drunk, and another staff will go out with members but will not invite them to the house. Thus in relation to boundaries, staff seem to make it up as they go along while still adhering to certain rules, and staff are all cognizant of their clinical role and the power differential. “There’s still an (unequal) dynamic of social worker to member. It’s not truly like an equal friendship : : : There is always that sense that I’m here and that I’m working.” Even though boundaries can fluctuate and often go unstated, members seem to appreciate their existence. According to one member:

The boundary is very clear, even though the status isn’t made clear. There’s no hierarchy (between staff and members) but you kind of understand that there are certain things that you do (or don’t do) around staff : : : The relationship (is clear) even though it’s not stated it’s kind of like you understand it.

In relation to the variety of social interaction choices (e.g., where to set boundaries, or what to share or whether or not to pursue connec- tion), the mere presence of choice (to interact socially with staff) is valued by members who report absence of such choice (i.e., a more general lack of agency) in certain other mental health agencies:

Choice is the one thing that means everything to me coming from some place that I never really had a choice in anything that had really ever happened. Being able to make that decision on whether I want these connections (with staff) : : : Whether I want to share certain things or get close to somebody not in an intimate way but as a friendship or perhaps this person (staff) can be seen as family to me one day : : : I mean, not being able to have that choice. Being in group settings where you’re told what to do 24/7.

In short, members feel empowered by having this particular choice (whether or not to pursue social connections with staff). That power is not granted in many other agencies.

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

A ss o ci at io n o r o n e o f it s al li ed

p u b li sh er s.

T h is ar ti cl e is in te nd ed

so le ly

fo r th e p er so n al

u se

o f th e in di v id u al

u se r an d is n o t to

b e d is se m in at ed

b ro ad ly .

WANNA GRAB SOME DINNER 549

In relation to our four dimensions of social interaction (activity type, relationship depth, relationship impetus, and various choices about what to share or withhold, for example, or whether to set certain boundaries), we understand that staff in some mental health agencies will sometimes or even regularly (e.g., trip groups our outings in day treatment centers) engage with members in non- traditional settings (e.g., parks or baseball games), but the difference in clubhouses lies in the timing of such engagement (e.g., evenings or weekends), the depth of the engagement (e.g., potential for true closeness), the wider range of venues (e.g., bars, staff homes, overnight or multiple-day excursions), and the number and fre- quency of the get-togethers, and agency encouragement of regular social interaction (instead of a certain discouragement). All Fountain House staff (in our sample) seems genuinely happy with their social relationships with members (and vice versa, except for the four members in our sample who avoid all such interactions), but staff is uniquely conscious of safeguarding and promoting member mental health during the course of companionship. For the most part, however, staff feels free to be themselves and to share freely as they would in any other similar relationship. Both staff and members report deciding at certain times to end relationships, and boundary setting by staff often fluctuates and is decided on case-by-base basis. Both members and staff report being aware of unarticulated bound- aries (e.g., drink without getting drunk) as well as the two pre- defined boundaries prohibiting romantic relationships and sharing of confidential material. Staff is aware of power differential and has over-arching concern for member rehabilitation even in the context of social interaction (e.g., “there is always that sense that I’m here and that I’m working”). Some relationships persist over time while others come and go, and clubhouse members in our study accept relationship loss as part of life. On the whole, according to club- house members in our study, social relationships signal that staff really cares. In other words, it lets members know that the relation- ship is valued beyond the staff paycheck, and that people are interested in them socially and can see them holistically (i.e., “more than my mental illness”). Simply having the choice to socialize with staff is empowering, for this power of choice is typically unavailable in other agencies.

Social Interaction Challenges

Nevertheless, certain problems can arise. Challenges relate to: (a) sexuality and gender, (b) feelings of exclusion and relationship downturns, (c) symptom flare-up while out socializing, (c) height- ened member expectations from companions on staff, and (d) financial constraints of members.

Sexuality and Gender. Occasionally staff (especially females—all of them in our sample) must respond to romantic overtures or feelings. According to one female administrative staff, “its just the guys that I worry about and I don’t want to have them think that being nice means that you can go further with me : : : If it's a male then it probably means that they’re interested.” There may be the rare member who misinterprets an outing with staff as a date. According to one member, “I used to get a lot of tickets to Broadway shows so I was very selective on who I was giving those very occasional tickets to. And sometimes those tickets would go to staff members here that showed an interest in me and my career. They were basically dates.” One female staff member suggested that

afternoon activities are safer than evening events, and also points out safety in numbers: “I’ve never gone out socially with someone in the evening alone unless I know the person very well. Lunch is a little different : : : and group events.”

Although the issue seems to arise less frequently in male staff (one in our sample), men can be similarly cautious:

I’ve been approached by female members of Fountain House : : : (where it was) something that was clearly inappropriate : : : The person would come up to me and make a certain comment or something. So it wasn’t something that was ever going to happen, cause I’ve only gone out with people where its very clear that there’s not going to be any issues with any inappropriate crossing of boundaries.

Male staff must also contend with the substantial number of female Fountain House members who have histories of victimiza- tion by males:

I think for a lot of the women at Fountain House, they have had a lot of very negative experiences with men. That seems to be a very common theme. Not all of them, but a lot of them have suffered harassment and worse. So I prioritize a feeling of safety around them. I wouldn’t maybe go to a movie with a female member alone. I would probably ask that person if they wanted to bring somebody : : : I don’t want to unneces- sarily trigger any kind of feelings of safety.

The triggers may not necessarily be sexual in nature, for violence in general may be problematic:

One time I took two people to see a movie as a free ticket. So these two girls wanted to go see it with me. It was a Steven Spielberg movie—War Horse. So I thought it's a really nice movie but within like half an hour these two girls left the movie theater : : : Soldiers were being killed and they got so scared and left. So next time I got to be more aware of what they can enjoy or not enjoy : : : They haven’t come back to a movie with me.

Thus staff is careful not to socialize with members who may have ulterior motives, and male staff must be especially cogni- zant of safety concerns around female members who have experienced sexual or other violence by men. The presence of a third party is helpful for certain staff and for some staff it is even a requirement.

However it’s not the case that issues relating to sexuality, for example, or male-on-female victimization, affect most staff con- nectedness with members: “For me, if we get along great, we’re cool. I don’t care what gender you are at all. Doesn’t make a difference to me.” Or, “I’ve never had that (sexual attraction as an issue) because either I’m doing something right : : : or people have an understanding. I think it’s because I sort of project this sort of understanding that we’re going to be buddies (and nothing else).” Thus rather than being omnipresent in staff-member connections, issues relating to sexuality only seem to arise sometimes, although female staff must more often contend with sexual overture, relative to male staff, and male staff must be especially careful not to trigger the many female members who have been traumatized by men.

Feelings of Exclusion and Relationship Down- turns. We asked staff if some of the members might feel left out or jealous if they are not included in social activities with staff, and were surprised that it did not seem to be much of an issue. “We don’t have a problem with favoritism...We try as much as we can to stress community as much as possible so we are all part of this

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

A ss o ci at io n o r o n e o f it s al li ed

p u b li sh er s.

T h is ar ti cl e is in te nd ed

so le ly

fo r th e p er so n al

u se

o f th e in di v id u al

u se r an d is n o t to

b e d is se m in at ed

b ro ad ly .

550 PRINCE, MORA-LETT, LALAYANTS, AND BROWN

Fountain House community. “ Or, “I haven’t (noticed any jealousy) because I feel that the invitation is sort of open. We’ve generally gone to places around here shortly after work so the option for somebody else to join us is very much there.” However when we posed the same jealousy-related question to

members, we got a slightly different story. “Sometimes you can have rivalries between members who want the attention of the staff member and I think not all members are treated equally in that sense but that doesn’t ruin the experience for me.” Similarly, some members felt left out when they were not invited to activities with staff:

On Facebook you get to see what people are doing and sometimes, when it's a weekend time, its like a little bit depressing for me, because I have nothing during the weekend and you see staff, and think ‘I really wish I could hang out with them, or be more social with them on the weekends.’ But this unfortunately is not necessarily the way it’s going to work out.

While some members may feel jealous or excluded, most seem to understand that such feelings are a part of life. According to one member, “there’s always jealousy wherever you are.” Some mem- bers seem to employ tactics to combat feelings of jealousy. “I don’t flaunt it (social time with staff) : : : I try to be good and not just throw it in people’s faces because it makes them jealous.” Although staff seems to have underreported feelings of jealousy or

exclusion among members, they did in fact realize that not all members are treated equally in relation to social interactions with staff. “It’s part of the real world, and you’re never going to treat people equally : : : so people are going to see that you gravitate towards one person or another.” Sometimes the less outgoing members may not make themselves as available to staff as more extraverted counterparts, and these more introverted individuals may be socially overlooked to a greater extent. According to one member, “those people : : : who are : : : slipping through the cracks, or the wallflowers or the people who are less gregarious or who are less engaged in the unit, they don’t get involved (in socializing with staff).” However even if they are left out socially, most members seem to feel connected to staff anyway simply because of the closeness of the Fountain House community more generally. It also seems that most members can appreciate the way that social connections work, in that some members and staff have a natural connection (click) while others do not. In addition to feeling excluded at times, a related challenge occurs

when staff-member connections sour. On rare occasions, a member might stop attending Fountain House as a result, or one staff recalls a member badmouthing him. “I remember hearing that she was just going around : : : saying all kinds of (negative) stuff about me.” In addition, if the relationship sours and staff need to end it, there is concern over the member’s mental health. For example, according to an administrative support staff at Fountain House:

I got so stressed out (over having to end a relationship) : : : I went to a social worker : : : and I said is it okay for me to close the door (to the relationship). I was scared that if I closed the door these members would go back and start feeling very depressed. After I talked to the social worker she said, “no, you can slam the door on him, its fine.”

Much more frequently, however, a staff suggests that, “We’re all about giving some third and fourth chances when some things go sour, and just like anything you want to take a step away from it, let things cool off.”

Symptom Flare-Up While Out Socializing. Occasion- ally, staff must address symptoms of mental illness while out socializing with members. Thus a third challenge is that staff must work on occasion when they are trying to enjoy free time. Because the goal is to enjoy free time with members, staff (when possible) forgoes activities with members who might be actively symptomatic or relapsing. According to one staff, “I don’t think I would be socializing with somebody who is going through a tough time. That wouldn’t be probably in their best interest either, like they need to be focusing on them and not going out to dinner and knowing that it could lead to some kind of flare up.” Similarly, according to another staff member, “if I saw the person was really struggling I would say, ‘you know, we can’t go out today. I have to cancel.’(I would) not put myself in that situation.” In short, staff is not supposed to work in their spare time. The point of socializing with members is to have fun or develop meaningful connection.

However should symptoms arise, staff switch from being a companion to being a staff who intervenes and offers therapeutic feedback:

If there was a case where (relapse or symptom flare-up) happens (while out socializing), if somebody starts having an anxiety attack or some- thing : : : then I would sort of switch on—“OK what do we need to do? Do we need to go outside and just wait out there or settle the bill and then we’ll kind of work through this?”

In rare events the socializing must stop in order for staff to take a member to the hospital:

Sometimes I will : : : move into rehab mode because if I feel that they’re unsafe : : : I just feel it’s unethical to be like, “come see me tomorrow.” I (took someone) to a hospital at like, 8 pm. We were supposed to meet at a park : : : (for) free jazz music and I was out there with a couple of other members and a couple of other friends of mine, and I think even a co-worker. We’re all there and the person did not show and as we’re leaving, the person came and was obviously disorganized, distant.

In relation to avoiding such situations, one staff notes that he might draw similar boundaries with companions elsewhere (i.e., outside of clubhouses):

I have just about the same patience for a friend of mine who has mental health issues as I have for a member here who I have a social relationship with who has mental health issues. I’m going to draw my own personal limit, kind of boundary with someone who is in the middle of feeling bad in their lives (as with) a member who is a friend. It's the same.

Heightened Member Expectations. In relation to a fourth challenge, sometimes members may feel that they should get special treatment when they interact socially with staff.

According to one staff, a member might say for example, “oh I trusted you : : : I thought because we were friends or because we had a relationship you wouldn’t have minded me doing x or y,” where x and y are behaviors that violate Fountain House policy. Another staff recalls that members who are companions can some- times expect to be promoted at work in Fountain House (i.e., in the work-ordered day), and might be let down if someone else (i.e., who is not a companion) gets the promotion. However rather than being anti-rehabilitative, the staff suggest that it can be helpful clinically to process the letdown—it tends to happen in life. Sometimes staff must also help members understand that the good times enjoyed

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

A ss o ci at io n o r o n e o f it s al li ed

p u b li sh er s.

T h is ar ti cl e is in te nd ed

so le ly

fo r th e p er so n al

u se

o f th e in di v id u al

u se r an d is n o t to

b e d is se m in at ed

b ro ad ly .

WANNA GRAB SOME DINNER 551

while socializing may not extend to the real work in the work- ordered day. According to one staff:

We (the staff and a member) get along so well and we joke around so well (while socializing) that when we’re going to tackle project X (in the work-ordered day), the member didn’t take it as seriously because they were just, “Oh its just me and (the staff), we’re just going to hang out and this will be fun.” And I was like, “nah, we actually have to get this done now. I’m counting on you to do this stuff.” And it was like, “Why are you talking to me that way. This is supposed to be fun : : : ” And then its gone sour.

Along the same lines, members can want a companion on staff to help them clinically instead of the staff who is in charge of the case. In this event, staff must decline assistance and instead refer the request to the primary worker.

Financial Constraints of Members. A lack of money among many members can constrain options in socializing with staff. As one staff puts it:

The constraint is really often financial because it costs money and we’re all paying our own way, so that can be the biggest constraint to someone joining. They might be invited but they may not have the money : : : This is midtown Manhattan, so you pay $25–$40 probably for a meal.

One staff sometimes waits until the beginning of the month (when SSI or other cash transfers arrive) before extending an invitation to socialize, and will typically suggest less expensive activities. Other times staff will pay for members, especially on special occasions such as birthdays. Other challenges could relate to alcohol use, which comes with its

own set of issues.

Alcohol Use and Associated Challenges in Staff-Member Social Interaction

When going out for drinks with members, all staff reports appreciating differences between members in relation to alcohol use. “There are some members that don’t drink or shouldn’t drink at all. There are members who can have two or three or maybe even more and not be affected negatively. So it’s not specifically about drinking but it’s getting to know the person.” Staff may choose not to drink with people who have substance use disorders, although some members in recovery are comfortable with exposure to alcohol consumption, and other members in recovery can use such drinking experiences in order to practice being comfortable around alcohol (without drinking). One staff reports asking members in advance about their alcohol consumption (“How many beers can you drink?”), and then monitors the situation accordingly. Members suggest that staff carefully choose whom to get drinks

with. “I think some staff choose who they want to hang out with and under what (conditions) they feel a person could handle alcohol : : : If I was staff I wouldn’t want to bring a member with me who had alcohol problems and who may not act responsible in certain situations.” Another member notes that invitations for drinks may simply be an invitation to socialize (although drinking is involved). “I’m sober for 24 years. It’s a euphemism when you say ‘drinks’ to me that the person means that he’s really inviting me to be a social person with them and they probably know that I’m sober a long time.”

If a member drinks problematically, then one staff reports waiting till the next day at Fountain House to discuss the overconsumption in order to avoid working clinically while out on the town. In contrast, a different staff will confront the excess on the spot if necessary. One staff member suggests that Fountain House mem- bers with active substance abuse problems (i.e., not in recovery) will often decline opportunities to drink small quantities with staff (e.g., a drink or two) because they favor peers who drink heavily or use other drugs (drinking buddies or running mates):

Most of the members that have (active) substance abuse problems : : : actually have a pretty good social network. It's a negative social network, so they don’t want to go out with you (the staff). They want to go out and score drugs and be with the people doing drugs and they want to drink and they want to go out and get drunk, and they got this small group of people that they do that with. So that doesn’t happen as much (i.e., members overdoing it while with staff).

A different staff reports choosing members who can drink in moderation without crossing the line. “I have two or three beers (at the baseball game). So when I’m picking who I want to go with, I want to make sure I go with someone I can have two or three beers at the game and not be self-conscious about that. And so there has to be a high degree of trust.”

Regular get-togethers at local bars are seen as opportunities for members to develop social relationships. As one staff puts it:

I know a lot of staff who have regular drinks with members : : : Our sister clubhouse in Amsterdam they have (a get-together) every single Friday night, they go to a bar together after the clubhouse is closed. They give drink tickets to the members so they get one free drink and then they stay longer than that : : : We experimented at one point with a bar down the street to try to have them be like a regular place for people to go and hang out outside. It’s been a big discussion in our program- ming meeting actually. Like how can we facilitate social relationships with members to try to help get them out of the clubhouse and socializing among many other people in the community...Well one example is going to a bar where you might actually meet somebody else not just a Fountain House person.

While bars may offer opportunities for members to enrich their social lives, one staff underscored challenges relating to the high cost of drinks, and a different staff noted that rapport could suffer when staff stops members from problematic drinking. In relation to drinking with staff, members note paying attention to the poor mix between alcohol and psychiatric medication. As a result, they report having only one or two drinks or sometimes having only soft drinks. Heavier drinking seems to occur only sometimes (e.g., four beers once or twice a year). According to a member:

I think it would be frowned upon to excessively drink around the staff : : : Not just for the staff but for the members also. They’d be like, ‘what’s going on? It’s just not cool : : : The liability potential would just be : : : the down side of it if something really happened bad. You could just see it posted in the daily news.

Interestingly, staff did not raise such liability potential. One member suggests that it might be up to staff to prevent excessive drinking while socializing. Thus both staff and members note the importance of staff knowing member limits, in relation to drinking, and both staff and members note the importance of staff monitoring such limits if necessary.

Social interaction challenges may be offset by benefits.

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

A ss o ci at io n o r o n e o f it s al li ed

p u b li sh er s.

T h is ar ti cl e is in te nd ed

so le ly

fo r th e p er so n al

u se

o f th e in di v id u al

u se r an d is n o t to

b e d is se m in at ed

b ro ad ly .

552 PRINCE, MORA-LETT, LALAYANTS, AND BROWN

Tearing Down the Wall: Benefits of Socializing

Benefits of staff-member social interaction include: (a) learning opportunities for members; (b) development among members of social network, social skill, and rapport with staff; (c) confronting and addressing stigma; (d) enrichment of staff social life; and (e) empowerment of members.

Learning Opportunities for Members. Social interac- tions create occasions for growth among members when they get to discuss relations with staff. As one staff puts it:

Somebody (a member) will be like, “where are you going?” (And I might say) “I’m going to a movie with Sally.” (And the member might respond) “Oh, how come you and I don’t go to a movie?” You get to have that conversation : : : That conversation is gold for recovery. It’s not the result of the conversation that matters, it’s just that people don’t talk to members that way. So I don’t know how they’re supposed to learn. People are afraid because they’re mentally ill, that they’re fragile or (people) just look through them : : : That type of conversation seldom happens in a safe space : : : So they feel safe enough to be jealous, envious, or just curious : : : If nothing else, doing that (socializing) allows those con- versations with the member, its super valuable.

Thus socializing allows members to process with staff the ways in which they may feel left out of social relations, or jealous, or to process any number of other feelings or thoughts relating potentially to interpersonal interaction. Similarly, members can learn about and process the ways in

which social relationships strengthen, weaken, or simply change over time. As one member puts it:

Part of having these relationships (with staff) : : : (is that they) flow and sometimes they get stronger, and sometimes they get weaker and some- times they evaporate : : : I mean, I have people in my personal life that I no longer speak to for a wide variety of reasons. We just drift, right? So I think its providing real world examples for these members of like, this is how the world works. It’s not just, you know, show up to a center or some sort of agency and someone talks to me because they’re paid to talk to me and they don’t even sound like they like talking to me because probably they’re being paid. They’re done with me once I walk out the door. It’s more genuine (at Fountain House). It’s more real. It’s more authentic.

Thus members are aware that staff really wants to be with them, for staff opt to spend free time with them (unpaid). Members then learn about companionship more generally by processing their social interaction with staff, and this helps them to develop a better understanding of the ups and downs and changing attachments that come with social connectedness. Another member describes such learning opportunity in the following account:

You’re going to get challenged. You’re going to get faced with scenarios, real world scenarios where you’re going to have to say, maybe this person doesn’t want to be my friend or doesn’t want to give me their home number or cell phone number : : : It’s a chance to have a real conversation about that kind of issue : : : It’s a moment for me to internalize and to learn and to grow.

In addition to these learning opportunities, there are other clinical benefits.

Social Network and Skill Development, Rapport Building, and Enhanced Assessment. Social interaction allows members to meet additional people through staff (“Oh, why

don’t you bring somebody else?”). According to one staff, “there’s a couple of members that have made friends with friends of mine, and they go out independently of me. They have their own relationship : : : but they’ve met through me.” In addition, staff can persuade certain members to socialize in order to overcome shyness, social isolation, or other reluctance to engage in social activity. According to one staff:

No matter how many times I tell him to walk those 10 blocks (to lose weight) he’s not going to do it unless I’m saying “hey I’ll walk with you” : : : But is he asking to go out walking with me? No, he doesn’t want to go out walking and so I need to draw out that engagement. Do they want to go to karaoke? No, I have to invite them. Do you want to go see a movie? They are not planning to but I have to draw it out.

In other words, some staff may be more assertive and take the initiative in order to draw out members who would not otherwise socialize. This can help to prevent isolation. Members also describe how social interaction with staff can increase social engagement and build interpersonal skills:

(Socializing with staff) could help you grow self-confidence to speak up, to communicate with other people : : : It’s not just the communica- tion with that staff member and the relationship. It could also bring up a whole bunch of other triggers and emotions that you’re dealing with. Whether you have agoraphobia, you can’t go outside or you’re triggered in certain crowds or with loud noises. It could help you therapeutically to have these relationships.

Finally, socializing also helps staff with assessment (i.e. obser- vation in diverse settings such as restaurants, bars, and staff or member homes):

You get to know people more fully : : : You get to see people in different aspects (of their life) that you don’t get to see : : : Its less superficial than a social event here within Fountain House so you really get to see how people interact, how they behave. It enables me to support people better : : : You get to see the whole person and not just a component. If you’re a therapist, you get that one hour. If you’re here, you get a much larger view : : : And so the more you see people fully human : : : the more you will : : : not stereotype someone by their diagnosis.

Such comprehensive assessment (i.e., off-hours or in external settings) could elude many traditional practitioners, as a clubhouse staff suspects:

I’m impressed that there’s a good result in psychiatry and therapy when they’re just working blind : : : I can just see that, “oh ok, this person whenever there’s four or five people in the room totally shuts up and doesn’t say a word. But when its two people in the room, it's a complete chatterbox.” I don’t know how a therapist would ever know that : : : and that that affects : : : why they hate family functions or why they can’t get a job or why they dropped out of school.

Confronting and Addressing Stigma. One staff notes that the opportunity to socialize with members forces self- examination of stigma, or negative beliefs about persons with severe mental illness that may keep helping professionals from wanting to develop social relations:

It makes you remember and realize that you are a human being first and it kind of makes you think about your stigma and it makes you think of what you’re trying to encourage other people to do

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

A ss o ci at io n o r o n e o f it s al li ed

p u b li sh er s.

T h is ar ti cl e is in te nd ed

so le ly

fo r th e p er so n al

u se

o f th e in di v id u al

u se r an d is n o t to

b e d is se m in at ed

b ro ad ly .

WANNA GRAB SOME DINNER 553

(i.e., socialize with people with severe mental illness). We are supposed to be modeling it.

A different staff member also notes benefits of stigma awareness (e.g., “Why don’t I want to hang out with this person?”), and suggests that it builds rapport with members while allowing mem- bers to realize that they can interact socially with people who don’t have severe mental illness. “Hey if I can be friends with somebody who’s on staff, I could be friends with people that aren’t just people with mental health problems.” As one member put it, when staff invite her to socialize they “think I’m a human being” and not just a “mental patient.” Or according to another member:

(Socializing gives me) hope that stigma is not all pervasive, that somewhere in the world we can find people who will not stigmatize us : : : I like that I’m treated on the same level as other people and I can have conversations that don’t revolve around my trauma and what has happened because that is not me as a person. I’m so much more, and being able to have someone that can treat me that I’m more than my mental illness, it’s very rewarding.”

Thus socializing helps staff confront their own stigma, or negative feelings about mental illness, and helps members feel that they are a whole person (“not just a mental patient,” as one member puts it, who is appreciated by people “in the real world”).

Enrichment of Staff Social Life. In addition to clinical benefits for members, it’s important not to undersell benefits to staff that gain camaraderie and support by interacting socially with members. That is, staff gains a companion or at least someone who can share similar interests. In short, benefits are reciprocal. “You build a very strong friendship : : : It’s all just building trust : : : You know this member paints. I paint so we critique each other’s paintings and she has one of mine and I have hers. So we keep it on our walls because I want to learn her techniques and she wants to learn my techniques so we exchange that way.”

Member Empowerment. In relation to letting members know that staff care about them (i.e., outside of a paid relationship), there is nothing quite like sharing free time. According to one member, staff that socializes shows “affection for you and it’s not like this distant wall where they can’t even tell you what they ate for breakfast today. It's a big difference (from other agencies).” In relation to reducing power differential, as one member puts it:

I think a lot of the benefits let’s say, when you’re going to the baseball games or the jazz shows with somebody, it allows that person to realize : : : you’re not just doing this because it’s your job : : : So no, no I’m really enjoying this : : : Oh, you go out with members so you don’t think you’re better than we are, and I think people can see that a lot, too : : : You know, he doesn’t think he’s superior.

Evident in the above account is the ability of social interaction to counter the power imbalance that separates service providers and members in many other mental health agencies. The message to members is that service providers really care, even beyond paid incentive to care, and that distance between staff and members is not so great that free time can’t be spent together. Members feel truly seen (“more than my mental illness,” as one member puts it), and simply having the option to socialize (typically unavailable in most other agencies) is empowering in itself (power of choice). The agency of members is increased, for they can opt to share social lives

with staff that can choose at times to freely offer a valuable resource (spare time). The Appendix highlights additional quotations that clarify benefits and challenges of social interaction policies.

Discussion

In relation to our research/practice question (what are social interaction policy dimensions, challenges, and benefits, and can it be implemented more widely?), a member correctly surmised the purpose of our investigation. “I’m guessing the research that you’re doing is to see if that choice (social interaction with staff) is an option that you want to weigh or is it better to just leave it the way it is, to have that wall up (between members and providers).” In short, rather than agencies discouraging social interactions, we are hoping that this research and future research on the topic can inform a more thoughtful, evidence-based decision on whether or not to think outside of this particular firm-boundary box. Our research shows that it is indeed possible for a social interaction policy to develop on an agency-wide basis, although it may be harder in non-clubhouse agencies. It seems to be the work-ordered days in clubhouses that are especially conducive to social interaction, for clubhouse staff and members work so closely together during the day that connection develops, and then it seems only natural to extend the relationship beyond the walls of the agency (like going out after work in the labor force more generally). Thus a social interaction policy may differ in agencies where there is less togetherness between members and providers.

Yet we reject the notion that social interactions policies cannot develop outside of clubhouses, for clubhouses are similar to other mental health programs in key respects. For example, both Fountain House and other community mental health programs (e.g., Bouras et al., 2018; Drake & Latimer, 2012) promote recovery, social connection, and access to resources (e.g., affordable housing; employment; education). Moreover, both Fountain House and some other community mental health programs can offer evening or weekend activities, and after-hours events can be available (perhaps occasionally) to both staff and members. As a result of these similarities between clubhouses and some other types of community mental healthcare, it seems possible that a social interaction policy (cost-free and optional for all agency staff and members) can form in non-clubhouse care as well (e.g., day treat- ment or partial hospitalization programs; assertive community treatment; housing or employment programs) or in other types of helping organizations (e.g., substance abuse treatment programs). Clubhouses are unique, yet not so unique that a social interaction policy cannot be tried or at least considered elsewhere. Literature on dual associations (e.g., Sonne, 2007; Zur, 2020) suggests that prolonged interventions (e.g., a 10-year relationship) and interven- tions in non-traditional settings (e.g., assertive community treat- ments in member homes or neighborhoods) can be more conducive to dual relationships (including social interactions) than very brief interventions (where a connection has less chance of forming) or office-based interventions (i.e., more clinical settings, such as psy- chodynamic care). In addition, some cultures may be more accept- ing of social interactions or other types of boundary loosening than other cultures.

Even though agency staff and members might occasionally get together after hours in some other community mental health pro- grams, the difference at Fountain House lies in the: (a) amount

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

A ss o ci at io n o r o n e o f it s al li ed

p u b li sh er s.

T h is ar ti cl e is in te nd ed

so le ly

fo r th e p er so n al

u se

o f th e in di v id u al

u se r an d is n o t to

b e d is se m in at ed

b ro ad ly .

554 PRINCE, MORA-LETT, LALAYANTS, AND BROWN

(frequency) of interactions and their timing (outside of normal working hours); (b) the depth of relationships, where some con- nections are acquaintances (loose or bridging ties) but others are close connections (bonding ties: Woolcock and Narayan; 2000); (c) the wider range of venues (e.g., bars or staff homes); and (d) agency encouragement of such bridges or bonds (instead of a certain discouragement). In relation to social interactions, there are a number of challenges that coexist with varying benefits. In relation to such benefits, Fountain House promotes intergroup contact (e.g., Page-Gould et al., 2008; Pettigrew et al., 2013; Stathi & Crisp, 2010) between: (a) staff and other people without severe mental illness (the more empowered in-group) and (b) frequently margin- alized individuals with severe mental illness (out-group). Thus, in accordance with intergroup contact theory, Fountain House mem- bers learn to address social anxiety and build trust in people without severe mental illness and helps staff (and all other people without severe mental illness) to consider any resistance they may have to share free time (i.e., address stigma). Other benefits of social interaction policies include: (a) learning opportunities for members who can process with staff the natural ups and downs (or waxing and waning) or disappointments of social interaction more generally; (b) social skill development (while members socialize with staff) and social network growth (e.g., making new social connections with staff; meeting friends of staff; meeting people while out socializing with staff); (c) enhanced assessment when staff gain information about members across different times and settings; (d) enrichment of staff social life (gaining companions or people to share interests with); and (e) empowerment of members (tearing down what some members call the wall between service users and providers). In relation to such empowerment, social interaction allow members to better control the: (a) when and where of service engagement (e.g., dinners out on weekdays; weekend baseball games) and (b) nature of interventions (by including potential for social interaction). Thus the social interaction policy promotes equal footing between service users and professionals. Empowerment practices such as this one can lead to a wide

variety of well-established positive outcomes (e.g., community participation; mental health; quality of life: Christens et al., 2011; Corrigan et al., 1999; Garcia-Ramirez et al., 2005; Hall & Nelson, 1996; Kloos et al., 2005; Levine et al., 2005; Nelson et al., 2001; Schulz et al.,1995; Speer, 2000; Ungar & Teram, 2000; Zimmerman, et al, 1992). Moreover, if members can learn to get close to providers instead of learning to maintain distance, then perhaps members could also learn how to get close to people more generally (Prince et al., 2017) and avoid loneliness and associated adverse outcomes such as relapse or suicidal behavior (e.g., Chrostek et al., 2016; Prince et al., 2018). Finally, the social interaction policy builds rapport with providers, and strong rapport leads to service approval, care adherence, and many other positive consequences (e.g., Duncan et al., 2003; Leach, 2005). In contrast, agencies may decide that disadvantages outweigh

benefits. For example, boundaries are less clear when social inter- action policies are in place. It might be confusing to members when some staff declines certain invitations (e.g., weekend getaways) that other staff might accept, or why some staff will refer to members as friends and others will not. Similarly, power differences (in hierar- chical relationships) might be confusing for some clubhouse mem- bers, for such differences can exist even while out socializing

(e.g., staff intervention in rare crisis situations). Roles and bound- aries may be clearer when dual relationships such as social inter- actions are avoided (Sonne, 2007), and social interaction could possibly increase risk for certain adverse outcomes such as sexual relations, lawsuits, or licensure loss. However in relation to these outcomes, it is worth noting that a sexual relationship formed once (that we were told of) in Fountain House’s 70-year history in New York City, and neither staff nor members reported other ethical breaches or lawsuits. Thus if social interactions are approached the right way, it remains unclear whether risk for these adverse out- comes is in fact greater in agencies with versus without social interaction policies.

Our findings on social interaction policy challenges relate to: (a) sexuality and gender (e.g., dealing with romantic overture); (b) feelings of exclusion or hurt (e.g., member letdown or jealousy, and effects on mental health); (c) symptom flare-up while out socializing (e.g., staff who must work [very] occasionally during free time); (d) heightened member expectations from companions on staff (e.g., wanting special treatment during the work-ordered day or in relation to service delivery); and (e) financial constraints of members (e.g., cost of dinner or drinks on limited incomes). In relation to use of alcohol, staff and members both report limiting consumption (“drink but don’t get drunk” or “only one or two”), but on rare occasions there is problematic overconsumption. Neverthe- less, bars offer real-world opportunities to meet people, and oppor- tunities to get better at talking to people, if real-world interaction is the goal.

For agencies that weigh benefits and challenges of social interac- tion policies and decide to give it a try, we offer eight suggestions.

Implications: Implementing Social Interaction Policies

Literature on dual or multiple relationships offers certain policy recommendations. For example, Sonne (2007) suggests that provi- ders must: (a) be aware of ethical considerations; (b) think carefully before entering into any relationship; and (c) keep do no harm in mind.

More specifically, the first step in implementing a social interac- tion policy involves establishing two rules prohibiting romantic or sexual involvement and ensuring confidentiality of member infor- mation shared in social interactions with staff. One Fountain House staff was fired for violating the first rule, and in relation to the second rule, one member reported being afraid that information shared in a social interactions would in some way come back to haunt him. Agencies can consider consequences for staff sharing of confidential member information (e.g., warning to the staff and amends to the member; probation or job termination for repeated violations).

Second, in order to implement a social interaction policy, it may be important to acknowledge that the very culture of the organiza- tion may have to change a little in order to include potential for social interaction between members and providers. After all, staff can for the first time consider spending free time (unpaid) with members, and members can for the first time have access (for free) to staff outside of normal working hours and locations. Third, in implementing social interaction policies, make it clear that both members and providers can forgo all social interactions, and thus such interactions are completely optional, and that there will be no repercussions for going it alone (e.g., failure to get promotions or

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

A ss o ci at io n o r o n e o f it s al li ed

p u b li sh er s.

T h is ar ti cl e is in te nd ed

so le ly

fo r th e p er so n al

u se

o f th e in di v id u al

u se r an d is n o t to

b e d is se m in at ed

b ro ad ly .

WANNA GRAB SOME DINNER 555

raises among staff). Fourth, make it clear to staff that social interactions are for enjoying time, or for sharing an interest, for example, but also make it clear that staff must act professionally in certain circumstances (e.g., suicidal ideation at a baseball game or at a bar or restaurant). Fifth, tell staff that anything can be shared with members as long as it is not clinically harmful. In other words, staff does not have to screen out certain material when interacting with members, but they must always consider the clinical wellbeing of the member. Sixth, consider providing consultation (perhaps one service provider and one member) if both parties request feedback on a relationship challenge. Such a challenge could include simple friction, on one extreme, to perhaps even (in rare events) agency non-attendance after a difference of opinion or conflict. Seventh, consider creating a research committee of both members and providers that studies policy strengths and limitations, for example, or perhaps implementation issues or outcomes. Eighth, weigh potential benefits of each suggestion (2–7 above) against a much more laissez-faire implementation approach that better reflects the reality of most real-world get-togethers. Such togetherness often evolves largely on its own, without need for much or any agency involvement.

Limitations and Research Agenda

Our case study of 20 Fountain members and six staff is small, and therefore exploratory. We studied only one mental health organiza- tion with only one type of mental health care in only one urban location. The extent to which other clubhouses encourage social interaction is unclear, so our findings may differ across the different clubhouse locations. In addition, our study included only those Fountain House staff that interacts socially with members. There may be staff that decides not to pursue such interactions. Staff reasons for forgoing social interaction (with all members) must be explored (e.g., personal circumstances such as childcare or other family responsibilities; personality differences such as introversion; personal views regarding boundaries). Some of these reasons could affect how agencies weigh social interaction policy strengths against challenges. In addition, diversity must be addressed. For example, the 20 Fountain House members in our self-selecting sample were 75 percent White and 85 percent male. Finally, there are limitations inherent in all focus groups that could have affected our results. For example, there could have been pressure for focus group members to express opinions that are voiced by others (e.g., group think in favor of staff-member social interactions), or more introverted members with different opinions may not have felt comfortable sharing (although 20 percent of Fountain House members in our sample spoke out against all social interactions with staff). Research is needed that further examines our benefits and chal-

lenges in social interaction policy implementation, and studies could compare outcomes (e.g., member self-esteem, social network, lone- liness, rapport with providers, psychiatric hospitalizations, use of detox facilities, criminal justice system involvement) among orga- nizations that have social interaction policies to organizations that do not. In addition, researchers could compare social interaction policy implementation and outcomes in relation to one type of care versus another (e.g., mental health versus substance abuse treat- ment). Finally, we invite agencies to research social interaction policies by simply trying them. However we respect the decision of agencies to forgo such policies in order to preserve integrity of

clinical relationships. For example, one clubhouse staff in our study chooses not to socialize with Fountain House members under his care (i.e., on his caseload), but opted only to interact socially with other members of the agency. Thus one possibility is allowing staff to interact socially only with members who are not primarily under their care (e.g., not on caseload). This could preserve the integrity of specific clinical relationships while allowing other get-togethers to occur. Even if only one or two agencies try to adopt social interac- tion policies, then these agencies can describe the rollout, and maybe the policy can spread. Some readers may react negatively, as did the clinician we cited on our first page, but we will nevertheless be happy to open a dialog that has thus far been closed. The topic is known to cause uneasiness (e.g., Sonne, 2007), but uncomfortable discussions can at times be quite fruitful. There is ample room for debate (e.g., deciding whether challenges outweigh benefits), but our research suggests that a social interaction policy is in fact doable (although perhaps more so in some agencies than others).

Keywords: clubhouses, friendship, dual associations, multiple associations, empowerment

References

American Psychological Association. (2020). Potential ethical violations. https://www.apa.org/topics/ethics/potential-violations

Auteri, S. (2014). Should dual relationships always be off-limits? https:// www.aasect.org/should-dual-relationships-always-be-limits

Bouras, N., Ikkos, G., & Craig, T. (2018). From community to meta- community mental health care. International Journal of Environmental Research and Public Health, 15, 806.

Chen, F. (2017). Building a working community: Staff practices in clubhouse for people with severe mental illness. Administration and Policy in Mental Health, 44, 651–663.

Christens, B. D., Speer, P. W., & Peterson, N. A. (2011). Social class as moderator of the relationship between (dis)empowering processes and psychological empowerment. Journal of Community Psychology, 39, 170–182.

Chrostek, A., Grygiel, P., Anczewska, M., Wciorka, J., & Switaj, P. (2016). The intensity and correlates of the feelings of loneliness in people with psychosis. Comprehensive Psychiatry, 70, 190–199.

Clubhouse International. (2020). Creating community: Changing the world of mental health. https://clubhouse-intl.org

Corrigan, P. W., Faber, D., Rashid, F., & Leary, M. (1999). The construct validity of empowerment among consumers of mental health services. Schizophrenia Research, 55, 77–84.

Dewane, C. J. (2010). Respecting boundaries—The don’ts of dual relation- ships. Social Work Today, 10, 18–24.

Doyle, A., Lanoil, J., & Dudek, K. (2013). Fountain house: Creating community in mental health practice. Columbia University Press.

Drake, R. E., & Latimer, E. (2012). Lessons learned in developing commu- nity mental health care in North America. World Psychiatry, 11, 47–51.

Duncan, B. L., Miller, S. D., Sparks, J. A., Claud, D. A., Reynolds, L. R., Brown, J., & Johnson, L. D. (2003). The session rating scale: Preliminary psychometric properties of a “working” alliance measure. Journal of Brief Therapy, 3, 3–12.

Garcia-Ramirez, M., Martinez, M. F., Balcazar, F. E., Suarez-Balcazar, Y., Albar, M. J., Domínguez, E., & Santolaya, F. J. (2005). Psychosocial empowerment and social support factors associated with the employment status of immigrant welfare recipients. Journal of Community Psychology, 33, 673–690.

Hall, G. B., & Nelson, G. (1996). Social networks, social support, personal empowerment, and the adaptation of psychiatric consumers/survivors— path analytic models. Social Science & Medicine, 45, 1743–1754.

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

A ss o ci at io n o r o n e o f it s al li ed

p u b li sh er s.

T h is ar ti cl e is in te nd ed

so le ly

fo r th e p er so n al

u se

o f th e in di v id u al

u se r an d is n o t to

b e d is se m in at ed

b ro ad ly .

556 PRINCE, MORA-LETT, LALAYANTS, AND BROWN

Herman, S. E., Onaga, E., Pernice-Duca, F., Oh, S., & Ferguson, C. (2005). Sense of community in clubhouse programs: Member and staff concepts. American Journal of Community Psychology, 36, 343–356.

Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277–1288.

Kloos, B., Nelson, G., & Prilleltensky, I. (2005). Creating new possibilities for promoting liberation, well-being and recovery: Learning from experi- ences of psychiatric consumers/survivors. In G. Nelson & I. Prilleltensky (Eds.), Community psychology: In pursuit of liberation and well-being (pp. 426–447). Palgrave Macmillan.

Koocher, G. P., & Keith-Spiegel, P. (2017). Boundary crossings and the ethics of multiple role relationships. https://www.continuingedcourses .net/active/courses/course066.php

Leach, M. J. (2005). Rapport: A key to treatment success. Complementary Therapies in Clinical Practice, 11, 262–265.

Levine, M., Perkins, D. D., & Perkins, D. V. (2005). Principles of community psychology: Perspectives and applications. Oxford University Press.

Lingard, L., Albert, M., & Levinson, W. (2008). Grounded theory, mixed methods, and action research. British Medical Journal, 337, 459–461.

McKay, C., Nugent, K. L., Johnsen, M., Eaton, W. W., & Lidz, C. (2018). A systematic review of evidence for the clubhouse model of psychosocial rehabilitation. Administration and Policy in Mental Health, 45, 28–47.

Mok, D. S. (2003). Multiple/dual relationships in counseling: Implications for the Asian context. Asian Journal of Counselling, 10, 95–125.

Nelson, G., Lord, J., & Ochocka, J. (2001). Empowerment and mental health in community: Narratives of psychiatric consumers/survivors. Journal of Community & Applied Social Psychology, 11, 125–142.

Pettigrew, T. F., Tropp, L. R., Wagner, U., & Christ, O. (2013). Recent advances in intergroup contact theory. International Journal of Intercul- tural Relations, 35, 271–280.

Pope, K. S., & Keith-Spiegel, P. (2008). A practical approach to boundaries in psychotherapy: Making decisions, bypassing blunders, and mending fences. Journal of Clinical Psychology, 64, 638–652.

Pope, K. S., & Vetter, V. A. (1992). Ethical dilemmas encountered by members of the American psychological association: A national survey. American Psychologist, 47, 397–411.

Page-Gould, E., Mendoza-Demon, R., & Tropp, L. R. (2008). With a little help from my cross-group friends: Reducing anxiety in intergroup con- texts through cross-group friendships. Journal of Personality and Social Psychiatry, 95, 1080–1094.

Prince, J. D., Ansbrow, J., Bennedict, A., DiCostanzo, J., Mora, O., & Schonebaum, A. (2017). Making connections: Severe mental illness and closeness with other people. Social Work in Mental Health, 15, 1–13.

Prince, J. D., Oyo, A., Mora, O., Wyka, K., & Schonebaum, A. D. (2018). Loneliness among persons with severe mental illness. Journal of Nervous and Mental Disease, 206, 136–141.

Rothman, D. (1978). The state as parent. In W. Gaylin, I. Glasser, S. Marcus, & D. J. Rothman (Eds.), Doing good: The limits of benevolence. Pan- theon Books.

Schulz, A. J., Israel, B. A., Zimmerman, M. A., & Checkoway, B. N. (1995). Empowerment as a multi-level construct—perceived control at the indi- vidual, organizational and community levels. Health Education Research, 10, 309–327.

Sonne, J. L. (2007). Nonsexual multiple relationships: A practical decision-making model for clinicians. https://kspope.com/site/multiple-relationships.php

Speer, P. W. (2000). Intrapersonal and interactional empowerment: Implica- tions for theory. Journal of Community Psychology, 28, 51–61.

Stathi, S., & Crisp, R. J. (2010). Intergroup contact and the projection of positivity. International Journal of Cultural Relations, 34, 580–591.

Ungar, M., & Teram, E. (2000). Drifting toward mental health—high-risk adolescents and the process of empowerment. Youth & Society, 32, 228–252.

Woolcock, M., & Narayan, D. (2000). Social capital: Implications for development theory, research, and policy. The World Bank Research Observer, 15, 225–249.

Zimmerman, M. A., Israel, B. A., Schulz, A., & Checkoway, B. (1992). Further explorations in empowerment theory—An empirical analysis of psychological empowerment. American Journal of Community Psychol- ogy, 20, 707–727.

Zur, O. (2020). Dual relationships, multiple relationships, boundaries, bound- ary crossings & boundary violations in psychotherapy, counseling & mental health. https://www.zurinstitute.com/boundaries-dual-relationships/

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

A ss o ci at io n o r o n e o f it s al li ed

p u b li sh er s.

T h is ar ti cl e is in te nd ed

so le ly

fo r th e p er so n al

u se

o f th e in di v id u al

u se r an d is n o t to

b e d is se m in at ed

b ro ad ly .

WANNA GRAB SOME DINNER 557