burnout and lack of agency structure a study of the clubhouse madel of psychosocial rehabilitation

7/27/2019 Burnout and Lack of Agency Structure a Study of the Clubhouse Madel of Psychosocial Rehabilitation

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McGllL UNIVERSITY

BURNOUT AND LACK OF AGENCY STRUCTURE: A STUDY OF THECLUBHOUSE MaDEL OF PSYCHOSOCIAL REHABil iTATION

A Thesis Submitted toThe School of Social WorkFaculty of Graduate Studies and Research

ln Partial Fulfillment of the Requirementsfor

The Master's Degree in Social Work

byTammy Lynn BarkleyMontreal, August 1999


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ABSTRACT

The Clubhouse model of psycho-social rehabilitation is a growing movement providingnon-traditional mental health services worldwide. Little research has been done on howworking in such an un-structured environment affects bumout levels among staff. Thestudy sample was chosen by categorizing the Clubhouses by city size, and selecting 14American and six Canadian Clubs at random with a total of 149 staff, of whom 97responded, including bath frantline staff and executive directors. Respondents completedthe Maslach Bumout Inventery, and a questionnaire which was designed for this study, tameasure work- related, worker-related, and client-related predictors of bumout. Bumoutscores for this sample matched the scores for Maslach's postsecondary educationsubgroup mest closely and were lower than the scores for her mental health subgroup.No significant differences were found between the Canadian and American samples, andsupervisory raie appeared to be a significant predietor of bumout levels among staff.These findings suggest that the International Centre for Clubhouse Development shouldexamine how effectively supervisors support their staff, how the model itself may beinhibiting supervisors from doing so, and that staff needs should be incorporated intoClubhouse standards.


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RESUMLe modle de rhabilitation psycho-sociale "Clubhouse" est un mouvement en expansionqui dispense des services de sant mentale non-traditionnels dans le monde entier. Peude recherches ont t ralises date concernant l'effet de cet environnement de travailnon-structur sur les niveaux de "bumout" affectant le personnel. L'chantillon de l'tudea t choisi en catgorisant les "Clubhouses" en fonction de la grosseur des villes danslesquelles ils taient implants et en slectionnant au hasard 14 clubs amricains et 6clubs canadiens. Nous avons distribu les questionnaires 149 employs, parmilesquels 97 (intervenants et directeurs) y ont rpondu. Les participants ont complt le"Maslach Burnout Inventory" et un questionnaire spcialement concu pour notre tudevisant prdire l'puisement professionnel en mesurant divers indicateurs relis au travail,aux employs et la clientle. Les rsultats obtenus auprs de notre chantilloncorrespondent peu prs ceux du sous-groupe "ducation post-secondaire" de Maslachet sont infrieurs ceux de son sous-groupe "sant mentale". Il n'y avait pas dediffrences significatives entre les nchantillons canadiens et amricains. Le faitd'occuper un poste de superviseur semble tre un facteur permettant de prdire de faonsignificative l'puisement professionnel. Les rsultats de notre recherche suggrent que''The International Centre for Clubhouse Development" devrait se pencher sur lesquestions suivantes: quel point le soutien offert par les superviseurs leurs employsest-il efficace? Comment le modle peut-il contribuer rduire l'efficacit de ce support?Finalement, les besoins du personnel devraient tre pris en compte dans l'laboration desnormes (Ustandardsll ) des "Clubhousesll

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ACKNOWLEDGEMENTSThis thesis would not have been possible without the support of so many people, who 1would Iike ta acknowledge here. Firstly, 1would like to thank Sydney Duder for herinvaluable guidance and feedback throughout the development, analysis and writing of thispaper. You made the SPSS program a whole lot less intimidating!

Next, 1would like to thank my family and friends for their constant support and interest inmy research. (lm looking-forward to that limo ride that was promised to me!

1would like ta extend a warm thank vou ta the members of the Clubhouse community whoalso supported my research: firstly, ta the staff of the twenty Clubhouses who took thetime to complete the questionnaires out of their already hectic schedule; ta the staff ofClubhouse New Horizons whose help in pre-testing of this questionnaire was invaluable;and lastly, thank vou ta my good friends at Causeway Clubhouse. Vour supportthroughout this long process was significant to me. Thanks to Don Palmer for his feedbackon my questionnaire. 1miss you ail!

Last but not least, my most important thank Vou goes to my best friends Aaron and Dan.Aaron, 1was sa lucky ta have you there ta discuss the hardships of homework. Vourinterest in my research meant a lot to me. You are a very special friend Aaron, and 1loveyou from here ta Pluto and back again!

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Dan, yeu should receive an honorary MSW degree for ail the work you did! You spentheurs on data entry, and deciphering SPSS with me, countless trips to the library and NewYork. Your unwavering love, support and encouragement helped pull me through ail thediscouraging setbacks 1encountered aleng the way. You are my best friend. Yeu waitedpatiently while 1finished this. Now l'm done. Let's go fishing 1

T.L.B

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CONTENTS

ABSTRACT .RESUM.................................................................................................. iiACKNOWLEDGEMENTS................ iiiLIST OF FIGURES..................................... viiLIST OF TABLES..................................................................................... viii1. INTRODUCTION.......... 1

Statement of Problem..................................................................... 1The Clubhouse Model....................................... 2The Concept of Burnout................................................................. 12The Concept of Job Satisfaction.................................................... 16Research Goals............................................................................. 172. METHOD.............................................................................................. 19

Questionnaire................................................................................. 19Sam pie and Distribution................................................................. 25Analysis.. 283. FINDINGS..................................... 30

Description of Sample: Clubhouses................................................... 30Clubhouse Demographies............. 30Factor Analysis... 35Measures of Bumout......................................................................... 39Comparison with Norms: Mean Scores........................................... 39Comparison with Norms: Frequency Distributions....................... 41Predictors of Bumout.................................................................... 44Stressors Attributed to Clientele.................................................... 48

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4. DISCUSSION .Summary of Key Findings .Limitations .Implications for Research .Implications for Practice .Conclusions .

APPENDICES

505051535659

A. Standards for Clubhouse Programs............................................ 61B. World-Wide Listing of Clubhouses..... 66C. Introduction to the Survey - Letter.. 67D. Cover Latter to Clubhouse Workers............................................ 68E. Executive Directors Questionnaire... 69F. Clubhouse Staff Questionnaire............................ 75G. Sources for Questions in Questionnaire...................................... 80H. Sample......................................................................................... 83

REFERENCES.......................................................... 85

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FigureFIGURES

Page1. Sample Scores Compared to Norms For Postsecondary Education and Mental

Health Subgroups: Emotional Exhaustion 422. Sample Scores Compared to Norms For Postsecondary Education and MentalHealth Subgroups: Oepersonalization 433. Sample Scores Compared to Norms For Postsecondary Education and MentalHealth Subgroups: Personal Accomplishment. 444. Examination ofWork Tasks Identified as Stressful by ClubhouseStaff (N=97} 48

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TableTABLES

Page1. Number of Clubhouses ta Whom Questionnaires Were Mailed 1 and

Return Rates By Country........................................................................ 272. Description of Clubhouses.............. 303. Clubhouse Characteristics: Members and Staff.............. 324. Description of Clubhouse Staff................................................................... 325. Clubhouse Staff Characteristics.. 356. Organizational Predictors of Burnout: Rotated Factor Analysis............ .... 367. Mean Scores for Factors for Canada and the United States.................... 388. Cutoff Subscores for Occupational Subgroups......................................... 409. Burnout Subscales by Country, Compared to Normative Samples........... 4110. Summary of Stepwise Regression Analysis for Variables PredictingBurnout in Clubhouse Workers.. 45

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INTRODUCTION

Statement of ProblemSocial workers in any area of pradice are facing new and unique challenges today, whichhave profound effects on their performance. Social work, and other helping professions,have been associated with burnout (Courage &Williams, 1987) and there has been agreat deal of literature produced about this topic (Maslach, 1987). Bumout is aphenomenon marked by emotional exhaustion, depersonalization, and decreased personalaccomplishment (Maslach, Jackson &Laiter, 1996, p.4).

Clubhouse programs serve adults with a mental illness, with the intent of strengtheningindividual skills and developing "the environmental supports necessary to sustain theindividual in the community" (Causeway Clubhouse, 1997, p.1). Clubhouses provide analtemative fonn of care to adults with mental iIIness. This care happens on an out-patientbasis, and encompasses multiple aspects of a members life: employment, education,housing, case management, Iife skills, and social interactions.

Staff working in Clubhouses using the Clubhouse model of psycho-social rehabilitation

face unique challenges. Although sorne staff have a social work education, Clubhousestaff do not per se operate as social workers. Their job description, however,encompasses sorne traditional social work roles.

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Staff working within the Clubhouse model not only face the universal budgetary cuts sacommonplace today, they also face the challenge of working within a model that is bereftof structure and clearly defined raies.

ln other words, by its very nature, the Clubhouse model incorporates many of the possiblepredictors of burnout and job dissatisfaction. such as lack of promotional opportunities(Himle, Jayaratne &Thyness, 1986; Jayaratne&Chess, 1983; Jayaratne &Chess, 198283), raie conflid or ambiguity (Jayaratne&Chess, 1986; Jayaratne & Chess, 1983; Quinn& Shepard, 1974), "minimal decision making authorityll and Iittle or no recognition ofsuccess (Finch, 1986, p. 225).

Clubhouse Model of Psycho-Social RehabilitationThe Clubhouse program had an informai beginning in the mid 1940s, when a group ofpost-psychiatric patients in New York City formed a social club called "We Are Not Alone"(WANA). When the group found a director, it became known as Fountain House, whichdeveloped the Clubhouse Model of Psychosocial Rehabilitation (Fountain Housa, dateunknown, b, p.1).

Gramps wrote about the importance of reminding ourselves that "a Clubhouse is not atreatment or an intervention, not even a method or a program. A Clubhouse is acommunity and a culturel! (1987, p.3). There are two central concepts found within theClubhouse which facilitate rehabilitation, and which help to create the community and


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3culture that Gramps wrote about: work and relationships. John Beard, the tirst directorof Fountain House, stated: 'work is a deeply generative and re-integrative force in the lifeof every human being which should underlie, pervade and inform ail of the activities thatmake up the lifeblood of the Clubhouse" (Fountain House, date unknown, b, p.1). Throughwork, staff and members are able to develap relationships which are based on the needto get work done; there is not a focus on illness.

The Clubhouse model is designed ta ensure that members are aware of four importantmessages: members participate in the Clubhouse and make it come alive; members aremade ta feel on a daily basis that their presence is anticipated and makes a difference tasomeone; that the program cannat survive without the participation of members: and thatevery member is needed in the program (Beard, Propst&Malamud, 1982, pp.1-2).

Membership in the Clubhouse is voluntary and for Iife. The only requirement formembership is a history ofmental illness, and there is no enforcement of participation ofmembers. Even though a member may be absent from the Club for an extended periodof time, he or she has the right ta immediately retum ta the Clubhouse at any time.

(Causeway Clubhouse, 1997).

Although Clubhouses have been in existence fo r over 50 years, they have only started taorganize formally in the last several years, in an effort ta ensure conformity ta the modeland ta promote it within the mental health and funding communities.


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4The Clubhouse community, through the International Centre for Clubhouse Development(ICCD) is formalizing information reporting and recording techniques, and at this earlystage, there is little quantitative information available. Previously, the focus had been onqualitative research of an anecdotal nature (Ely, 1991; Glickman, 1992; Peckoff, 1989).

Clubhouse WorkMembers of a Clubhouse program are presented with several different types of work. Thedaily work of the Clubhouse, that work which keeps the Clubhouse functioning, is alsoknown as "pre-vocational" work. Members of the Club valuntarily contribute theirassistance, and often do not perceive themselves as undergoing a formai rehabilitationprocess.

Ali pre-vocational work is designed ta help members leam or regain vocational skills,which will enable them ta gain and maintain paid employment in the community. The workof the Clubhouse provides members with the opportunity ta regain their confidence, andgather job references (Beard, Propst &Malamud, 1982, pp 3-4).

The work of the Clubhouse, while fundamental in its own right, cannot be separated tromthe importance of developing relationships: "Work is the medium out of which Clubhouserelationships are created. It is the source of i!1teractionr satisfaction, a sense ofaccomplishmentr and the basis of friendship among members themselves and betweenthe staff and members" (Jackson, 1988, p.1).


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5Clubhouses are divided into areas known as work units. Although the units vary somewhatfrom Clubhause ta Clubhouse, there are several standard units which can be found in mastClubs. These include a kitchen unit, a maintenance unit, a clerical unit, and a memberservices unit. Dividing the work of the Club into these units enables members to focus onpart icular tasks that are of interast ta them. For example, the kitchen unit enablesmembers to help provide a daily lunch to mambers at a reasonable priee. This work is alsohelpful in preparing members who have as a goal retuming ta work in a kitchen typesetting, such as a restaurant. Members are able to leam ail aspects of food preparation,budgeting and shopping, meal planning, and clean-up fram other members and staff.Although members work alongside staffto accomplish any work that needs to be done, "noopportunity is lost to convert every activity generated by the Clubhouse into a potentialproductive contribution by members" (Beard, Propst&Malamud, 1982, p.2).

Members are not taught these skills formally, but rather leam by working side by sida withmore experienced staff and members. Clubhouse staff come from a variety of educationalbackgrol1nds. A 1996 ICCD Clubhouse survey reported that only 4 9 ~ of Clubhouse staffhave a bachelors degree, and another 3 0 o ~ have only a high school diploma, or sornecollege education. Almost half of Clubhouse staff come to Clubhouse with a backgroundin social sciences, but at least 3 0 o ~ have no formai training in social services (Macias,Jackson, Schroeder, Wang, 1997, p.2). Presumably then, approximately 30% ofClubhouse staffcome to the Clubhouse with work experience in sorne of the areas that arefocussed on through work units (e.g., kitchen, building maintenance, social recreation).


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6Transitional EmploymentClubhouses also have an innovative way of looking al work from a slightly differentperspective. The Transitional Emplayment Program (TEP) is anather step in preparingmembers for independent emplayment. The Clubhouse halds a job in trust for itsmembers, and interested members are rotated through the job, generally every six months.These jobs are typically entry-Ievel, and can be found in a number of different fields,including clerical work, janitorial, kitchen, and sa farth. Generally one full time position willbe divided ta create two half-time positions. Members are selected for the positions bythe Clubhouse, and receive training fram staff or members who have already been trained.There are back up members for each position, and if there are no members available todo the job, a trained staffwill fil! in: employers are guaranteed that the shift will always becovered. The only criterion required for working a TE, is the desire to wark. Failure in apreviaus placement does not prevent an interested member fram applying for anotherposition (International Centre for Clubhouse Development, 1997, p.39).

The 1996 Clubhouse survey reported that, during 1995, approximately 3400 members inthe 222 Clubhouses participating in the survey worked at least one TEP. "0verall,

Clubhouses in the survey sample contracted with 1000 different businesses ta providemembers with work and facilitate the eaming of approximately 4.3 million dollars perannum". On average participating Clubhouses had 11.5 TEs with 6.2 employers in 1995,and "memberwork opportunity, expressed as the ratio of available TE jobs ta usual weekday attendance, averaged 27%". (Macias et al, 1997, p.5).


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On average, "16A, of each Clubhouse's active membership were competitively employedfo r some length of time during 1995." and "total member earnings in competitiveemployment fo r 1995 averaged $52,923 per Clubhouse for part-time employment and$83,864 for full-time employment" (Macias et al, 1997, p.5).

Staff/Member RelationshipsThe work of the Clubhouse is facilitated by relationships that are developed amongst staffand members. The relationship is therapeutic because the focus is not on the membersillness, or weaknesses, but rather on the unique and valuable contribution each membercan make, their "strengths, talents and abilities ll (International Centre for ClubhouseDevelopment, 1996, p.41). Vorspan (1985) wrote, "the relationships in a Clubhouse areborne of the work, and the work is borne of the relationships" (p.4). Members learn thattheir presence and contributions are necessary to the daily running of the Clubhouse, andthat the staff and members of the Clubhouse look forward ta seeing them on a daily basis.

The concept of empowerment is central ta the Clubhouse model, and to the developmentof relationships. This term has never been clearly defined within the Iiterature(Chamberlin, 1997, p.1). Gramps (1987) explored the concept of mutual empowermentas it relates ta Clubhouse. He wrote that members and staff mutually empower each otherby participating equally in ail Clubhouse work, and having a raie within the Clubhouse.Vorspan (1987) wrote that trom day one, staff are "placed in a situation in which they nead


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8to be membersn Staff are forced to "search out the talent and potential in the Clubmembership" (p.6)

Staff in the Clubhouse face unique challenges not present in other jobs. Staff must be"fully, genuinely and spontaneously involved with the members with whom we workt andat the same time ta ratain enough objectivity ta be conscious of each one's particular andindividual needs." AJthough staff are also members of the Club, they have a very real raiewhich they are accountable for (Vorspan, 1985, pp.3-4).

Staff are considered generalists, in that they share employment, housing, evening andweekend and unit responsibil ities. Staffing levels are deliberately kept low enough thatalthough there are enough staff ta engage members, there are not enough to do ail of thework without signifiesnt member involvement (ICCO, 1996, p.40).

The International Centre for Clubhouse Development (ICCO)The Clubhouse movement is now international, with 340 Clubhouses in countries includingAustralia, Korea, Germany, and Egypt, as weil as Canada and the United States (two ofthase Clubhouses serve adults with traumatic brain injuries) (leCO, 1997, pp.1-31;Appendix B). A National Training Program bagan in 1976, enabling hundreds ofcolleagues to be trained through Fountain House. There was no provision within thistraining program, however, for continued quality assurance. In 1988, the National


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9Clubhouse Expansion Program (NCEP) enabled the Clubhouse community ta developstandards for Clubhouse programs (Propst, date unknown, p.1; Appendix A).

The ICCO was chartered in 1992. Although the leeo is housed within Fountain House,it has its own board and staff. The ICCO is currently working on several projects, includingdeveloping a research protocol for ail Clubhouses, a comparative study on the Clubhousemodel and other community mental health models, and the support and development oflocal Clubhouse coalitions. The mission of the ICCO is Ilto develop new Clubhouses,proteet and strengthen existing Clubhouses, and ta serve as the hub of this vibrantnetwork of communities around the world tl (ICCO, date unknown). Members of the leCDcan take advantage of networking, advocacy, problem solving and research opportunities(ICCO, date unknown).

ln addition ta the above mentioned projects, the ICCO has also begun the pracess ofcertitying Clubhauses, ta ensure conformity ta the standards for the Clubhouse model(Fountain House, date unknown, b, p.1). The process involves the Club seekingcertification undertaking a self study, ta examine haw closely they are adhering ta thestandards. This is followed by a site visit by colleagues fram another Clubhouse whothemselves evaluate how closely the standards are being followed. Based on thisevaluation, a Clubhouse is either denied certification, or is granted a one or three yearcertification.


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10Approximately 4 0 o ~ to 70% of a Club's budget cornes from Federal, state or provincialdepartments of mental health and local govemment funding. American Clubs also receivefunding trom medicaid reimbursements or black grants (Macias et aL, 1997, p.2).

Macias et al. (1997) reported thatjust over one hait (52%) of Clubhouses in the study ownor rent their own building: 37% are under the auspices of another community mentalhealth centre; 2 9 ~ are part of another kind of non-profit agency; 3% are governmentoperated, and 2%) are run bya for-profit agency.

The Clubhouse community has published sorne costs for running the Clubhouse program,as compared ta ether medical model day treatment programs and psychiatric hospitals.These figures are somewhat problematic, as it is unclear how they are arrived at. A 1996survey by the ICCO reported that the 222 Clubhouses respending to the survey served25,000 adults with mental iIIness daily. ''The annual cost per member te provideClubhouse rehabilitation (Le., total budget divided by total active members) averages$3559. a year". (Macias et aL, 1997, p.2). Fountain House has reported that it is "at leastas effective in promoting recovery at less than hait the cost ofmedical model day treatmentprograms: $35 par day versus at least $100". Fountain House also reported that "it's 80percent less expensive to house and support individuals through Fountain House than tomaintain them in a state institution: an average of $21,000 versus $120,000 annuallylf(Fountain House, date unknown, p.1).


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11Job Tenure, Job Satisfaction and Bumout in the ClubhouseA 1995 Clubhouse survey reported that 93% of ail Clubhouse staff surveyed wereemployed by their Clubhouse for twelve full months (Macias et aL. 1997. p.2). AlthoughClubhouse research has indicated that job tenure is high. the research available does notspeak ta job satisfaction, burnout, or intent ta turnover.

Finch (1986) reported that Clubhouse staff at Fountain House. in New York City,experienced significantly lower levels of burnout than the normative sample of mentalhealth professionals presented byMaslach et al., as part of the Maslach Burnout Inventory(MSI) (p.231). Finch used an earlier version of the MSI, (1981) which was somewhatdif ferent than the 1996 version, as it required respondents ta rate how often and howstrong they were experiencing the statements in the survey. She suggested severalpossible reasons for these low levels of bumout, which might include: the ideology of theClubhouse model, personal characteristics of staff, the leave of burned out staff, or theexpeetation of ideelagical commitment which would prevent staff tram indicating that theywere bumed out (pp.233-34).

Significant changes have occurred in funding and the size of the movement since the studyby Finch, which necessitated another look ta determine if bumout remains low amongClubhouse staff. As weil, levels of bumout may vary among Clubhouses which do nothave the reputation of Fountain House, and there may be differences between Canadianand American Clubhouses.


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12BumoutBumout is a difficult concept to define, because there is no commonly accepted definition(Powell, 1994, p.229). Burnout is "ambiguously defined, measured, and assessed, andthe same is true for the correlates of bumout (Soderfeldt, Soderfeldt & Warg, 1995,p.641). The definition of burnout seems to be more of a description of the phenomenon.

There is confusion in the Iiterature as to whether stress and burnout mean the same thing(Walsh, 1987, p.279). Freudenberger has described burnout as a coping mechanism,while Farber has described bumout lias an outcome of stressful working conditions ratherthan as a coping mechanism" (Soderfeldt et al, 1995, p.639).

There is also disagreement as to the causes of burnout: is the individual or theenvironment responsible? Soderfeldt et al. (1995), citing Farber (1983), wrote:

Freudenberger's model of burnout emphasized primarily the psychology of theindividual, whereas Maslach (1982) and subsequent writers investigated burnoutfram a social psychological perspective, with a focus on the relationship betweenenvironmental and individual factors (p. 639).

Maslach has written that there are at least 30 different definitions of burnout, sorne ofwhich include causes in the definition, and sorne include consequences. (Saderfeldt etal, 1995, p.639). For the purposes of this paper, Maslachls definition of bumout was usedas the working definition. "Bumout is a syndrome of emotional exhaustion,


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depersonalization, and reduced personal accomplishment that can occur amongindividuals who work with people in sorne capacity." (Maslach et aL, 19961 p.4).

Maslach defined burnout as having three key aspects: increased emotional exhaustion:lias emotional resources are depleted, workers feel they are no longer able ta give ofthemselves at a psychological level ll ; increased feelings of depersonalization: "negative,cynical attitudes and feelings about ane's clients"; and reduced feelings of personalaccomplishment: 'au,e tendency to evaluate oneself negatively, particularly with regard toone's work with clients" (Maslach et aL, 1996, p.4)

Causes of BumoutThere are several theories as to the causes of bumout. Researchers have mentioned threegroups of factors associated with bumout and job satisfaction: work-related, worker..relatedand client-related factors. Work..related factors may include the following: low workautonomy, lack of job challenge, lowdegrees of support, role ambiguity, work in the publicsector, low professional self-esteem, low salary, dissatisfaction with agency goals, minimaluse of coping strategies at work, difficult ies in providing services ta clients, negativeatti tudes towards the profession, high degrees of work pressure, and bad agencyfunctioning (Soderfelt et al, 1995, p.641). Other work-related factors appearing in theIiterature include "quantity of the workload, the availability of a supportive environment,and the ability ta mobilize resources for the provision of services" (Courage &Williams,1987, p.9).


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14Caseload size is one of the most commonly identified work-related factors contributing tabumout (Courage&Williams, 1987, p.9). The size of a workers caseload may not be thebest indicator of workload. Rather it is the workers perception of the manageability oftheir workload which may be a more telling factor (Jayaratne &Chess, 1984, p. 449).

Worker-Related CausesCauses of bumout attributed to the individual worker most commonly include personalitytraits. Courage and Williams (1987), citing Maslach and Freudenberger, wrote:

When the relationship between the care provider and the recipient of care achievesneither the recipient's expectations nor the expected outcomes of the care provider,culpability may be assigned to either (Maslach. 1982). In the literature, culpability ismost frequently assigned to personality traits of care providers. Freudenberger (1975)described the personality type susceptible to bumout as the over-dedicated and avercommitted worker. (pp. 8-9).Other personality traits associated with bumout in the literature include "non-assertivenessin dealing with people, impatience, intolerance in confronting obstacles, and lack of self-confidence" (Courage & Williams, 1987, p.9). Freudenberger identified workers whoderive ail meaning and gratification fram work, with little achieved frem their saciallife, asanother persanality trait associated with bumout (Courage &Williams, 1987, p.9). Larsen,Gilbertson and Powell (1978) wrote that workers who have difficulty setting Iimits, may besetting themselves up for bumout (LeCroy &Rank, 1987, p.26).

Client Related CausesCourage and Williams (1987) indicated that client-related factors related to the


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development of bumout have not been explored in great detail in the literature (1987,p.16). Factors which have been identified include: "behavioural manifestations ofpersenality such as anger, anxiety. hostility, and despair", and "individual anddemographic charaderistics, chronicity, acuity, and cemplexity of preblem variables" (pp.16-17).

Effects Of BurnoutAlthough there are many different perceptions of the causes of bumout, mest authersagree that the affects of burneut or severe stress can vary, and can be extremely costlyto the worker, clients, and the organization, friends and family.

Cerceran (1986), citing Jackson and Maslach, wrote that the effect of bumout "is sean asreaching not only the individual worker and client, but the social service agency and nonwork relationships, such as the worker's family" (p.5a).

Organizations suffer as a result of bumeut due to high job tumover, deterioration in thequality of services available to clients, absenteeism and low morale (Maslach et al., 1996,p.4). Cerceran (1987) reported that "burnout adversely affects the delivery of services"(p.57). At present, there are no statistics available on these trends in Clubhouses.

Clients suffer from bumout because workers may not have the energy or compassion to


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16devate ta ther care. Staffmay become cynical and develop negative impressions of theirclients bath intellectually and interpersanally (Corcoran. 1987. p.63).

Warkers themselves suffer fram burnout in a number of ways. Workers may suffer fromphysical exhaustion, insomnia, increased use of drugs and alcohal, gastrointestinalproblems, poor self-esteem, withdrawal, depression. feelings of helplessness andhopelessness l excessive rigiditYI alienation, and 1055 of spirit, emotional exhaustion,reduced personal productivity, sense of depersonalization (Courage & Williams, 1987, p.8;Freudenberger, 1975, p. 74; Maslach et al, 1996, p.4; Walsh, 1987, p.280).

Friends and family members may also suffer from the effects of bumout. Workers sufferingfram burnout often tend to blame others for their difficulties, and often are faced withmarital and family problems (Maslach et al, 1996, p.4), and a difficulty in interpersonalrelationships and intimacy (Powell, 1994, p.229).

Job SatisfactionLeCroy and Rank note that although low job satisfaction is closely related ta burnout, the

concepts are not identical (1987, p. 24-25). It is not clear which is the cause and whichis the effect. Herrick, Takagi, Coleman and Morgan (1983), citing severa1 previousstudies, identified "such factors associated with job dissatisfaction as bumout (Chemiss,1980), raie conflids (Lewin, 1962), insufficient recognition of professional knowledge andskil ls (Meinert, 1975), and lack of opportunities for innovation and professional self-


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17

development (Otis & Cavagonne, 1979)" (p.78). Raie ambiguity, role conflict and workloadhave also baen described as predictors of job dissatisfaction. "Factors which causallyaffect job satisfaction also affect feelings of bumout, although the extent may vary with onlythe extreme cases resulting in bumout" (Jayaratne et al, 1991, pp. 248-249).

There has been a great deal more research on job satisfaction than on bumout, with thebulk of the research facussed on aspects within the work environment which causesatisfaction or dissatisfaction among warkers. The symptoms of job dissatisfaction, suchas anxiety, depression, irr itability and somatic complaints have been largely ignored.These symptoms are similar ta the symptoms described above as relating to burnout.There does not seem ta be a clear relationship between job satisfaction and jobperformance (Jayaratne et al, 1991, p. 248).

Most authors on the subjects of job satisfaction and bumout will agree that the conceptsoverlap conceptually, hawever the extent of the relationship between the two concepts hasnever been developed (Jayaratne&Chess, 1982-83, p.2).

Research GoalsThis study is an attempt ta determine if bumout is a problem for Clubhouses, through asurvey of Clubhouse staff in the United States and Canada. Although there are manyfactors which can cause bumout, this study addresses three main types: organizational,cl ient-related and worker-related.


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18The goals of this study are:

1) To measure the levels of bumout that Clubhouse workers encounter, and comparethem to levels in other work settings.2) To identify predictors of bumout3) Ta identify whether workplace, personal or client-related factors are the main cause ofburnout4) To examine the costs of bumout ta the agency, clients and personallives ofworkersby use of anecdotal evidence.

Findings in the /iterature, as weil as the complicated structure of the Clubhouse whichexpects each worker to hold multiple positions within the agency, have led ta thehypothesis that Clubhouse workers experience higher levels of burnout than their peersin more traditional mental health settings. A second hypothesis is that bumout is largelyattributed to the organizational predictors of bumout.


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METHOOQuestionnaireTwo different questionnaires were developed for this study: one for executive directors,and a second for the remaining staff in the Clubhouse. The questionnaires were slightlydifferent (Appendices E and F). Appendix G cantains a detailed 1ist of sources for eachquestionnaire.

ln most instances, respondents were asked for their perception of a situation. Forexample, respondents were asked if they perceived their workload ta be too high, asopposed to asking for an actual size of the caseload: Lewin stated that this method U tapsa person's perceptions of a situation rather than the absolute context of that situation"(Jayaratne & Chess. 1983, p.14). Many studies have followed this method of measuringa worker's perceptions (Himle, Jayaratne, & Thyness, 1986 & 1989).

Executive Director's QuestionnaireThe executive director's questionnaire began with a frfteen- item caver sheet on Clubhousedemographics. Ali questions in this section were developed specifically for this study.This portion of the survey was organized in three sections:

Three questions on the operating budget of the Clubhouse, whether the Clubhousewas freestanding or under an auspice agency and the length of time operating asa Clubhouse.

19


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20Three questions on certification: Was the Clubhouse paying annual fees to theICCO, had the Clubhouse been certified, and length of time of certification.

Two questions on members, including the number ofmembers in the Club as of July1, 1997, and the average daily attendance.

Seven questions on staff, including the number of full and part-lime staff, hiringrequirements, the number of staff with three-week Clubhouse training, how manystaff had left in the following year and for what reasons. Lastly, respondents wereasked whether staff had access ta an ernployee assistance prograrn, and how manytirnes that program had been accessed in 1996.

The second part of the questionnaire consisted of three sections:

Eight questions which focussed on personal characteristics of the respondent andon non-work stressors which could affect the respondent's experience in theClubhouse, including such factors as social support, methods of coping,personality, and home situation outside of work. Responses for the tirst sevenwere scored using a three point scale (1=never, 2=sometimes, 3=always). Samplequestions included: "My family is supportive of me ll and fil exercise regularly".Question eight was open - ended: "Please indicate any significant transition, lifeavent and/or loss that you may have experienced in the past 18 months: (Le.


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21

illness, change of jobs, pregnancy. divorce, etc.)".

Forty questions focussed on organizational factors which can affect an employee'swork experience. including indicators such as raie ambiguity, raie conflict, coworker support, promotional opportunities, job satisfaction, autonomy, intent ta quit.and job preparation. Scoring was carried out using the following procedures:

Responses to the first twenty-six questions of this section were scored usinga three-point scala (1 =naver, 2=sometimes, 3=always). Sample questionsincluded: tlJob security is something 1worry about", "My responsibilities areclearly defined", "1 have the opportunity for training and skill development","Our meetings are ineffective", and "1 receive enough recognition for mysuccesses". Questions 18 and 19 focussed on staffs openness ta changeand the involvement of staff in the decision making process.

Questions 27 through 34 were scored using a different three point scale(1 =agree, 2=undecided, 3=disagree). Sample questions included: "1 am

adequately paid", and "I have received sufficient training to do this job".

Respondents were asked in Question 35, to detail how they spant their day:how much time was spent in direct contact with members, doing paperwork,attending meetings, and supervising staff; ln Question 36 they were asked


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22whether or not they had attended a three week Clubhouse training session.

Job satisfaction was measured with three questions (37 through 39). Thefirst question was scored on a four-point scale, ranging fram very dissatisfiedta very satisfied: "Ali in ail, how satisfied would you say vou are with yourjob". The second question measured the likelihood of the respondentmaking an effort ta find a new job within the next year. This question wasmeasured on a three point scale ( 1= not at ail likely, 2=somewhat likely, 3=very Iikely), and has appeared in many similar studies. The final questionon job satisfaction was open-ended, and focussed on reasons for leaving thecurrent position if the respondent had indicated that they were somewhat orvery Iikely to search for new employment.

Salary range was measured with one question (40). Respondents were asked toindicate which salary range they fit into. There were six categories, ranging from"below $30,000" to "over $70.0001f

Two questions (41 and 42) which were open-ended: "Is there anything else youwould l ike ta tell me about your experience, positive or negative, as an exeeutivediredorlstaff in the Clubhouse?" and "Based on your personal experience workingwithin the Clubhouse model, what recommendations would Vou make to improve astaffmembers experience?" These questions were developed for this study.


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23Staff QuestionnaireThe staff questionnaire was slightly different from the executive director's version; it didnot include the Clubhouse demographic caver sheet, and was organized in four sections:

Eight questions (1 through 8) about personal characteristics and non-workstressors. This section was identical to the executive directars version.

Forty-two questions (Questions 1 through 42 in Part 2 of the questionnaire) aboutorganizational factors which can affect an employeels work experience. Thissection was identical to the executive directors questionnaire, with the exceptionof four additional items: "1 feel supported by my supervisor'\ "1 receive adequateperformance feedback from my supervisor', "1 am involved in the decision makingprocess'\ and 'The promotional opportunities are fair". As weil, two questions fromthe executive director's questionnaire (Questions 18 and 19), were amitted fram thestaff questionnaire. In addition, the question on salary (42) had only five categoriesin the staff questionnaire, ranging fram "below $20,000" ta "over $50,000".

A check-off list of sixteen items (Part 3 of the questionnaire) which respondentswere asked to identity as stressful or not These questions were not included in thedirectars survey. Sorne researchers believe that a staff members experience islargely influenced by the cHentele that he or she serves. The items listed included:Working with a member who is suicidai, engaging members in unit work, and the


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24

chronic nature of members' problems. This list was developed through personalexperience working in the Clubhouse model, through discussions with staff currentlyworking within the model, and from previous research on the Clubhouse model.

An open-ended question in Part 3 of the questionnaire, where respondentshad the opportunity to indicate anything else that they found stressful aboutworking with members.

Two open-ended items which were identical to Part 3 in the executive director'squestionnaire.

Maslach Bumout InventoryBoth questionnaires contained a copy of the Maslach Bumout Inventory (Maslach et al.,1996) and a demographic sheet developed by the same authors. The MBI is labelled theHuman Services Survey to avoid sensitization to burnout. The survey measures burnoutusing three subscales which represent the three aspects of bumout: Emotional exhaustion,

which assesses "feelings of being emotionally over-extended and exhausted by one'swork"; depersonalzation, which measures "an unfeeling and impersonal response towardrecipients of one's service, care, treatment, or instruction", and lack of personalaccomplishment, which measures 'lfeelings of competence and successful achievementin one's work with people" (Maslach et al, 1996, p.4).


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25The demographic section of the MBI contained questions on age, race, religion, andeducation.

Sampling and DistributionThe target sample was 150 Clubhouse staff, drawn using the following procedure. TheClubhouses listed in the 1996 Clubhouse Directory (ICCD, 1997) were stratified by citysize (City Profiles, 1998; Cambridge Gazeteer, 1995) in order to obtain a morerepresentative sample and decrease probable sampling errer (Rubin & Babbie, 1993).

Initially, twe Clubheuses were chosen from each of the categories fram the UnitedStates, and one from each of the Canadian categories, as there are fewer CanadianClubheuses in each category. Individual Clubheuses were selected from eachcategory using a table of randam numbers, with a random start (Rubin & Babbie,1993). In the end, due to non-respenses, sorne categories were over-represented.

Several executive directors of Clubhouses on the first sample drawn wereunreachable, which meant that the desired sample of 150 staff was notobtained.

.. A second list of additional Clubhouses was randomly drawn in the samemanner as the first, to replace Clubhouses missing in a category. Again,several Clubhouses on the second Iist were unreachable.


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26Four Clubhouses refused ta participate: two were no longer operating asClubhouses, and two were in the middle ofmoves, and did not have the timeta participate. The twenty Clubhouses that did agree ta participate had atotal of 149 staff. A Iist of the participating Clubhouses can be faund inAppendix H, and the sample is shawn in Table 1.

Letters of introduction outlining the purpose of the study were sent to the executivedirectors af each of the twenty Clubs (Appendix Cl. Fallow-up phone calls weremade ta the directors ta determine if staff at each Clubhouse were interested inparticipating in the study.

A packet of questionnaires was mailed ta the directors of participating Clubs, fordistribution to staff. Ali staff, including administrative and management were askedta participate, except for staff who held non-generalist positions such as housingstaff, or drivers. A stamped ratum envelope was provided with each questionnaire.Respondents were asked ta complete their questionnaires and return them as saonas possible (Appendix 0). Each questionnaire was numbered and dated as it wasreturned. A retum rate graph was kept, detailing the retum pattern.


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Table 1. Number of Clubhouses To Whom Questionnaires Were Mailed, and Return Rates. by Country

CANADA UNITED STATES

Staff ln Staff lnClubhouses ln Chosen Chosen Staff Surveys Clubhou58s ln Chosen Chosen StaffSurveysCnySlze Category Clubhouses Clubhouses Retumed Category Clubhouses Clubhouses Returned(N) (N) (N) (N) (N) (N) (N) eN)under 10,000 2 1 5 5 16 2 15 710.001-50.000 6 2 14 11 80 3 19 1750.001-200,000 11 1 5 3 52 3 19 10200,001-500,000 3 2 23 10 23 1 12 8500.001-800,000 1 0 0 0 9 2 17 9

800,001-1 milllon+ 0 0 0 0 21 2 16 13Unknown 0 0 0 0 24 1 4 4

Tatals 23 6 47 29 225 14 102 68~ The 97 respondents consisted of 17 Executive Directors, and 80 staff.


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28Follow -up phone calls were made to each Clubhouse to ascertain whether theyhad received their package of questionnaires, and that they had been distributed.Thank you cards were sent out ta ail Clubhouses, to thank staff for theirparticipation. Reports on the results were promised to each of the twentyClubhouses.

AnalysisAli demographic variables were compared for the two countries, and tests of significance(t-test and chi-square) done. The coding of the three negatively worded items in Part 1 ofthe survey was reversed, 50 that ail items could be interpreted with the higher numbershaving a positive connotation. The questions were: HI find it hard to refuse a favour orrequest", "My home life is stressful", and HI tend to neglect my own needs". The mean ofQuestions 1 through 7 was calculated to form one composite variable, called Lifestyle.

A factor analysis of 34 of the items in Part 2 of the questionnaire was done (Questions 1through 14, 16, and 18 through 36), and standardized factor scores were calculated,using SPSS (v. 7.5, 1997) with varimax rotation and otherwise default options.

The three bumout scores from the Human Services Survey (emotional exhaustion,depersonalization, and personal accomplshment) were calculated using the scoring keyprovided with the MBI testing kit (Maslach et al, 1996). Each question was rated on ascalefrom 0 (never) ta 6 (every day). The scoring key shows which questions are used


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29to calculate the scores for each of the subscales, and cut-offs are given to divide thescores into the low, average or high thirds for various normative groups.

The mean factor scores and bumout scores for Canada and the United States werecompared, using t-tests.

Bumout scores were compared to Maslach's norms using two statistical tests: differencesin mean scores were examined, using t-tests, and the numbers of cases faIHng betweenMaslach's cut-offs were compared to her 1/3 - 1/3 - 1/3 distribution, using one-way chisquare tests.

ln arder to oblain a better understanding of each of the three dimensions of burnout(emotional exhaustion, depersonaHzation and persona1 accomplishment), stepwiseregressions 'Nere performed. Possible predictors examined inctuded eight demographicvariables: age; number of chHdren in the home, sex, level of education, hours worked perweek, length of time on the job, length of time doing similar work, and degree of religiosity.Other variables considered were country (Canada or the United States), category of

Clubhouse, the Lifestyle score, and the factor scores calculated trom Part 2 of thesurvey.


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FINDINGSDescription of Sample: ClubhousesClubhouse DemographiesTable 2 shows information on Clubhouse demographics. On average, more American than

Table 2. Description of ClubhousesUnited States (N=141

Variable N J i N ~Paying Fees to ICCOYes 3 50.0 8 57.1No 2 33.3 5 35.7Missing 1 16.6 1 16.6

Length of CertificationOne year 0 0.0 3 21.4Three years 1 16.6 2 14.3Pending certification 1 16.6 1 7.1Not certified 3 50.0 7 50.0Missing 1 16.6 1 7.1

Annual Operating BudgetUnder $300,000 3 50.0 5 35.7$300,000-$499,999 2 33.3 6 42.9$500,000-$799,999 0 0.0 2 14.3Over $1,000,000 0 0.0 0 0.0Missing 1 16.6 1 7.1

AuspicesFreestanding 1 16.6 1 7.1Under auspice agency 4 66.6 12 85.7Missing 1 16.6 1 7.1

Employee Assistance ProgramsYas 2 33.3 4 28.6No 3 50.0 9 64.3Missing 1 16.6 1 7.1

Note. Three of the U.S Executive D i r e d o ~ s questionnaires were completed by staff members.

30


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31

Canadian Clubhouses in this sample were paying tees ta the ICCD (57.1 % compared to50.0%). As weil, more American than Canadian Clubhouses were certified for one or threeyears (35.74 compared ta 16.64,). At least 50% of Clubhouses in the United States andCanada did not Pfovide Employee Assistance Programs for their staff. Tests of statisticalsignificance were not done due to the small number of Clubhouses in the sample.

Canadian Clubhouses in the sample reported that 7 staff had left in the past year: 4 hadquit and 3 had feft for ether reasons. The American Clubhouses reported that 23 staff hadleft the Clubhouses in the past year: 20 had quit and 3 had laft for other reasons. Nostaff in any Clubhouse had been laid of f or fired.

Table 3 shows mean values for ether Clubhouse variables. The Canadian Clubhousesin the sample had a higher average number of members than the American Clubhouses,and a higher average daily attendance. Despite the higher numbers of members, the

..

American Clubhouses reported more full time staff than the Canadian Clubhouses.Nene of the differences reported in this table are statistically significant.


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32

Table 3. Clubhouse Characteristics: Members and StaffVariable Canada United StatesN Mean N ~Number of Members 5 183.8 13 134.8

Average daily attendance 5 33.5 13 39.3Number of staff 5 6.6 13 7.9

P a r t ~ t j m e 5 2.0 11 2.2FuJl-time 5 4.8 12 6.3

Length of years in operation 5 7.3 13 7.4

Table 4 shows a description of Clubhouse staff in the sample. Sorne categories werecollapsed to allow for analysis. Overall, very few respondents indicated that they were

Table 4. Description of Clubhouse StaffVariable

Job Tltle

Canada (N=29)N

United States (N=68)N AJ

Staff membersSupervisorslmanagersAdministratorsOtherMissing

RaceWhite, caucasianBlackOther

ReligionRoman CatholicProtestantJewishOtherMissing

18 62.1 40 58.84 13.8 18 26.54 13.8 6 8.83 10.3 2 2.90 0 2 2.9

26 89.7 52 76.51 3.4 10 14.72 6.9 6 8.8

12 41.4 18 26.57 24.1 21 95.91 3.4 5 7.49 31.0 23 33.80 0 1 1.5


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33Table 4 - ContinuedVariable Canada (N=29) United States(N=68)N ~ N ~Marital StatU&Married 22 75.9 38 55.9Single 4 13.8 14 20.6Divorced 1 3.4 8 11.8Other 2 6.9 8 11.8

EducationB.A/B.S. 10 34.5 23 33.8M.A./M.5.1M.S.W. 1 34 15 22.1Other 11 38.0 17 25.0Missing 7 24.1 13 19.1

Prlmary Area of WorkMental Health 28 96.6 57 83.8Other 1 3.4 9 13.2Missing 0 0.0 2 2.9

3 week ClubhousetrainingVes 10 10.4 18 26.5No 18 96.2 50 73.5Missing 1 3.4 0 0.0

SalaryBelow $20,000 1 3.4 16 23.5$20,000 - $29,999 8 27.6 33 48.5$30,000 - $39,999 13 44.8 10 14.7Over $40,000 6 20.7 7 10.3Missing 1 3.4 2 29.4

Job SatisfactionVery Satisfied 17 58.6 31 45.6Somewhat Satisfied 7 24.1 31 45.6Very DissatisfJed 4 13.8 5 7.4Missing 1 3.4 1 1.5

Intent ta TurnoverNot at ail likejy 16 55.2 46 67.6Somewhat Iikely 9 31.0 16 23.5Very likety 4 13.8 4 5.9Missing 0 0.0 2 2.9


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34dissatisfied with their job. The only variable where the difference between countries wasstatistically significant was salary; without factoring in any exchange rates, it appears thatCanadian Clubhouse workers in the sample were paid better than American workers. Ahigher percentage of Canadian workers in this sample were in the $30,000 - $39,999category (44.8AJ compared ta 14.?Ok), while a higher number of American workers in thissample were in the $20,000 - $29,999 category (48.5% compared to 27.6%). As weil,there were more American than Canadian workers in this sample eaming less than$20,000 (23.5% compared to 3.4%). Factoring in the exchange rate, the salaries betweenthe countries are much closer. Assuming that the Canadian dollar was worth 66 centsU.S. at the time of the survey, the salary range of $30,000 - $39,999 becomes $19,800 $ 26, 399 U.S. It is interesting to note that American Clubhouses in this sample havemore staff at the Masters level than Canadian Clubs (22.1 % compared ta 3.4AJ).

Table 5 shows a comparison of Clubhouse staff characteristics. The only differenceswhich are statistically significant are the number of hours worked in a week (Canadianworkers in this sampie worked on average 34.45 hours, while American workers workedan average of 38.59), and number of years in this job (Canadian workers had spent anaverage of 6.56 years in this job, while American workers had spent an average of 4.0years).


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35Table 5. Clubhouse Staff Characteristics

Variable Canada United StatesN Mean N Mean

Age (years) 29 38.2 68 40.1Degree of religioslty 28 3.3 67 3.5Length of marriage (years) 22 11.7 38 12.1Number of children at home 28 1.0 63 0.7Number of hours worked per week 29 34.5 * 65 38.6 *Number of years in this job 29 6.6 - 65 4.0 -Number of years in similar work 29 11.7 66 9.1Number of hours in direct contact with 28 5.5 63 5.5Number of hours doing paperwork 27 1.7 62 1.8Number of heurs in meetings 27 1.8 63 1.2Number of heurs supervising staff 6 1.2 9 1.2

Note. Degree of retiglositymeasures how rellgious respondents consider themsetves to be. Respondents rate themsetves on a scale trom1 ta 7. with 1 meanlng they are very reiiglous, and 7 meaning they are nct at an religious. (Maslach et al, 1996).-t(92) =2.86, p< .01-- t(92) =2.33, p< .05

Factor AnalysisTable 6 shows the results of the factor analysis of 34 questions about organizationalstructure (Part 2 of both the executive director and staff questionnaires). A six-factormodel was chosen, which explained 52.1 % of the total variance and yielded factors whichseemed to be interpretable. The names given ta the factors are intended to represent thegeneral theme of the variables loaded on each factor. Negatively-worded items in eachfactor were negatively loaded in the calculation of the factor scores.


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36Table 6. Organizational Predietors of Bumout: Rotated Factor AnalysisVariable Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6Supervisory Agency Training Workload Job IntrusionRole Structure Challenge onPersonalL1fePerformance feedback .n .34Supervisor support .71 .36Input is valued .68Involvement ln decisions .66Recognition for success .63 .39 .30Ineffective meetings -.62 .33 -.40Professionsl values conflict -.60Skill devetopment .52Work directly with members .49 -.45Cfear responsibilities .48 .38Adequate pay -.66TIme to complete oork .60 .35Freedom ta do work .59Expected to give tao much -.41 -.53 .32Worry about job security -.46Mastery of practl methods .63Training ta do job -.63Competent coworkers .43 .59 .35Frtendly coworkers .57Satlsfy some, upset ethers -.46Knowtedge ofmentalillness .73Tao manymeetings .nTao much paperwork .64Regular staff meetings .71Interesting job .33 .66Opportunity ta develop .47 .52Challenging problems .48 .37Fair promotionaI -.33 -.43KnaNtedge of CH mode! .41Question CH values -.37On caU afterhours .69Goocf frfnge benefits .37 .64see coworkers socially .61Bring work home -.38 .46

Note. Dashes indicate loadings under .30


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37The factors were:

1) Supervisory Role, which included questions on superviser support, performancefeedback, recognition for successes, and involvement in the decisien making process.There were three negatively worded questions in this factor. An example of a negativelyworded question is "our meetings are ineffective" ;

2) Agency Structure, which included items, such as pay, freedom to decide how ta dotheir own work, and job security. There were five negatively worded questions in thisfactor. An example of a negatively worded question is "I am expected to give too muchtime to my job";

3) Training, which included items such as training, the competence of co-workers, andmastery of practice methods. There were four negatively worded question in this factor.An example ofa negatively worded question is "in order to satisfy sorne people on the job,1have to upset others";

4) Workload, which included items on spending too much time in meetings, and onpaperwork. There were no negatively worded questions in this factor;

5) Job Challenge, which included items such as doing work that the worker consideredinteresting, having the opportunity ta solve challenging problems. and having the


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38opportunity for promotions. There were three negatively worded questions in this factor,An example of a negatively worded question is "l question the values and beliefs of theClubhouse model";

6) Intrusion of Work on Personal Life r which included items such as having to bringwork home, and seeing their co-workers on a social basis. There were no negativelyworded questions in this factor.

Table 7 shows a comparison of the mean factor scores for each of the factors Iisted aboveplus the Lifestyle score (Part 1 of bath questionnaires), for Canada and the United States.There were no significant differences in scores between countries.

Table 7. Mean Factor Scores by CountryScore Canada United StatesN Mean N MeanLifestyle 29 2.34 68 2.39Factors

Supervisory RaIe 21 -.19 49 .oaAgency Structure 21 .24 49 -.10Training 21 .27 49 -.12Workload 21 .02 49 -.01Job Challenge 21 -.32 49 .14Intrusion ofWork on Persona! Life 21 .27 49 -.12


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39

Measures of Surnout

Maslach Bumaut InventoryThe Maslach Bumout Inventory measures the level of bumout a person is experiencing,by measuring a worker's levels of depersonalizatian, emotional exhaustion, and personalaccomplishment. Scoring is such that a higher level of bumoutwould be indicated by highscores on emotional exhaustion and depersonalization, and low scores on personalaccomplishment. This inventory has been extensively tested. Maslach and her colleagueshave provided average scores for a number of occupational groups, including a group ofmental heafth warkers.

The postsecondary education subgroup was chosen as a comparison group for empiricalreasons, because of ail Mashlach's subgroups, it matched the scores for the samplemast c1osely. This subgroup completed a slightly different version of the MBI, where theword "recipient" was replaced with "student" (Maslach et aL, p.29). The mental healthsubgroup was used for theoretical reasons, as it was hypothesized that i t would mostc1asely match the scores for the sample, as the occupational subgroup and the Clubhouse

sample service the same type of clientele.

Comparison with Norms: Mean ScoresTable 8 shows the mean scores and standard deviations for each of the three subscoresof bumout, by country, and as compared ta the norms for the past-secondary education


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40and mental health subgroups. No significant differences were found between theCanadian and American samples, or between the total sample and the norms for post-secondary education. Ali three total sample scores were significantly different from thenorms for the mental health group, with the emotional exhaustion score being higher(worse) than the norms, the depersonalization score was lower (better) than the norms andthe personal accomplishment score was higher (better) than the norms.

Table 8. Bumout Subscales by Country, Compared to Normative SamplesEmotionalExhaustionM 50

DepersonalizationM 50

PersonalAccomplishmentM 5DClubhouse SamplesCanada (N=29) 17.76United States (N=64) 19.65

Nonnative Samples

10.7010.28

3.974.43

4.433.60

37.1239.90

7.406.40

7.929.17.63.571.958.57ostsecondaryEducation Subgroup(N=635)Mental Heafth 16.89- 8.90 5.72b 4.62 30.S-r: 6.37Subgroup (N=730)

Note. US sample for Emotional Exhaustion was 63; there was 1missing value.(Maslach et al, 1996, p.8).'(820)=2.15, p


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41

Comparison with Norms: Frequency DistributionsMaslach et al have provided cut-off points dividing the scores for the occupational groupsinto thirds, and labelling thase thirds as low, average and high levels of bumout. Table9 shows the cut-off points for the postsecondary education and mental health groups.

Table 9. Cut-off Scores for Occupational SubgroupsOccupational Low Average HighSubgroups (Iower third) (middle third) (upper third)

PostsecondaryEducationEE s13 14 - 23OP s2 3-8PA 42 - 36Mental HealthEE s13 14 - 20OP s4 5-7PA 33 -2 9 s28Note. Maslach et al, 1996, p.6

Figure 1 shows the distribution of scores for the sample on emotional exhaustion,classified as low1 average and high, using Maslach's cut-off points for the post-secondaryeducation and mental health subgroups shawn in Table 9. These numbers were notsignificantly different from the 1/3-1/3-1/3 breakdown reflected in Maslach's norms.


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42

Figure 1. Emotion,1 Exhaustion: Sample ScoresCompared to Normsf34l

Postsecondary Education Mental HealthLawHigh

Average

Note. For this sample of 91 respondents, the expected numbers for "Iow", "average" and "high" wouldbe 30.7. (reference Hne).Chi Square (2, n=91)=1.1, pis not significant (mental health subgroup)Chi Square (2, n=91)=.61, pis not significant (postsecondary subgroup)(SPSS NonPar test procedure)

Figure 2 shows a similar comparison for depersonalizatian scores. Here the study samplewas significantly different from bath normative groups, the difference being most markedfor the mental health group. The number of high scores (reflecting greater bumout) wasconsiderably lower in the sample than the expected one-third for bath groups.


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43

Figure 2. Depersonalization: Sam pie ScoresCompared ta Norms

60 l f56li SO l10 l3 0 i ----@-0ai 20.aEi10

Postsecondary Education Mental Health~ Low High

Average

Note. For this sample of 93 respondents, the expected numbers for "Iow", "average", and "high" wouldbe 31.0 (reference line).Chi Square (2, n=91) = 30.26, p


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44

~~ 5 0 j

~ 4 0 1~ ~ 3 0 iID 1

~ 2 0 l210o ---l....-_--1:..---_Postsecondary Education Mental Health

D Low High

Average

Note. Forthis sample of 93 respondents, the expeeted numbers for "Iow", "average", and "high" would be31.0. (reference fine).Chi square (2, n=93) = 111.7, p


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45demographic variables (age, number of children in home, sax, level of schooling, hoursworked, length of time on the job and doing similar work, and degree of religion), country(U.S. vs. Canada) and city size. Table 10 shows the significant predictors found in theseregressions.

Table 10. Summary of Stepwise Regression Analysis for Variables Predicting Bumoutin Clubhouse Workers (N=57)

Variable B Std. Error Beta SigEmotional Exhaustion (R square=.413)Supervisory Role -4.44 1.09 ~ . 4 5 -4.10 .001Lifestyle -14.51 4.50 -.35 -3.23 .006Job Expectations -2.63 1.01 -.28 -2.61 .012Country 454 226 22 201 049Depersonalization (R square= .201)Leve1of Education .94 .46 .25 2.06 .045Supervisory Role -1.15 .46 -.32 ~ 2 . 5 1 .015Country 1 QO 95 25 2 Q1 050Personal AccompIishment (R square=.236)Job Challenge 3.00 .73 .49 4.12 .000Note. Coding: Canada = 1t US =2.Four variables were significantly related ta emotional exhaustion, and explained 41.3% ofthe total variance:

Supervisory Role: The 8 coefficient was negative, meaning that, as scoresfor the factor items are higher, emotional exhaustion is lower. As asupervisor provided more support to workers by means of performance


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Three variables were significantly related to depersonalization, and explained 20% of thetotal variance:

46feedback, inclusion in decision making and recognition for successes, forexample, the emotional exhaustion score was lower for workers.

Lifestyle: The negative B coefficient indicates that as scores for the items inLifestyle are higher, emotional exhaustion is lower. Workers who hadsupportive family and friends and who exercise regularly, will experienceless emotional exhaustion.

Job Expectations: The negative B coefficient means that as the scores foritems in Job Expectations are higher, emotional exhaustion is lower.Workers will experience less emotional exhaustion if they have cfear jobexpedations, such as having enough time to complete their work, competentcoworkers, and comfort in their level of knowledge about mental iIIness.

Country: Canada was scored as 1 and United States as 2 ,50 the positiveB coefficient means that American Clubhouse workers experienced moreemotional exhaustion than Canadian workers.

Level of Education: The positive B coefficient means that workers with a


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higher level of education reported experiencing higher levels ofdepersonalization.

Supervjsory Raie: The negative B coefficient indicates that workers withsupportive supervisors experience less depersonalization. Supportivesupervisorswill, among other things, offer workers the opportunity to developtheir special skills, and offer opportunities for training and skill development.

Country: Canadawas scored as 1 and United States as 2 sa the positive Bcoefficient means that American Clubhouse workers experienced moredepersonalization than Canadian workers.

One variable was significantly related ta personal accomplishment, and accounted for 24%of the total variance:

Job Challenge: The positive B coefficient means that as job challengeincreases, the level of personal accomplishment is higher.

The fact that the predictors included in this questionnaire accounted for a relatively lowproportion of the variance in bumout (41 % for emotional exhaustion, 20%) fordepersonalization, and 24% for personal accomplishment) suggests that there are otherpossible predictors of bumout that were missing frcm this model.


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Stressors Attributed ta ClienteleClubhouse staff were asked to rank items which they found particularly stressful whenworking with members. Figure 4 shows the seven mast stressful items, ranked in arderfram mast stressful ta least stressful.

Figure 4. Examination of Work Identified as Stressful by Clubhause Staff (N=97)

10

V.r t l ' " AbuiN' ....mb.r la Suicidai Not EnougllTIm.PIlyIIc-'t AII... nlw. M.mll.n Woa't H.1p S.IW.lNolEnough RIIDurUl1A H.1p M.mll.r ln Criiis

Possible Stressors

Five stressars involved working directly with members. They included: working with amemberwho becomes physically violent or verbally abusive, working with those who don't


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49

take an active role in helping themselves, and working with a member who is suicidai, orwho is in crisisl l Other stressors are stressful not because of the member's mental iIIness,but because of the nature of the Clubhouse model itself, coupled with a lack of resources:"not having the resources ta adequately help members", and "not having enough time tadevote ta each member".

The top seven stressors were largely associated with the chronically mentally il! clianteleserved by Clubhouses, rather than with any kind of deficit within the Clubhouse model orwith the individual Clubhouse. The exceptions ta this are not having the resources toadequately help members, which relates ta the funding source, and not having enoughtime te devote ta each member which could relate ta the model itself, or the operation ofthe individual Clubhouse.


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DISCUSSION

Summary of Key Findings

There were no significant differences between the Canadian and Americansamples, on demographics, on any of the factors used for analysis, or indirect comparison of the mean MBI scores. In the regression analysis,controlling for the other variables, there was an indication that the U.S.sample reported higher levels of emotional exhaustion anddepersonalization than the Canadian sample, but this was of borderlinestatistical significance.

Clubhouse staff in the study sample reported relatively high job satisfaction.

The scores for this sample matched the scores for Maslach's postsecondaryeducation subgroup more closely than any of the other subgroups. Theywere significantly and markedly lower for depersonalization and personalaccomplishment than the scores for the mental health subgroup, but higherthan the scores for emotional exhaustion in either of the two subgroups.

Clubhouse staff in this survey indicated that five of the top seven stressorsthat they encountered involve working directly with members who are

50


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51physically violent, verbally abusive, who don't take an active raie in helpingthemselves, who are suicidai, or who are in crisis; Members who werephysically aggressive or verbally abusive, or who do not help themselveswere reparted to be the most stressful members ta work with.

The supervisory raie score was the most significant predictor of emotionalexhaustion and depersonalization scores. Key supervisor behaviours in thisscore were: recognizing successes, providing performance feedback,clearly defining job responsibilities, and involving staff in decisions.

LimitationsThere were saveral problems in the design and distribution of this survey.

There was an overlap in sorne of the questions on the MBI and part twa of the survey(organizational factors). The questionnaire developed for this study appears ta beconceptually similar ta the questions on the MBI, which may have been partiallyresponsible for the significant correlations found. Specifically, the question Il 1feel l'mworking too hard on my job" appeared on the MBI and overlapped conceptually with thequestion "My workload is too highn which appeared in part two of the questionnaire. Thissecond question was eliminated from the analysis.

The pracess of sampling, as described in the methodology, resulted in an over-


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52representation of Clubhouses in sorne city size categories. As weil, although there wasa sample of 97 Clubhouse staff, there were only 20 Clubhouses represented in thisresearch. This small number makes it difficult to draw any conclusions about the size ofthe city as related to levels of bumout.

The demographic data sheet included in the Maslach Bumout Inventory is clearly designedfor an American audience. Many Canadian respondents had difficulty answering thequestion, l'what was the highest level you completed in schoel?" One of the options was"campleted four years of college". In Canada, four years of post-secondary education,would general ly be called university. Col lege is usual ly completed in two years. Sorneinterpretation of the data was necessary. For example, a Canadian respondent indicatingthat he or she had a university level degree (e.g., B.S.W.), would be coded into theI&completed four years of collegeJl category.

The question in Part Two asking respondents ta detail howmuch time each day was spentin direct contact with members, doing paperwork, attending meetings, or supervising staff(executive director's copy only) was frequently misunderstood. Several respondents

tabulated their respenses on a weekJy basis, instead of daily. Other respondents indicatedthat it was difficult to separate their day in such a way, as the nature of the Clubhousemodel meant that everything they did, including attending meetings, and doing paperworkwas done while working directly with members. In cases where more than one number


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was indicated for a category (e.g., if a respondent indicated that he or she spent 3-5 hourson direct member contact), the mid-point was used as the response.

The length of the survey may have been problematic for busy Clubhouse workers. Manydiverse aspects of bumout were examined in this research. A shorter, more focussed,survey might have encouraged more responses and a richer amount of information.

Implications for ResearchIt is unclear why the scores for the sample more closely resemble the scores for thepostsecondary education subgroup than the mental health subgroup. Maslach's norm foremotional exhaustion is actually higher for the postsecondary education subgroup than forthe mental health subgroup, however the norms for depersonalization and personalaccomplishment are lower. The mental health subgroup consists of psychologists,psychotherapists, counsellors, mental hospital staff, and psychiatrists, and therefore havedifferent qualifications than the study sample. Although the professionals in the mentalhealth subgroup and Clubhouse workers ail work ~ v i t h the same cHentele, the wark thatthey do appears to be very different, which may aceaunt for the disparity in scores.Clubhouse workers do not counsel or treat Clubhause members, activities which membersof the mental health subgroup engage in. It may be necessary ta further examine whyClubhouse workers are more cfosely associated with the postsecondary educationsubgroup, in arder ta effectively address issues of emotional exhaustion. For example, like


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54the postsecondary education subgroup, there is an element of teaching involved in workingwith Clubhouse members, although it is not done in a formai manner.

There were sorne differences in the level of statistical significance found for the twodifferent methods of comparing this sample with Maslach's norms. For example, the meanscores for personal accomplishment in this sample and in the postsecondary educationsubgroup were almost identical, while the distribution shawn in Figure 3 was significantlydifferent trom a 1/3-1/3-1/3 distribution. However, this apparent contradiction arose frema stronger central tendency in the study sample which was picked up in the chi-squaretest, rather than from a difference in the level of personal accomplishment scores.

The predicters included in this questionnaire account for a relatively low proportion of thevariance in emotionaJ exhaustion (41%), depersonalization (20%), and personalaccomplishment (24%). This suggests that there are ether possible predictors of bumoutthat are missing trom this model. Future research might focus on predictors which wouldmore completely explain the three subscales of bumout: For example, a doser look atworker duties and responsibilities, Clubhouse structure, and the role of the supervisor in

reducing emotional exhaustion among staff requires further research.

The ICCO, acting as the agency over-seeing the well-being of the movement, needs totake a closer look at the raie of the superviser in supporting Clubheuse workers, with afocus on howthe model itself may be inhibiting supervisors fram providing their staffwith


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55the support they require. For example, it will be important ta examine how supervisorscan recognize the successes of their staff, and clearly define staff responsibilities, whilenot eontradicting the spirit of the Clubhouse modal.

A longitudinal study, on an intemational level, would yield a wealth of information on thetapie of bumout among Clubhouse staff. A multi-year stu

burnout and lack of agency structure a study of the clubhouse madel of psychosocial rehabilitation

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