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The Impact of COVID-19 on Clubhouse Employment Programs

The Clubhouse model of psychosocial rehabilitation provides several employment opportunities to individuals who experience mental health concerns, including transitional, supported, and independent employment. The COVID-19 pandemic resulted in Clubhouses having to adapt existing programs to online formats. Employment programs were further impacted, as many workplaces in the community closed or reduced capacity. The present study aimed to examine the rates of involvement in transitional, supported, and independent employment across six Clubhouses in Canada throughout the pandemic. 462 members completed surveys at five time points pertaining to participation in Clubhouse employment programs. The data was analyzed using Cochran’s Q tests to determine differences in employment rates across time points. The results demonstrated an overall decrease in transitional and supported employment rates throughout the pandemic. Conversely, rates of independent employment were unchanged. It is evident that Clubhouse employment programs assist members in obtaining employment. The results suggest Clubhouses may benefit from exploring novel employment opportunities to support their members, such as remote work.

2014). Such programs have been effective in helping those with mental illness obtain long term employment at significantly higher rates than traditional vocational rehabilitation programs (Hoffman et al., 2014). The Clubhouse model is a type of psychosocial rehabilitation that supports individuals living with mental illness and provides them with access to employment, education, and meaningful relationships to support their recovery (Mckay et al., 2018;ICCD, 2015). Clubhouses have been particularly effective in addressing the employment gap; members obtain employment and stay employed for longer durations compared to other vocational rehabilitation programs (Schonebaum et al., 2006;Macias et al., 2006).
The COVID-19 pandemic led to drastic increases in unemployment among the general Canadian population (Statistics Canada, 2020b). The consequences of COVID-19 for Clubhouses were also significant, as they were required to pause employment programs due to government restrictions, despite being able to rapidly adapt many of their other non-employment programs (Mutschler et al., 2021).
It is unclear what impact the pandemic had on the rates of employment amongst those accessing supportive employment through Clubhouses during the COVID-19 pandemic.

The Impact of COVID-19 on Clubhouse Employment Programs
Employment rates among individuals experiencing mental illness remain consistently low despite their willingness to work (Nordt et al., 2012). In Canada, the employment rate among individuals with mental health-related disabilities is 46%, compared to 80% for those without a mental healthrelated concern (Statistics Canada, 2020a). In order to address this gap in employment, supported employment programs have been developed to assist individuals with mental illness obtain competitive employment (Hoffman et al., The current study seeks to document the participation rates of employment programs for Clubhouse members.

Clubhouse Employment Programs
Employment programs are a central component of programming offered at Clubhouses;the accreditation standards for Clubhouses include four standards pertaining to employment. Employment programs offered include the work-ordered day where members and staff work alongside each other to complete the day-to-day operations of the Clubhouse (McKay et al., 2018), as well as three employment programs 1) transitional employment; (2) supported employment; and (3) independent employment opportunities (ICCD, 2015). The work-ordered day involves members voluntarily joining units and departments of the Clubhouse to improve their social and cognitive skills (Pernice et al., 2020). Members are able to choose both the departments and staff members they would like to work with. The workordered day typically operates during the weekdays from 9am to 5pm, helping members establish a routine corresponding to employment hours.
Transitional employment (TE) refers to time-limited parttime opportunities (Mckay et al., 2018), generally involving 12 to 20 h a week for a period of 6 to 9 months (ICCD, 2015). Clubhouses work to maintain relationships with employers, provide training, onsite support, and coverage by a Clubhouse member or staff when members are absent. Members can participate in as many TE opportunities as they need, and the employers allow Clubhouses to decide who will fill TE positions, as Clubhouses "own" these positions (Mckay et al., 2018). The TE program includes significant support, both at work and outside of work, from Clubhouse staff. It acts as a rehabilitation program where members can gain the skills and confidence needed to obtain a job in the "real world" (ICCD, 2015). At the end of the transitional employment term, members can pursue another transitional employment placement or independent employment. In contrast, supported employment programs involve helping clubhouse members receive successful employment at a local business or public employer. Supported employment (SE) is not time-limited and can include part-time or full-time positions where Clubhouses provide support on or off-site if the member requires it. Although Clubhouses have relationships with the employers in the SE programs, these jobs are not "owned" by the Clubhouse and there is a competitive aspect to the interviewing process. Other employment programs are similar to the Clubhouse SE program, such as the individual placement and support model (IPS). Similar to the Clubhouse supported employment program, the IPS model provides individuals with job support to participate in competitive employment. Participating in employment serves as a component of psychological treatment and provides individuals with support to seek out jobs and maintain that support once individuals are employed (Rodevand et al., are ready (ICCD, 2017). Finally, independent employment (IE) involves helping Clubhouse members seek out and obtain jobs on their own when they are ready (ICCD, 2015). Independent employment involves no formal relationship between employers and Clubhouses. Accordingly, there is no onsite support, meaning that members who participate in IE have gone through a fully competitive interview (Mckay et al., 2018). Clubhouses will often postIE positions for their members to apply.

Outcomes of Clubhouse Employment Programs
Research has documented that participation in Clubhouse employment programs is associated with increases in positive wellbeing outcomes and employment outcomes. Gold et al. (2016) found that members who participated in supported employment programs at Clubhouses reported greater quality of life and increases in self-esteem compared to unemployed Clubhouse members. Further, Clubhouse members who participated in employment programs were found to be employed for longer durations and earned more on average, as compared to those in an alternative mental health-based program (Schonebaum et al., 2006;Macias et al., 2006). Additionally, members who reported higher rates of participation in the work ordered day prior to being employed also tended to be employed for more extended periods, indicating that the work-ordered day was positively impacting member's subsequent employment success (Schonebaum et al., 2012). Similarly, a study in China found that Clubhouse members had higher employment rates after six months than participants in a general community service group (Chen et al., 2020).
An 18-month longitudinal study showed improved employment outcomes across time points for Clubhouse members (Bouvet et al., 2021). Qualitative analysis indicated that employment was one of the main reasons members joined the Clubhouse, and members relied on Clubhouses for support in order to pursue employment (Bouvet et al., 2021). In addition, TE programs help members determine their work capacity, encourage members to pursue future education and new opportunities, which leads to increased social inclusion (Pirttimaa & Salovitta, 2009). Thus, there is a solid research base for the effectiveness of Clubhouse employment programs on a variety of member outcomes.

Impact of COVID-19 on Clubhouses
The COVID-19 pandemic disrupted many in-person services offered by Clubhouses, and several Clubhouses were forced to close and also rapidly adapt their programming to meet their members' needs (Mutschler et al., 2021). Across Canada, many Clubhouses closed their in-person services and reported several challenges including increased mental health symptoms, loneliness, difficulty accessing services, and establishing routine due to the disruption of the work ordered day (Mutschler et al., 2021). Clubhouses rushed to adapt their programming to meet new needs created by the pandemic by expanding their meal programs, increasing communication through outreach programs, and delivering programming through virtual means (Mutschler et al., 2021). In addition, members who were engaged with their Clubhouses reported greater well-being over time (Hinchey et al., 2021). Despite rapid innovations in program delivery, Clubhouses faced many challenges with continuing the employment programs, due to the COVID-19 restrictions required by employment partners (e.g., reduced capacity, closure, Provincial Health Protocols, PPE compliance).

Current Study
To date, no research has been done on the impact of COVID-19 on Clubhouse employment programs. The present research is part of a larger 24-month longitudinal study that was conducted with six Canadian Clubhouses. Over the course of the study, the COVID-19 pandemic disrupted Clubhouse programming and employment opportunities. Given that employment is a core component of the Clubhouse model of psychosocial rehabilitation, the present study seeks to understand the impact of COVID-19 on the employment rates of Clubhouse members. Furthermore, since the pandemic disproportionately impacted employment rates in marginalized groups, examining employment rates among individuals with mental health concerns would allow Clubhouses to determine which members were impacted by the pandemic and how to adapt their future programming and services. The purpose of the present study was to examine employment rates in transitional, supported, and independent employment programs at six Clubhouses across Canada over the course of the pandemic.

Method
The present study includes data from a larger Canada-wide study of six accredited Clubhouses. The Clubhouses are located in the following provinces: Alberta (n = 1), Ontario (n = 2), Nova Scotia (n = 1), and Prince Edward Island (n = 2). Accredited Clubhouses were chosen to participate in order to provide a level of standardization across the sites. The purpose of the larger study is to assess various aspects of psychosocial recovery during member's Clubhouse involvement and is currently in preparation for publication.
The present study obtained research ethics approval from Ryerson University, the Nova Scotia Health Authority, and the Health Research Ethics Board of Alberta.

Procedure
Each Clubhouse had a research team consisting of Clubhouse staff and members that provided information to members about participating in the present study. Informed consent was reviewed with interested members. Members completed a paper-based questionnaire that asked about various aspects of their psychosocial functioning. The questionnaire took approximately 45 min to complete. Members completed the survey every six months for a two-year period, resulting in the collection of five data points. Importantly, the COVID-19 pandemic and subsequent physical distancing and program closures occurred during the 12-month follow up period of data collection (March-April 2020). Therefore, the study has collected two data points prior to the pandemic and three during the pandemic.

Sample
The present study recruited 462 members from the six accredited Clubhouses across Canada. All active members were given the opportunity to participate. An active member means that the member must have utilized the Clubhouse within the last 90 days. The number of active members at the six Clubhouses combined is 1953, therefore the present study represents 23.7% of active members. Exclusion criterion was that if an individual was deemed unable to consent in the informed consent process, they were deemed unable to participate in the study. Capacity to consent included understanding the purpose of the study, risks and benefits, as well as their confidentiality, privacy, and withdrawal rights. Descriptive information on the sample can be found in Table 1.

Measures
The present study reports on demographics and employment of members during the data collection period. Demographic information was collected at baseline including age, gender, education, and length of Clubhouse membershi. Members were asked at each time point whether they were currently employed, and their involvement in transitional and supported employment programs at the Clubhouse over time (e.g., Have you participated in the transitional employment program at your Clubhouse in the past 6 months?) with a binary response of yes/no. This test was chosen in order to assess the binary outcome of employment, coded as 0 or 1. The test assesses whether the proportion of the binary outcome is the same within the five timepoints. Upon rejection of the null hypothesis that the groups are equal, the test computes pairwise multiple comparison tests to determine which of the individual groups are significantly different. The alpha level is adjusted using the Bonferroni method to control the error rate. Cochran's Q test was completed for overall employment status as well as participation in Clubhouse employment (i.e., transitional and supported) throughout the timepoints.

Results
The present study recruited 462 Clubhouse members. The average age of members was 48.8 years (SD = 12.6) and 52.2% were male. Demographic information of the

Analysis
The present study utilized non-parametric statistics (i.e., related-samples Cochran's Q test) in SPSS (IBM Corp, 2021) in order to determine if differences emerged on a dichotomous variable between three or more timepoints.   employment outcomes for Clubhouse members during the pandemic, pointing to an important area of future development for researchers, Clubhouses, and other supported employment programs, as they navigate the changing policies and regulations of physical distancing.
The results of the present study highlight the importance of Clubhouse programming in assisting individuals with mental illness in obtaining employment. The findings suggest that when Clubhouse members do not have access to employment programs, employment rates decrease. This is consistent with previous findings that indicate that the employment rates of individuals with mental health disabilities are about half the rate of individuals without mental health-related disabilities in Canada (Statistics Canada, 2020b). Employment programs at Clubhouses are able to address the reduced rate of employment for individuals with mental health symptoms and allow for their members to obtain employment while still being supported if symptoms worsen. Previous literature has noted that when individuals with severe or persistent illness receive employment services through mental health programs, they have greater rates of employment compared to individuals who received no employment services (Pandiani et al., 2004;Burns et al., 2007). Meaningful employment is seen as a central component of recovery (Pandiani et al., 2004). As such, providing funding for supported employment programs for individuals with psychiatric disabilities in order to achieve competitive employment is integral, as well as supporting businesses to join and participate with these programs.
Qualitative research has found that Clubhouse members experienced increased mental health symptoms, as well as isolation and loneliness, during the pandemic (Mutschler et al., 2021). Mental health declines were observed even in the general population, among individuals without mental illness (Swaziek et al., 2020). In Canada, the pandemic exacerbated mental health symptoms for individuals already experiencing poor mental health prior to the pandemic, in part due to loss of employment and inadequate financial resources (Statistics Canada, 2020b). Additionally, those unemployed at the start of the pandemic reported the greatest declines in mental health (Statistics Canada, 2020b). The COVID-19 pandemic disproportionately impacted marginalized communities who lacked power, agency, and social protections, such as individuals who could not work from home or were employed in precarious employment (Basu, 2021). Given the unequal impact of the COVID-19 pandemic on marginalized groups, the present study showcases the importance of employment programs for individuals with mental illness who are disproportionately impacted by economic downturns.
Clubhouses offered significant support to their members during the COVID-19 pandemic by rapidly adapting overall sample can be found in Table 1 and demographics by employment type can be found in Table 2. Demographics of participants were similar across the employment types. In terms of employment rates at baseline, 107 members reported participation in transitional employment, 72 in supported employment, and 108 in independent employment. This rate dropped across the time points, with rates provided in Table 2.

Employment
Four related-samples Cochran's Q tests were calculated in order to determine differences in employment rates across the five timepoints. The first independent variable studied was overall employment rate. Cochran's Q test indicated a significant difference across the five time points, χ 2 (4) = 17.2, p = .002. Pairwise comparisons were conducted using Bonferroni correction to assess this significant difference. The results indicated that 6-month and 18-month (p = .014), and 6-month and 24-month (p = .002) employment rates significantly differed, indicating a decrease in the overall employment rate during COVID-19.
Second, Cochran's Q test was conducted for involvement in transitional employment at the Clubhouses. Cochran's Q test indicated a significant difference among the five proportions, χ 2 (4) = 19.3, p = .001. Pairwise comparisons using Bonferroni correction indicated significant differences between baseline and 24 months (p = .012), 6-month and 24 months (p = .012), and 12-month and 24 months (p = .036), further indicating an impact of COVID-19 on employment rates.
Cochran's Q test was conducted for supported employment rates. The overall test indicated a significant difference across the proportions, χ 2 (4) = 9.82, p = .043. However, after correcting for multiple comparisons using Bonferroni correction, no pairwise comparisons were statistically significant. Lastly, we conducted a Conchran's Q test for independent employment rates over the timepoints. Unlike the previously conducted tests, the test indicated no significant difference across the proportions, χ 2 (4) = 4.22, p = .377.

Discussion
The present study examined the rates of employment among members of Canadian Clubhouses during COVID-19. The results suggest an overall decrease in employment status, and in transitional and supported employment programs specifically, during the pandemic. Additionally, the results demonstrate similar demographic characteristics of Clubhouse members regardless of employment program type they were participating in. This is the first study to examine The present study has numerous strengths, including the use of a longitudinal study design, a large sample size, and the inclusion of Clubhouse members from six accredited Clubhouses in Canada. Despite these significant strengths, some limitations exist. First, the present study was unable to determine income outcomes during the pandemic, due to variation in participant reporting (e.g., members reporting COVID relief funds as income). Future studies are needed to determine the impact of various government income relief programs during the pandemic. Further, additional employment outcomes (e.g., hours worked) during the pandemic may be important to understand how members were impacted during this time. Finally, an important future direction is to examine Clubhouse employment outcomes after the pandemic, to determine the impact of Clubhouse employment programs on various psychosocial recovery outcomes of Clubhouse members. This is an integral area of future research, as past qualitative studies have noted that due to the pandemic, Clubhouses will be "forever changed" (Mutschler et al., 2021).

Conclusion
Individuals with mental illness experience lower rates of employment, despite a desire to work (Nordt et al., 2012). The findings of the present study demonstrate that lower rates of employment among individuals experiencing mental illness was exacerbated due to the closure of Clubhouse employment programs. Despite this, it is important to note that Canadian Clubhouses rapidly adapted much of their programming and maintained a connection with their members to mitigate the negative effects of the pandemic on their members (Mutschler et al., 2021). While limitations exist, including the lack of data on hours worked and average income, the study provides insight into the employment rates of Canadian Clubhouse members during the pandemic. Despite the overall decrease in employment across the pandemic, members continued to work, demonstrating the resilience of Clubhouse members and the strength of Clubhouse employment programs in supporting members to develop the skills necessary to maintain stable employment. Implications of the present study suggest that Clubhouses and their employment partners must continue to adapt and find novel ways in which to provide employment opportunities for Clubhouse members. This may include remote employment positions to allow Clubhouses to continue their employment programs and provide new employment opportunities to members despite restrictions in the workplace. Remote employment is able to offer greater flexibility and their programming (Mutschler et al., 2021). They were able to successfully adapt a significant amount of their programming to be offered virtually and continue to support member's well-being (Mutschler et al., 2021;Hinchey et al., 2021). Specifically, Clubhouses implemented various policies such as increasing communication and outreach with members throughout the pandemic, expanding their meal programs and delivering their programming virtually, through services such as Zoom and Facebook (Mutschler et al., 2021). Despite these adaptations, offering employment programs during the pandemic was found to be difficult, due to employment partner's changing their policies of in-person work. Thus, there were fewer employment opportunities available to members during the pandemic, which may have contributed to the decline in supported employment rates. Interestingly, while rates of transitional and supported employment decreased, rates of independent employment increased. This increase in independent employment could have been due Clubhouses increasing virtual programming during the closure of their typical employment program. Anecdotal evidence from Clubhouse directors revealed that some Clubhouses provided virtual sessions on vocational skills such as building resumes and job applications leading members to seek out independent employment (C. Habal-Brosek, personal communication, January 3, 2022). Further, the skills that were previously developed through supported employment programs may have led members to seek out additional independent employment opportunities. This may explain why rates of independent employment remained consistent while transitional and supported employment decreased. Additionally, the rise in independent employment may have been due to the changing nature of the labor market, where there was an increase in remote employment over the course of the pandemic (Ameri & Kurtzberg, 2022;Lisa et al., 2021), which may have better fit the needs of some Clubhouse members due to its greater flexibility (Lisa et al., 2021). In light of previous findings where Cubhouse employment programs are able to increase member's employment durations and earnings, as well as the greater quality of life (Gold et al., 2016;Schonebaum et al., 2012), Clubhouses may benefit from exploring ways in which they can assist members in obtaining employment during the pandemic, for example, through virtual opportunities. This is particularly relevant, given that Clubhouse members reported increased mental health symptoms during the pandemic (Mutschler et al., 2021) and employment outcomes have been shown to facilitate recovery outcomes such as increased self-esteem and reduced hospitalization and readmission rates (Gold et al., 2014, Burns et al., 2007. is solely governed by the terms of such publishing agreement and applicable law. Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article