In his ground-breaking 1963 book, Community Life for the Mentally Ill, Dr. Fairweather established thirteen principles for successfully integrating people with mental illness into the community. Although all thirteen were valid at the time, the eight principles updated for this assessment tool are those which remain relevant to distinguishing the unique values of a Fairweather Lodge. A program which is at odds with these principles might be a wonderful program, but it is not a Fairweather Lodge.
Principle I. The lodge must provide a safe, healthy and caring environment, which reinforces the recovery process.
Principle II. The Lodge must be part of the plan for managing symptoms and promoting good mental health.
Principle III. Services must be available as long as the participant wants and needs them.
Principle IV. People with psychiatric disabilities increase their community success and raise their social status through employment, through accumulating wealth, and through direct (not third-party) consumerism.
Principle V. Above and beyond economic roles, participants need to perceive(and to have) meaningful social roles in both the Lodge and the larger community.
Principle VI. Successful Lodges resemble a healthy family.
Principle VII. In order to progress, people with psychiatric disabilities need autonomy commensurate with their behavioral performance, with the ultimate goal of full autonomy. Similarly, the Lodge needs autonomy commensurate with its behavioral performance, with total autonomy being the ultimate goal.
Principle VIII. Lodges must not be dependent on resources from any single entity.
We presume that anyone associated with a Fairweather Lodge will have a philosophical affinity for the values defined by the eight Principles and sixteen Practices. And it is easy to get engrossed in implementing the principles and practices while at the same time struggling to obtain/maintain funding, hire/supervise staff, recruit/ screen participants. But hopefully, the reason practitioners choose the Lodge Model in the first place is because of the potential outcomes, and any assessment of Lodge success needs to examine the outcomes produced.
Housing, Employment, Social and Autonomy
Although a Fairweather Lodge is understood to be a package of highly-integrated services, we have broken the assessment into four domains for the purpose of evaluation. Surveys of the needs/wants/desires of people with serious mental illness provide three obvious domains -- housing, employment, and a social life. To this we add the uniquely Fairweather perspective of group autonomy. A successful Fairweather Lodge should score well across all four domains.
Domains
Housing
Principle I. The lodge must provide a safe, healthy and caring environment, which reinforces the recovery process.
Practice A. Lodges should be located in a safe and accepting neighborhood.
Practice B. Lodges should be attentive to exercise and nutrition.
Practice C. Lodges should control the use of alcohol and street drugs
Proposed Outcome Measures:
Number of undesirable interactions (e.g., getting mugged, name-calling) in the neighborhood per participant-year, (or versus desirable interactions.)
Percentage of participants eating healthy.
Percentage of participants exercising regularly.
Percentage of participants using drugs or alcohol.
OR
4.a Undesirable incidents related to drugs or alcohol.
Principle II. The Lodge must be part of the plan for managing symptoms and promoting good mental health.
Practice D. Good quality psychiatric care (implying a doctor-patient partnership) should be available.
Proposed Outcome Measure #5: Average length of wait for non-routine psych visit.
Practice E. Lodges should have a standard mechanism for ensuring medication compliance (This mechanism should be adjustable in response to variance in earned autonomy.)
Proposed Outcome Measure #6: Percentage of medications taken as prescribed.
Principle III. Services must be available as long as the participant wants and needs them.
Practice F. (Except as established by the Lodge) There should not be any minimum or maximum time limits on participation.
Principle IV. People with psychiatric disabilities increase their community success and raise their social status through employment, through accumulating wealth, and through direct (not third-party) consumerism.
Practice G. Everyone of working age should be employed (except in the event of temporary incapacity) and employment should begin immediately upon entry into the lodge.
Proposed Outcome Measure #7: Average weekly wages per participant.
Practice H. Employment (and costs related to participation in the Lodge) should be structured so as to ensure financial reward for increasing participation in employment.
Proposed Outcome Measure #8: Percentage of participants earning more than the cost of their room and board.
Practice I. Employment may be offered in the form of a (affirmative) business operated by the lodge. If employment through an affirmative business is provided:
Work opportunities should include a range of tasks from simple to complex, with appropriate accommodations for the illness;
Participants should be paid commensurate with their contribution to the business;
There should be frequent and realistic evaluation of performance and an opportunity to advance; and
Participants should have a choice between working in the affirmative business and outside employment, especially if the affirmative business does not provide opportunities commensurate with the participant’s skills and experience (but not working should not an option, and neither should prolonged job-search).
Social
Principle V. Above and beyond economic roles, participants need to perceive (and to have) meaningful social roles in both the Lodge and the larger community.
Practice J: Every participant should contribute to the collective good to the limit of his/her ability. (Equity of contribution and autonomy from one participant to the next is of secondary importance).
Proposed Outcome Measure #9: Social adjustment/level of functioning.
Principle VI. Successful Lodges resemble a healthy family.
Practice K. Participants should share at least one meal a day.
Practice L. Participants should share at least one social/recreational event a week.
Proposed Outcome Measures 10 & 11:
Number of meals per week shared by at least 75% of members.
Number of social/recreational event per month shared by at least 75% of members
Autonomy
Principle VII. In order to progress, people with psychiatric disabilities need autonomy commensurate with their behavioral performance, with the ultimate goal of full autonomy. Similarly, the Lodge needs autonomy commensurate with its behavioral performance, with total autonomy being the ultimate goal. (Peer support is ultimately more powerful than assistance from paid service providers.)
Practice M. The lodge participants, through some form of collective decision-making, should be responsible (to the extent that the skills are present) for all aspects of Lodge management including but not limited to finance, maintenance, meal planning and preparation, social life, transportation, rules related to interaction between members and symptom management including the taking of medications. Professionals serve as advisors to the Lodge, never managers.
Proposed Outcome Measure #12: Average # of hours/week paid service providers are present in the Lodge.
Practice N. If the skills required for certain tasks are not available within the membership, the advisors should provide these skills temporarily. Training should be provided so as to help one or more participants to acquire these skills and advance individual and group autonomy.
Practice O. Lodges typically need assistance and feedback on how they are doing; this need should decrease over time, but may never disappear. It is advisable, especially during the training phase, to have a special communication system which facilitates this assistance and feedback while simultaneously promoting autonomous group decision-making.
Principle VIII. Lodges must not be dependent on resources from any single entity.
Practice P: Lodges and Lodge Programs require strong leadership, committed to all 8 principles and focused on long-term success.
Proposed Outcome Measures 13 & 14:
Number of “engaged” community partners providing on-going resources.
Largest single source of revenue as a percentage of total revenue.
Implementation of Lodge Practices
Although choices are often limited by an under-developed community mental health system, the Fairweather philosophy is based on the assumption that Lodge members participate voluntarily. One of the implications of voluntary participation is that adherence to the principles, implementation of the practices, and even the production of desirable outcomes, are meaningless unless the participants are satisfied that their basic needs are being met.
Most surveys of the needs/wants/desires of people with serious mental illness produce the same general results with respect to the BIG 3 (not always in the same order): a “nice place to live,” a “good job, ” and friends. It is a given that a Lodge provides housing, but is it a “nice place to live?” Does the employment provided meet the standard of a “good job?” Are the other participants really “friends?” And does allegiance to the autonomy principles and a low staffing ratio actually produce empowerment? The most direct way to answer these questions is to ask the participants.
However, one limitation of satisfaction surveys is that some people always express satisfaction, even while planning to leave the program, and others will complain bitterly for years but never contemplate leaving. (This phenomenon is not exclusive to mental illness.) It is important, therefore, to measure retention -- a less direct, but potentially more telling strategy for measuring satisfaction. So we add:
Proposed Outcome Measure #15: The percentage of participants, at a given starting point, still participating at a certain benchmark.